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Challenges in Awake Craniotomy for Intrinsic Brain Tumors in Eloquent Cortex

Debabrata Mukhopadhyay1 , Asha Bakshi2 , A S Mathani2 , A K Verma2 and Anil Gurnani2

Journal Title:Medical & Clinical Research

Introduction: Surgical treatment of brain tumors in the eloquent areas has high risk of functional impairment like speech or motor. These tumors represent a unique challenge as most of the patients have a higher risk of treatment related complications. A wake craniotomy is a useful surgical approach to help to identify and preserve functional areas in the brain and maximizes tumor removal and minimizes complications. Methods: Selected patients admitted with intrinsic brain tumor between from July, 2011 to August, 2016 in the eloquent area of brain like speech or motor area were chosen for awake craniotomy. A retrospective analysis was done. A preoperative assessment was also done. These patients were presented with seizure and or progressive neurological deficit like speech or motor. A standard anesthesia monitoring was done during surgery. Long acting local anesthesia (Bupivacaine) was used for scalp block. The surgeries were performed in a state of asleep-awake-asleep pattern, keeping the patients fully awake during tumor removal. Propofol and Fentanyl was used as anesthetic agents which was completely withdrawn prior to tumor removal. The speech and motor functions were closely monitored clinically by verbal commands during tumor resection. No brain mapping was performed due to lack of resources. All patients underwent noncontrast computed tomogram head in the first post-operative day. Results: A total of 35 patients were included in the study. The oldest patient was 55 years and youngest being 24 years (mean 36 years). 20 (57.14 %) were females and 15(42.85 %) males. 20 (57.14%) patients presented with predominantly seizure disorders and rest with progressive neurological deficit like speech or motor. 30 (85.71%) patients were discharged on second post-operative day. Complications were encountered in 4 (11.42 %) patients who developed brain swelling intraoperatively and 5(14.28 %) deteriorated neurologically in the immediate post-operative period however managed successfully and discharged in a week’s time. 5(14.28%) patients require ICU/ HDU care for different reasons. There was no mortality during the hospital stay. Histopathology revealed 25 (71.42 %) patients as low grade glioma, 8 (22.85%) as high grade glioma and 2 (5.71%) of them were metastases. Conclusion: A wake Craniotomy is a safe surgical management for intrinsic brain tumors in the eloquent cortex although surgery and anesthesia is a challenge. It offers great advantage towards disease outcome. However long follow up and more studies are required.