Awake surgery for glioma

Awake surgery for glioma

Craniotomies for glioma surgery under conscious sedation (CS) have been well-documented in the literature for glioma surgery that are in or adjacent to eloquent area1) 2) 3) 4) 5).

Awake surgery for glioma aims to maximize resection to optimize prognosis while minimizing the risk of postoperative deficits.

The oncological and functional results of awake glioma surgery during the learning curve are comparable to results from established centers. The use and utility of resection probability maps are well demonstrated. The return to work level is high 6).

AC with the input of the speech and language therapist (SLT) and an experienced neuro-physiotherapist (NP) is a key component in ensuring optimal functional outcomes for patients with gliomas in eloquently located areas 7).

5 aminolevulinic acid guidance during awake craniotomy

Awake surgery for insular glioma

To determine the benefit of awake craniotomy for language, motor, and neurological functions, as well as other clinical outcomes, Bu et al. searched Medline, Embase, the Cochrane Library, and the Chinese Biomedical Literature Database up to December 2019. Gray literature was also searched. They included randomized and non-randomized controlled studies comparing awake craniotomy versus general anesthetic resection and reporting the language and neurological outcomes. Ten studies with 833 patients were included in the meta-analysis. The pooled risk ratio (RR) suggested no significant differences in language and neurological outcomes between the general anesthesia group and the awake craniotomy group without electrical stimulation. Awake craniotomy with electrical stimulation, however, was associated with improved late language and neurological outcomes (≥ 3 months) versus general anesthesia with pooled RR of 0.44 (95% CI = 0.20-0.96) and 0.49 (95% CI = 0.30-0.79), respectively. Awake craniotomy with electrical stimulation was also associated with a better extent of resection with the pooled RR of 0.81 (95%CI = 0.71-0.92) and shorter hospital stay duration with the pooled weighted mean difference (WMD) of – 1.14 (95%CI = – 1.80 to – 0.48). This meta-analysis suggested that the application of awake craniotomy with electrical stimulation during glioma resection is associated with lower risks of long-term neurological and language deficits and higher extent of tumor resection, as well as shorter hospital stay duration 8).

Mandonnet et al. reported a case series of four patients operated on for a glioma in awake conditions and in whom task-based functional magnetic resonance imaging (fMRI) demonstrated right-dominant activity during a language production task. Language functional sites were identified intraoperatively by Electrostimulations only in the patient with a right-sided lesion. Furthermore, the pre- or postoperative cognitive evaluations in the three patients operated on for a left-sided glioma revealed right spatial neglect and dysexecutive syndrome, hence demonstrating that, in patients with right-dominant activity on language fMRI, the left hemisphere is implicated in spatial consciousness and cognitive control. This study supports the interest of presurgical task-based language fMRI to identify patients with a reversed lateralization of cognitive functions and to make an adequate selection of the battery of intraoperative cognitive tasks to be monitored in those rare outliers 9).

Corns et al. describe the case of a patient with recurrent left frontal GBM encroaching on Broca’s area (eloquent brain). Gross total resection of the tumour was achieved by combining two techniques, awake resection to prevent damage to eloquent brain and 5-ALA fluorescence guidance to maximise the extent of tumour resection.This technique led to gross total resection of all T1-enhancing tumour with the avoidance of neurological deficit. The authors recommend this technique in patients when awake surgery can be tolerated and gross total resection is the aim of surgery 10).


Bejjani GK, Nora PC, Vera PL, Broemling L, Sekhar LN. The predictive value of intraoperative somatosensory evoked potential monitoring: Review of 244 procedures. Neurosurgery 1998;43:491-8.

De Benedictis A, Mortiz-Gasser S, Duffau H. Awake mapping optimizes the extent of resection for low-grade gliomas in eloquent areas. Neurosurgery 2010;66:1074-84.

Peruzzi P, Bergese SD, Viloria A, Puente EG, Abdel-Rasoul M, Chiocca EA. A retrospective cohort-matched comparison of conscious sedation versus general anesthesia for supratentorial glioma resection. Clinical article. J Neurosurg 2011;114:633-9.

Taylor MD, Bernstein M. Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: A prospective trial of 200 cases. J Neurosurg 1999;90:35-41.

Wiedemayer H, Sandalcioglu IE, Armbruster W, Regel J, Schaefer H, Stolke D. False negative findings in intraoperative SEP monitoring: Analysis of 658 consecutive neurosurgical cases and review of published reports. J Neurol Neurosurg Psychiatry 2004;75:280-6.

Mandonnet E, De Witt Hamer P, Poisson I, Whittle I, Bernat AL, Bresson D, Madadaki C, Bouazza S, Ursu R, Carpentier AF, George B, Froelich S. Initial experience using awake surgery for glioma: oncological, functional, and employment outcomes in a consecutive series of 25 cases. Neurosurgery. 2015 Apr;76(4):382-9. doi: 10.1227/NEU.0000000000000644. PubMed PMID: 25621981.

Trimble G, McStravick C, Farling P, Megaw K, McKinstry S, Smyth G, Law G, Courtney H, Quigley G, Flannery T. Awake craniotomy for glioma resection: Technical aspects and initial results in a single institution. Br J Neurosurg. 2015 Jul 13:1-7. [Epub ahead of print] PubMed PMID: 26168299.

Bu LH, Zhang J, Lu JF, Wu JS. Glioma surgery with awake language mapping versus generalized anesthesia: a systematic review. Neurosurg Rev. 2020 Oct 21. doi: 10.1007/s10143-020-01418-9. Epub ahead of print. PMID: 33089447.

Mandonnet E, Mellerio C, Barberis M, Poisson I, Jansma JM, Rutten GJ. When Right Is on the Left (and Vice Versa): A Case Series of Glioma Patients with Reversed Lateralization of Cognitive Functions. J Neurol Surg A Cent Eur Neurosurg. 2020 Feb 17. doi: 10.1055/s-0040-1701625. [Epub ahead of print] PubMed PMID: 32066189.

Corns R, Mukherjee S, Johansen A, Sivakumar G. 5-aminolevulinic acid guidance during awake craniotomy to maximise extent of safe resection of glioblastoma multiforme. BMJ Case Rep. 2015 Jul 15;2015. pii: bcr2014208575. doi: 10.1136/bcr-2014-208575. PubMed PMID: 26177997.

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