Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: a prospective trial of 200 cases

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Object. Awake craniotomy was performed as the standard surgical approach to supratentorial intraaxial tumors, regardless of the involvement of eloquent cortex, in a prospective trial of 200 patients surgically treated by the same surgeon at a single institution.

Methods. Patient presentations, comorbid conditions, tumor locations, and the histological characteristics of lesions were recorded. Brain mapping was possible in 195 (97.5%) of 200 patients. The total number of patients sustaining complications was 33 for an overall complication rate of 16.5%. There were two deaths in this series, for a mortality rate of 1%. New postoperative neurological deficits were seen in 13% of the patients, but these were permanent in only 4.5% of them. Complication rates were higher in patients who had gliomas or preoperative neurological deficits and in those who had undergone prior radiation therapy or surgery. No patient who entered the operating room neurologically intact sustained a permanent neurological deficit postoperatively. Of the most recent 50 patients treated, three (6%) required a stay in the intensive care unit, and the median total hospital stay was 1 day.

Conclusions. Use of awake craniotomy can result in a considerable reduction in resource utilization without compromising patient care by minimizing intensive care time and total hospital stay. Awake craniotomy is a practical and effective standard surgical approach to supratentorial tumors with a low complication rate, and provides an excellent alternative to craniotomy performed with the patient in the state of general anesthesia because it allows the opportunity for brain mapping and avoids general anesthesia.

Article Information

Address reprint requests to: Mark Bernstein, M.D, F.R.C.S.(C), Division of Neurosurgery, The Toronto Hospital, University of Toronto, 2–405, McLaughlin Pavilion, 399 Bathurst Street, Toronto, Ontario, M5T 2S8 Canada.

© AANS, except where prohibited by US copyright law.

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Figures

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    Bar graph depicting the location of mass lesions by lobe and side.

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    Bar graph showing the median OR time (hours) by study quartile.

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    Bar graph showing the percentage of patients who stayed in the ICU postoperatively by study quartile.

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    Bar graph displaying the median total hospital stay (days) by study quartile.

References

  • 1.

    Ammirati MVick NLiao Yet al: Effect of the extent of surgical resection on survival and quality of life in patients with supratentorial glioblastomas and anaplastic astrocytomas. Neurosurgery 21:2012061987Ammirati M Vick N Liao Y et al: Effect of the extent of surgical resection on survival and quality of life in patients with supratentorial glioblastomas and anaplastic astrocytomas. Neurosurgery 21:201–206 1987

    • Search Google Scholar
    • Export Citation
  • 2.

    Berger MS: Functional mapping-guided resection of low-grade gliomas. Clin Neurosurg 42:4374521994Berger MS: Functional mapping-guided resection of low-grade gliomas. Clin Neurosurg 42:437–452 1994

    • Search Google Scholar
    • Export Citation
  • 3.

    Berger MS: The impact of technical adjuncts in the surgical management of cerebral hemispheric low-grade gliomas of childhood. J Neurooncol 28:1291551996Berger MS: The impact of technical adjuncts in the surgical management of cerebral hemispheric low-grade gliomas of childhood. J Neurooncol 28:129–155 1996

    • Search Google Scholar
    • Export Citation
  • 4.

    Berger MS: Lesions in functional (“eloquent”) cortex and subcortical white matter. Clin Neurosurg 41:4444631993Berger MS: Lesions in functional (“eloquent”) cortex and subcortical white matter. Clin Neurosurg 41:444–463 1993

    • Search Google Scholar
    • Export Citation
  • 5.

    Berger MS: Malignant astrocytomas: surgical aspects. Semin Oncol 21:1721851994Berger MS: Malignant astrocytomas: surgical aspects. Semin Oncol 21:172–185 1994

    • Search Google Scholar
    • Export Citation
  • 6.

    Berger MSCohen WAOjemann GA: Correlation of motor cortex brain mapping data with magnetic resonance imaging. J Neurosurg 72:3833871990Berger MS Cohen WA Ojemann GA: Correlation of motor cortex brain mapping data with magnetic resonance imaging. J Neurosurg 72:383–387 1990

    • Search Google Scholar
    • Export Citation
  • 7.

    Berger MSDeliganis AVDobbins Jet al: The effect of extent of resection on recurrence in patients with low grade cerebral hemispheric gliomas. Cancer 74:178417911994Berger MS Deliganis AV Dobbins J et al: The effect of extent of resection on recurrence in patients with low grade cerebral hemispheric gliomas. Cancer 74:1784–1791 1994

    • Search Google Scholar
    • Export Citation
  • 8.

    Berger MSKincaid JOjemann GAet al: Brain mapping techniques to maximize resection, safety, and seizure control in children with brain tumors. Neurosurgery 25:7867921989Berger MS Kincaid J Ojemann GA et al: Brain mapping techniques to maximize resection safety and seizure control in children with brain tumors. Neurosurgery 25:786–792 1989

    • Search Google Scholar
    • Export Citation
  • 9.

    Berger MSOjemann GA: Intraoperative brain mapping techniques in neuro-oncology. Stereotact Funct Neurosurg 58:1531611992Berger MS Ojemann GA: Intraoperative brain mapping techniques in neuro-oncology. Stereotact Funct Neurosurg 58:153–161 1992

    • Search Google Scholar
    • Export Citation
  • 10.

    Berger MSOjemann GALettich E: Neurophysiological monitoring during astrocytoma surgery. Neurosurg Clin North Am 1:65801990Berger MS Ojemann GA Lettich E: Neurophysiological monitoring during astrocytoma surgery. Neurosurg Clin North Am 1:65–80 1990

    • Search Google Scholar
    • Export Citation
  • 11.

    Bernstein M: Avoiding complications in intra-axial brain tumor surgery. Perspect Neurol Surg 5:1291391994Bernstein M: Avoiding complications in intra-axial brain tumor surgery. Perspect Neurol Surg 5:129–139 1994

    • Search Google Scholar
    • Export Citation
  • 12.

    Black PMRonner SF: Cortical mapping for defining the limits of tumor resection. Neurosurgery 20:9149191987Black PM Ronner SF: Cortical mapping for defining the limits of tumor resection. Neurosurgery 20:914–919 1987

    • Search Google Scholar
    • Export Citation
  • 13.

    Blomstedt GC: Craniotomy infections. Neurosurg Clin North Am 3:3753851992Blomstedt GC: Craniotomy infections. Neurosurg Clin North Am 3:375–385 1992

    • Search Google Scholar
    • Export Citation
  • 14.

    Cabantog AMBernstein M: Complications of first craniotomy for intra-axial brain tumour. Can J Neurol Sci 21:2132181994Cabantog AM Bernstein M: Complications of first craniotomy for intra-axial brain tumour. Can J Neurol Sci 21:213–218 1994

    • Search Google Scholar
    • Export Citation
  • 15.

    Ciric IAmmirati MVick Net al: Supratentorial gliomas: surgical considerations and immediate postoperative results; gross total resection versus partial resection. Neurosurgery 21:21261987Ciric I Ammirati M Vick N et al: Supratentorial gliomas: surgical considerations and immediate postoperative results; gross total resection versus partial resection. Neurosurgery 21:21–26 1987

    • Search Google Scholar
    • Export Citation
  • 16.

    Fadul CWood JThaler Het al: Morbidity and mortality of craniotomy for excision of supratentorial gliomas. Neurology 38:137413791988Fadul C Wood J Thaler H et al: Morbidity and mortality of craniotomy for excision of supratentorial gliomas. Neurology 38:1374–1379 1988

    • Search Google Scholar
    • Export Citation
  • 17.

    Gregorie EMGoldring S: Localization of function in the excision of lesions from the sensorimotor region. J Neurosurg 61:104710541984Gregorie EM Goldring S: Localization of function in the excision of lesions from the sensorimotor region. J Neurosurg 61:1047–1054 1984

    • Search Google Scholar
    • Export Citation
  • 18.

    Haglund MMBerger MSShamseldin Met al: Cortical localization of temporal lobe language sites in patients with gliomas. Neurosurgery 34:5675761994Haglund MM Berger MS Shamseldin M et al: Cortical localization of temporal lobe language sites in patients with gliomas. Neurosurgery 34:567–576 1994

    • Search Google Scholar
    • Export Citation
  • 19.

    King RBSchell GR: Cortical localization and monitoring during cerebral operations. J Neurosurg 67:2102191987King RB Schell GR: Cortical localization and monitoring during cerebral operations. J Neurosurg 67:210–219 1987

    • Search Google Scholar
    • Export Citation
  • 20.

    Kowalczuk AMacdonald RLAmidei Cet al: Quantitative imaging study of extent of surgical resection and prognosis of malignant astrocytomas. Neurosurgery 41:102810381997Kowalczuk A Macdonald RL Amidei C et al: Quantitative imaging study of extent of surgical resection and prognosis of malignant astrocytomas. Neurosurgery 41:1028–1038 1997

    • Search Google Scholar
    • Export Citation
  • 21.

    LeRoux PDBerger MSHaglund MMet al: Resection of intrinsic tumors from nondominant face motor cortex using stimulation mapping: report of two cases. Surg Neurol 36:44481991LeRoux PD Berger MS Haglund MM et al: Resection of intrinsic tumors from nondominant face motor cortex using stimulation mapping: report of two cases. Surg Neurol 36:44–48 1991

    • Search Google Scholar
    • Export Citation
  • 22.

    McCormack BMMiller DCBudzilovich GNet al: Treatment and survival of low-grade astrocytoma in adults—1977–1988. Neurosurgery 31:6366421992McCormack BM Miller DC Budzilovich GN et al: Treatment and survival of low-grade astrocytoma in adults—1977–1988. Neurosurgery 31:636–642 1992

    • Search Google Scholar
    • Export Citation
  • 23.

    Ojemann GOjemann JLettich Eet al: Cortical language localization in left, dominant hemisphere. An electrical stimulation mapping investigation in 117 patients. J Neurosurg 71:3163261989Ojemann G Ojemann J Lettich E et al: Cortical language localization in left dominant hemisphere. An electrical stimulation mapping investigation in 117 patients. J Neurosurg 71:316–326 1989

    • Search Google Scholar
    • Export Citation
  • 24.

    Ojemann GA: Individual variability in cortical localization of language. J Neurosurg 50:1641691979Ojemann GA: Individual variability in cortical localization of language. J Neurosurg 50:164–169 1979

    • Search Google Scholar
    • Export Citation
  • 25.

    Ojemann JGMiller JWSilbergeld DL: Preserved function in brain invaded by tumor. Neurosurgery 39:2532591996Ojemann JG Miller JW Silbergeld DL: Preserved function in brain invaded by tumor. Neurosurgery 39:253–259 1996

    • Search Google Scholar
    • Export Citation
  • 26.

    Paoletti PButti GSpanu G: Surgery of cerebral gliomas. State of the art. Dev Oncol 66:1291361992Paoletti P Butti G Spanu G: Surgery of cerebral gliomas. State of the art. Dev Oncol 66:129–136 1992

    • Search Google Scholar
    • Export Citation
  • 27.

    Patchell RATibbs PAWalsh JWet al: A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 322:4945001990Patchell RA Tibbs PA Walsh JW et al: A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 322:494–500 1990

    • Search Google Scholar
    • Export Citation
  • 28.

    Puce AConstable RTLuby MLet al: Functional magnetic resonance imaging of sensory and motor cortex: comparison with electrophysiological localization. J Neurosurg 83:2622701995Puce A Constable RT Luby ML et al: Functional magnetic resonance imaging of sensory and motor cortex: comparison with electrophysiological localization. J Neurosurg 83:262–270 1995

    • Search Google Scholar
    • Export Citation
  • 29.

    Sartorius CJWright G: Intraoperative brain mapping in a community setting—technical considerations. Surg Neurol 47:3803881997Sartorius CJ Wright G: Intraoperative brain mapping in a community setting—technical considerations. Surg Neurol 47:380–388 1997

    • Search Google Scholar
    • Export Citation
  • 30.

    Silbergeld DLMueller WMColley PSet al: Use of propofol (diprivan) for awake craniotomies: technical note. Surg Neurol 38:2712721992Silbergeld DL Mueller WM Colley PS et al: Use of propofol (diprivan) for awake craniotomies: technical note. Surg Neurol 38:271–272 1992

    • Search Google Scholar
    • Export Citation
  • 31.

    Skirboll SSOjemann GABerger MSet al: Functional cortex and subcortical white matter located within gliomas. Neurosurgery 38:6786851996Skirboll SS Ojemann GA Berger MS et al: Functional cortex and subcortical white matter located within gliomas. Neurosurgery 38:678–685 1996

    • Search Google Scholar
    • Export Citation
  • 32.

    Taylor WASThomas NWMWellings JAet al: Timing of postoperative intracranial hematoma development and implications for the best use of neurosurgical intensive care. J Neurosurg 82:48501995Taylor WAS Thomas NWM Wellings JA et al: Timing of postoperative intracranial hematoma development and implications for the best use of neurosurgical intensive care. J Neurosurg 82:48–50 1995

    • Search Google Scholar
    • Export Citation
  • 33.

    Uematsu SLesser RFisher RSet al: Motor and sensory cortex in humans: topography studied with chronic subdural stimulation. Neurosurgery 31:59721992Uematsu S Lesser R Fisher RS et al: Motor and sensory cortex in humans: topography studied with chronic subdural stimulation. Neurosurgery 31:59–72 1992

    • Search Google Scholar
    • Export Citation
  • 34.

    Van Buren JMFedio PFrederick GC: Mechanism and localization of speech in the parietotemporal cortex. Neurosurgery 2:2332391978Van Buren JM Fedio P Frederick GC: Mechanism and localization of speech in the parietotemporal cortex. Neurosurgery 2:233–239 1978

    • Search Google Scholar
    • Export Citation
  • 35.

    Walsh ARSchmidt RHMarsh HT: Cortical mapping and local anaesthetic resection as an aid to surgery of low and intermediate grade gliomas. Br J Neurosurg 6:1191241992Walsh AR Schmidt RH Marsh HT: Cortical mapping and local anaesthetic resection as an aid to surgery of low and intermediate grade gliomas. Br J Neurosurg 6:119–124 1992

    • Search Google Scholar
    • Export Citation
  • 36.

    Yetkin FZPapke RAMark LPet al: Location of the sensorimotor cortex: functional and conventional MR compared. AJNR 16:210921131995Yetkin FZ Papke RA Mark LP et al: Location of the sensorimotor cortex: functional and conventional MR compared. AJNR 16:2109–2113 1995

    • Search Google Scholar
    • Export Citation

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