Awake surgery for hemispheric low-grade gliomas: oncological, functional and methodological differences between pediatric and adult populations

Trevisi, Gianluca; Roujeau, Thomas; Duffau, Hugues

doi:10.1007/s00381-016-3069-3

Cited by 26 publications

(15 citation statements)

References 205 publications

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“…Beyond the highly specific management of awake craniotomy per se, its performance in children poses an additional challenge due to their differences in cognitive development and maturity. The developing brain presents anatomical and functional peculiarities that influence the sensitivity of the cortical mapping, limiting the practice of awake craniotomy . Moreover, only 30%‐40% of brain tumors in childhood are supratentorial, and they are most frequently diagnosed in the first 2 years of life, where awake craniotomy is not viable .…”

Section: Introductionmentioning

confidence: 99%

Feasibility of awake craniotomy in the pediatric population

García‐Tejedor

Echániz

Strantzas

et al. 2020

Pediatric Anesthesia

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Background: Awake craniotomy with direct cortical stimulation and mapping is the gold standard for resection of lesions near eloquent brain areas, as it can maximize the extent of resection while minimizing the risk of neurological damage. In contrast to the adult population, only small series of awake craniotomies have been reported in children. Aims:The aim of our study is to establish the feasibility of awake craniotomy in the pediatric population. Methods:We performed a retrospective observational study of children undergoing a supratentorial awake craniotomy between January 2009 and April 2019 in a pediatric tertiary care center. Our primary outcome was feasibility of awake craniotomy, defined as the ability to complete the procedure without conversion to general anesthesia. Our secondary outcomes were the incidence of serious intraoperative complications and the mapping completion rate.Results: Thirty procedures were performed in 28 children: 12 females and 16 males.The median age was 14 years (range 7-17). The primary diagnosis was tumor (83.3%), epilepsy (13.3%), and arterio-venous malformation (3.3%). The anesthetic techniques were asleep-awake-asleep (96.7%) and conscious sedation (3.3%), all cases supplemented with scalp block and pin-site infiltration. Awake craniotomy was feasible in 29 cases (96.7%), one patient converted to general anesthesia due to agitation. Serious complications occurred in six patients: agitation (6.7%), seizures (3.3%), increased intracranial pressure (3.3%), respiratory depression (3.3%), and bradycardia (3.3%).All complications were quickly resolved and without major consequences. Cortical mapping was completed in 96.6% cases. New neurological deficits occurred in six patients (20%)-moderate in one case and mild in 5-being all absent at 6 months of follow-up. Conclusion: Awake craniotomy with intraoperative mapping can be successfully performed in children. Adequate patient selection and close cooperation between neurosurgeons, anesthesiologists, neuropsychologists, and neurophysiologists is paramount. Further studies are needed to determine the best anesthetic technique in this population group. 1. Ojemann GA. Individual variability in cortical localization of language. J Neurosurg. 1979;50:164-169.

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Section: Introductionmentioning

confidence: 99%

Feasibility of awake craniotomy in the pediatric population

García‐Tejedor

Echániz

Strantzas

et al. 2020

Pediatric Anesthesia

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“…AC with direct cortical and subcortical electrical stimulation is an essential tool for minimizing the risk of permanent deficit during surgery for ERG [3,5,7,11,12]. However, despite the high-quality data of its usefulness in adults, the same has not been translated for pediatric cohorts, limited to few case reports or small series in children and almost nonexistent for preadolescents [9,[13][14][15][16][17][18][19].…”

Section: Discussionmentioning

confidence: 99%

Technical Considerations in Awake Craniotomy with Cortical and Subcortical Motor Mapping in Preadolescents: Pushing the Envelope

Ratha¹,

Sampath²,

Subramaniam

et al. 2021

Pediatr Neurosurg

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Introduction: Unlike adult gliomas, the utility of combined application of awake anesthesia and intraoperative neurophysiological monitoring (IONM) for maximal safe resection in eloquent region gliomas (ERG) has not been established for pediatric population while it remains unexplored in preadolescents (below 11 years old). Case Presentation: We report 2 cases of awake craniotomy with IONM in an 8 and 9 year old for safe maximal resection of ERG. In both the cases, repeated preoperative visits of the operating room was performed to familiarize and educate the children about intraoperative communication, comfortable positioning, and neurological assessment. Under conscious sedation protocol, cortical and subcortical mapping, and electrocorticography, gross total resection was achieved. In both the cases, there were no postoperative neurodeficits or perioperative complications. Conclusion: Our 2 cases illustrate the first instance of successful use of awake IONM for maximal safe resection of ERG in preadolescent age-group. We believe, with proper preoperative planning and careful titration of anesthetics, it is safe and feasible. The blanket notion that preadolescent age-group should be excluded from awake mapping needs to be challenged, rather curated on a case basis.

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“…[ 8 , 18 ]. The minimal age for surgery while awake has not been established [ 19 ], with some authors [ 18 ] consider 11 to 12 years of age being the absolute minimum, whereas other authors have successfully applied this technique in children as young as 8 years of age [ 6 , 7 ].…”

Section: Discussionmentioning

confidence: 99%

Awake Craniotomy in a Child: Assessment of Eligibility with a Simulated Theatre Experience

Labuschagne

Lee

Mutyaba

et al. 2020

Case Reports in Anesthesiology

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Background. Awake craniotomy is a useful surgical approach to identify and preserve eloquent areas during tumour resection, during surgery for arteriovenous malformation resections and for resective epilepsy surgery. With decreasing age, a child’s ability to cooperate and mange an awake craniotomy becomes increasingly relevant. Preoperative screening is essential to identify the child who can undergo the procedure safely. Case Description. A 11-year-old female patient presented with a tumour in her right motor cortex, presumed to be a dysembryoplastic neuroepithelial tumour (DNET). We had concerns regarding the feasibility of performing awake surgery in this patient as psychological testing revealed easy distractibility and an inability to follow commands repetitively. We devised a simulated surgical experience to assess her ability to manage such a procedure. During the simulated theatre experience, attempts were made to replicate the actual theatre experience as closely as possible. The patient was dressed in theatre attire and brought into the theatre on a theatre trolley. She was then transferred onto the theatre bed and positioned in the same manner as she would be for the actual surgery. Her head was placed on a horseshoe headrest, and she was made to lie in a semilateral position, as required for the surgery. A blood pressure cuff, pulse oximeter, nasal cannula with oxygen flow, and calf pumps were applied. She was then draped precisely as she would have been for the procedure. Theatre lighting was set as it would be for the surgical case. The application of the monitoring devices, nasal cannula, and draping was meant not only to prepare her for the procedure but to induce a mild degree of stress such that we could assess the child’s coping skills and ability to undergo the procedure. The child performed well throughout the simulated run, and surgery was thus offered. An asleep-awake-asleep technique was planned and employed for surgical removal of the tumour. Cortical and subcortical mapping was used to identify the eloquent tissue. Throughout the procedure, the child was cooperative and anxiety free. Follow-up MRI revealed gross total removal of the lesion. Conclusion. A simulated theatre experience allowed us to accurately determine that this young patient, despite relative contraindications, was indeed eligible for awake surgery. We will continue to use this technique for all our young patients in assessing their eligibility for these procedures.

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Awake surgery for hemispheric low-grade gliomas: oncological, functional and methodological differences between pediatric and adult populations

Abstract: Therefore, even though awake procedure with cortical and axonal stimulation mapping can be adapted in a specific subgroup of children with a diffuse glioma from the age of 10 years, only few pediatric patients are nonetheless candidates for awake brain surgery.

Cited by 26 publications

References 205 publications

Feasibility of awake craniotomy in the pediatric population

Feasibility of awake craniotomy in the pediatric population

Technical Considerations in Awake Craniotomy with Cortical and Subcortical Motor Mapping in Preadolescents: Pushing the Envelope

Awake Craniotomy in a Child: Assessment of Eligibility with a Simulated Theatre Experience

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