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Awake Craniotomy Surgery –

Principles and Management

Zamzuri Idris

USM


Which type of neurosurgery?

1. Removal: Lesion near the eloquent cortex or

vital areas of the brain [motor/speech etc]

2. Deep Brain Stimulation (DBS) for Refractory

Parkinson’s/dystonia/Tourette’s syndrome

3. Brain biopsy

4. IORT – intraoperative radiation therapy

[1 = craniotomy & 2, 3, 4 = burr hole procedure]


Why?

Main Reason: It is the best way to monitor the

neurological status of the patient/effect of the

intervention (DBS)

Others:

• Simple burr hole surgery/elderly with comorbidity

– brain biopsy

• Way to ascertain the sensitivity and specificity of

the extraoperative functional neuroimages

• Data can be used to study the brain connectome

(oscillation and synchronisation of brain networks)


Interaction and monitoring


Who and where?

Centre that has:

• Neuroanaesthetist - experience in awake

neurosurgery/DBS.

• Neurosurgeon – experienced neurosurgeon:

Fast/well planned/systematic – attention to

minor details.

• Good nursing assistant – scrubed/circulating

nurses

• Experienced neurophysiologists – EMG/EEG etc

• Neurologist and neuropsychologist

• Neuro-radiation for IORT


Which patient for awake craniotomy

procedure?

Not all patients

Selected patients:

• Superficial (cortical/subcortical) intra-axial lesion

The exclusion criteria include:

a) deep seated tumor,

b) very young (< 14 years old) or elderly patient (> 65

years old)

c) non-educated or non-motivated patients,

d) agitative or fretful patients,

e) demented patients, and

f) presence of other co-morbidity.


Which patient for awake DBS

• All DBS patients

• Except: Severe Tourette with violent

involuntary movements = may need GA


Which patient for awake brain biopsy

Brain lesion

• Too eloquent/important areas inside the brain

• Too unknown

• Too many

• Too diffused

• Too deep

• Too large/big & ?Too small


Which patient for IORT

• High grade brain tumors as adjuvant

• Deep seated brain tumors

• Patient preference


Awake craniotomy


What’re required for awake

craniotomy procedure?

• Extraoperative functional/anatomical

neuroimages – extraoperative brain mapping:

MRI/fMRI/DTI/MEG/TMS

MRI


FUNCTIONAL MRI


MEG


MEG:

MAGNETOENCEPHALOGRAPHY

OR MSI = MAGNETIC BRAIN

WAVES ANALYSIS


TRACTOGRAPHY OR DTI TO

STUDY BRAIN CONNECTOME


BRAIN CONNECTOME


TRANSMAGNETIC

STIMULATION TO

MAP THE BRAIN

AREAS


Intraoperative neurophysiological

monitoring


When?

• ELECTIVE CASE


How?

• EXTRAOPERATIVE FUNCTIONAL

NEUROIMAGES:fMRI/MEG/TMS

• HEAD FIXATION – MAYFIELD HEAD CLAMP (IGS)

• NEURONAVIGATION (IGS) – TO LOCALISE THE

AREA OF THE LESION OR ELOQUENT CORTICES

QUICKLY; TO ESTIMATE THE SIZE OF

CRANIOTOMY

• INTRAOPERATIVE BRAIN MAPPING

• ACTUAL SURGERY

• CLOSURE


HEAD FIXATION

AND

NEURONAVIGATIO

N


NEURONAVIGATION WITH MEG


INTRAOPERATIVE BRAIN MAPPING


Awake 1: In operating theatre – no ET tube, removal of

tumour was under fully awake state

MAPPING: A = Motor area; 1,2,3 =

Sensory area

Trans-sulcal

approach


Outcome 1: Radiology: Cavernoma

PREOP

POST-OP


AWAKE 2: Intraoperative Mapping

Motor

area:

face,

hand


Outcomes:

Mets

Mean FAs for UP/DOWN FIBRES (Blue)

Preop: 0.234; Post op: 0.374


Awake 3: Awake with needle EMGs: weak hands (no MEG

signal obtained preop)

Motor area for facial (A, also at 4 and 5) and

deltoid (C) and brachioradialis (F)


Motor area for facial

(A, also at 4 and 5)

and deltoid (C) and

brachioradialis (F)

Approach – trans-sulcal from superior aspect

The facial fibres splay around the tumour,

bulky at the anterior and posterior part.


Adjuvant Therapy:

IORT

Outcomes -

GBM


Awake 4: Awake and bleeding

cavernoma with seizures

PYRAMIDAL

FIBRES ON

DTI

CAVERNOMA

LEFT MOTOR STRIP

ON MEG

RIGHT MOTOR STRIP

ON MEG


Awake 5: Awake surgery- “Brain oscillation” : Stim at motor

cortex induced responses at opposite motor cortex areas

Intraoperative EEG Recording at opposite

hemisphere

Stimulation area


Awake 6: Epilepsy surgery and awake craniotomy


Baseline prior to right fingers movement

ECoG: Electrodes

No. 1 (Gamma

activit

y

?execution/plannin

g) ;2;3;4;5 (slowing)

and ??? 11;12;13

During right fingers movement: real-time grid mapping in epileptic patient


MAPPING THE HAND AREA WITH GRID ELECTRODES

Real-time grid mapping and MEG


REMOVAL OF LESION AND MULTIPLE SUBPIAL

TRANSECTION (MST)/(motor cortex) UNDER AWAKE STATE

LESION – AT AREA 15 ELECTRODE

IGS

GUIDED

BRAIN MAPPING

MST

KNIFE

MST: NOTE THE BLUE LINES – capillary bleed


ECoG pre and after removal of lesion and MST


DBS

FUNCTIONAL NEUROSURGERY-DBS: parkinson,

dystonia and Tourette


Stereotactic

Brain biopsy


IORT


What are the complications?

• Craniotomy: Seizures

• DBS: Haemorrhage

• Biopsy: Haemorrhage

• IORT: Haemorrhage


Summary

• Awake Surgery in Neurosurgery includes surgery for DBS, Lesional

biopsy, Precision Radiation Therapy and removal of lesion near

eloquent brain (awake craniotomy)

• Awake craniotomy needs a skillful team

• Awake craniotomy needs extraoperative brain mapping (various

functional and anatomical neuroimages)

• Awake craniotomy can prevent further morbidity to the patient

(neuro monitoring during surgery)

• Awake craniotomy is a method of real-time functional brain

mapping: it therefore can validate other methods of brain mapping

• Awake craniotomy data can be used for Neuroscientific

research/publication & help us to understand better the functions

of the brain

(example: innovation in “brain-computer interface” for

neurorehabilitation)


The end

• Reference: in Google for free (Dec 2012): Brain tumor E-book

edited by Dr. Terry Lichtor

Rush Medical College, Department of Neurosurgery, Chicago,

United States

• ISBN 980-953-307-721-0

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