Awake surgery in pediatric patient

Awake surgery in pediatric patient

Awake brain surgery (ABS) in children remains a subject of controversial debate for the potential psychological limitations that are related to this type of procedure. However, the tolerance and benefits of ABS in adults advocate for increased application of ABS in children.

Literature review

literature review was performed using the MEDLINE(PubMed) electronic database applying the following MeSHterms to the keyword search within titles and abstracts: “awake brain surgery children,” “awake brain surgery pediatric,” “awake craniotomy children,” “awake craniotomy pediatric,” and “awake surgery children.” Of the initial 753 results obtained from these keyword searches, a full text screening of 51 publications was performed, ultimately resulting in 18 eligible articles for this review.

A total of 18 full-text articles reporting the results of 50 patients were included in the analysis. Sixteen of the 18 studies were retrospective studies, comprising 7 case series, 9 case reports, and 2 reviews. Eleven studies were conducted from anesthesiological (25 patients) and 7 from neurosurgical (25 patients) departments. Most of the patients underwent ABS for supratentorial lesions (26 patients), followed by epilepsy surgery (16 patients) and deep brain stimulation (DBS) (8 patients). The median age was 15 years (range 8-17 years). Persistent deficits occurred in 6 patients, (12%), corresponding to minor motor palsies (4%) and neuropsychological concerns (8%). An awake procedure was aborted in 2 patients (4%) due to cooperation failure and anxiety, respectively.

Despite well-documented beneficial aspects, ABS remains mainly limited to adults. This review confirms a reliable tolerability of ABS in selected children; however, recommendations and guidelines for its standardized implementation in this patient group are pending. Recommendations and guidelines may address diagnostic workup and intra-operative handling besides criteria of eligibility, psychological preparation, and coordinated neuropsychological testing in order to routinely offer ABS to children 1).

Case series

Huguet et al., reported the psychological assessment, evaluation algorithm, and outcome of pediatric patients, who underwent ABS for surgical treatment of lesions in eloquent areas. Psychological selection criteria and the specifications of psychological support are described. A retrospective review and analysis of psychological assessment and psychological outcome of pediatric patients, who underwent ABS between 2005 and 2018 at the Department of pediatric neurosurgery, of Hôpital Femme Mère Enfant, was performed. Long-term psychological outcomes are reported. ABS was proposed to 18 children aged between 9 and 17 years and their families. After psychological evaluation of the individual patient and their familial surrounding, five boys and 12 girls (n = 17) were accounted eligible for ABS. They underwent asleep-awake-asleep brain surgery with intraoperative testing. In 16 cases, ABS could be performed as planned. Psychological alterations were postoperatively observed in 3 patients, symptoms of a post-traumatic stress disorder in 1 patient. The precise preoperative evaluation of the risk-benefit ratio in children plays a crucial role in anticipating a good psychological outcome. Professional psychological preparation and support of the child and his or her family are the key elements for successful completion of ABS 2).


Balogun et al., from The Hospital for Sick Children, reported the experience of awake craniotomy and cortical stimulation for epilepsy and supratentorial tumors located in and around eloquent areas in a pediatric population (n=10, five females). The presenting symptom was mainly seizures and all children had normal neurological examinations. Neuroimaging showed lesions in the left opercular (n=4) and precentral or peri-sylvian regions (n=6). Three right-sided and seven left-sided awake craniotomies were performed. Two patients had a history of prior craniotomy. All patients had intra-operative mapping for either speech or motor or both using cortical stimulation. The surgical goal for tumor patients was gross total resection, while for all epilepsy procedures, focal cortical resections were completed without any difficulty. None of the patients had permanent post-operative neurologic deficits. The patient with an epileptic focus over the speech area in the left frontal lobe had a mild word finding difficulty post-operatively but this improved progressively. Follow-up ranged from 6 to 27 months. Pediatric awake craniotomy with intra-operative mapping is a precise, safe and reliable method allowing for resection of lesions in eloquent areas. Further validations on larger number of patients will be needed to verify the utility of this technique in the pediatric population 3).


Ard et al., presented the experience with the use of dexmedetomidine, an alpha2 agonist, in two children undergoing awake craniotomy. General anesthesia with the laryngeal mask airway was used for parts of the procedure not requiring patient cooperation to reduce the duration of wakefulness and abolish the discomfort of surgical stimulation. Dexmedetomidine was used as a primary anesthetic for brain mapping of the cortical speech area. The asleep-awake-sleep technique provided adequate sedation and analgesia throughout the surgery and allowed the patient to complete the necessary neuropsychological tests. This is the first description of the use of dexmedetomidine in pediatric neurosurgery 4).

References

1)

Lohkamp LN, Mottolese C, Szathmari A, Huguet L, Beuriat PA, Christofori I, Desmurget M, Di Rocco F. Awake brain surgery in children-review of the literature and state-of-the-art. Childs Nerv Syst. 2019 Aug 3. doi: 10.1007/s00381-019-04279-w. [Epub ahead of print] Review. PubMed PMID: 31377911.
2)

Huguet L, Lohkamp LN, Beuriat PA, Desmurget M, Bapteste L, Szathmari A, Mottolese C, Di Rocco F. Psychological aspects of awake brain surgery in children-interests and risks. Childs Nerv Syst. 2019 Jul 27. doi: 10.1007/s00381-019-04308-8. [Epub ahead of print] PubMed PMID: 31352575.
3)

Balogun JA, Khan OH, Taylor M, Dirks P, Der T, Carter Snead Iii O, Weiss S, Ochi A, Drake J, Rutka JT. Pediatric awake craniotomy and intra-operative stimulation mapping. J Clin Neurosci. 2014 Nov;21(11):1891-4. doi: 10.1016/j.jocn.2014.07.013. Epub 2014 Oct 1. PubMed PMID: 25282393.
4)

Ard J, Doyle W, Bekker A. Awake craniotomy with dexmedetomidine in pediatric patients. J Neurosurg Anesthesiol. 2003 Jul;15(3):263-6. PubMed PMID: 12826975.

Pediatric intracranial epidural hematoma outcome

Pediatric intracranial epidural hematoma outcome

Regardless of the intracranial epidural hematoma size, the clinical status of the patients, the abnormal pupillary findings, or the cause of injury, the outcome and prognosis of the pediatric intracranial epidural hematoma are excellent 1).

Mortality can be significantly reduced with gratifying results if operated early. Best motor response at presentation, pupillary abnormalities, time between injury to surgery, and location of hematoma have been identified as the important factors determining outcome in patients of EDH2) 3) 4) 5).

Binder et al., found that immediate as well as delayed surgical evacuation of EDH resulted in excellent outcomes in most cases. Conservative treatment was started in 76% of our cases – however needing in 35% delayed surgical intervention. Overall in all groups excellent final clinical and neurological outcomes could be reached 6).

Of all laboratory data obtained on admission, the blood potassiumpH and glucose test results correlated significantly with prognosis. Prognosis can be adequately and expeditiously estimated by selected markers within a comprehensive evaluation of children with AEH 7).

References

1)

Gerlach R, Dittrich S, Schneider W, Ackermann H, Seifert V, Kieslich M. Traumatic epidural hematomas in children and adolescents: outcome analysis in 39 consecutive unselected cases. Pediatr Emerg Care. 2009 Mar;25(3):164-9. doi: 10.1097/PEC.0b013e31819a8966. PubMed PMID: 19262419.
2)

Faheem M, Jaiswal M, Ojha BK, Chandra A, Singh SK, Srivastava C. Traumatic Pediatric Extradural Hematoma: An Institutional Study of 228 Patients in Tertiary Care Center. Pediatr Neurosurg. 2019 Jul 9:1-8. doi: 10.1159/000501043. [Epub ahead of print] PubMed PMID: 31288223.
3)

Umerani MS, Abbas A, Aziz F, Shahid R, Ali F, Rizvi RK. Pediatric Extradural Hematoma: Clinical Assessment Using King’s Outcome Scale for Childhood Head Injury. Asian J Neurosurg. 2018 Jul-Sep;13(3):681-684. doi: 10.4103/ajns.AJNS_164_16. PubMed PMID: 30283526; PubMed Central PMCID: PMC6159040.
4)

Erşahin Y, Mutluer S, Güzelbag E. Extradural hematoma: analysis of 146 cases. Childs Nerv Syst. 1993 Apr;9(2):96-9. PubMed PMID: 8319240.
5)

Paşaoğlu A, Orhon C, Koç K, Selçuklu A, Akdemir H, Uzunoğlu H. Traumatic extradural haematomas in pediatric age group. Acta Neurochir (Wien). 1990;106(3-4):136-9. PubMed PMID: 2284988.
6)

Binder H, Majdan M, Tiefenboeck TM, Fochtmann A, Michel M, Hajdu S, Mauritz W, Leitgeb J. Management and outcome of traumatic epidural hematoma in 41 infants and children from a single center. Orthop Traumatol Surg Res. 2016 Oct;102(6):769-74. doi: 10.1016/j.otsr.2016.06.003. Epub 2016 Sep 9. PubMed PMID: 27622712.
7)

Ben Abraham R, Lahat E, Sheinman G, Feldman Z, Barzilai A, Harel R, Barzilay Z, Paret G. Metabolic and clinical markers of prognosis in the era of CT imaging in children with acute epidural hematomas. Pediatr Neurosurg. 2000 Aug;33(2):70-5. PubMed PMID: 11070432.

Pediatric Hydrocephalus

Pediatric Hydrocephalus

by Giuseppe Cinalli (Editor), M. Memet Özek (Editor), Christian Sainte-Rose (Editor)

Price: $569.05

Buy

Since the first edition of this book, the impressive development of neuroendoscopy has dramatically changed the surgical approach to hydrocephalus, the main pathology pediatric neurosurgeons worldwide have to deal with. This revised and updated second edition, written by worldwide leaders in the field, fully reflects this progress: not only existing chapters have been reviewed whenever required, but new ones have been added thus taking into consideration every aspect of hydrocephalus, even when associated with the rarest pathologies. The general part include now more data on history, biomechanics, circulation and molecular basis. Special consideration for fetal surgery has been added, whereas the section on neonatal hydrocephalus has been further developed. Section 4, on the different pathologies associated with hydrocephalus, has been significantly expanded. and is now amazingly detailed, as well as the section on shunt treatment. Infections are now dealt with in two different chapters, and special attention to shunt complications (the nightmare of every Pediatric Neurosurgeon.) is paid in five different chapters. A very complete overview of the endoscopic treatment, that will surely draw the reader’s attention thanks to the wonderful full color images, is also included. Written by acknowledged experts in the field, this title is an indispensable tool for all those facing this pathology in their daily practice.

WhatsApp WhatsApp us
%d bloggers like this: