Feasibility of awake craniotomy in the pediatric population

Abstract

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.

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

“…Due to these neurophysiological challenges, neurofunctional mapping in preadolescents must be supported by neuronavigation guidance and awake surgery to enhance the strength of IONM for maximal safe resection of such gliomas in preadolescents [30]. As noted in our series, the Toronto series also clearly establishes the feasibility of awake mapping, with cortical mapping successfully completed in 28 of 29 cases [14].…”

“…In the last 65 years, there have been only 9 cases of awake anesthesia in preadolescent age-group. Of these, 5 were from the Toronto group alone, which published the largest data on pediatric AA earlier this year (Table 1) [9, 14]. Of these 9 cases, 7 were supratentorial lesions, while the other 2 were deep brain stimulation [20].…”

“…Of these 9 cases, 7 were supratentorial lesions, while the other 2 were deep brain stimulation [20]. Even in the adolescent age-group (11–19 years), presumed to be psychologically and intellectually more matured, AA has been successfully attempted in a total of 49 patients [9, 14].…”

“…Lohkamp et al [9] reported that of the 50 cases in literature, 96% tolerated A-A-A well with only 2 cases requiring conversion to GA. All 3 preadolescents successfully tolerated awake mapping. The Toronto series used the A-A-A approach and only one out of the 29 cases needed GA while 1 patient was managed entirely under CS [14]. As our institution protocol for adult awake surgery is CS, we extrapolated the same successfully on pediatric cases without any complications [34].…”

“…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]. "The Global Burden of Disease Study 2016," illustrated that the preadolescents (less than 11 years) should be considered a separate cohort due to their special requirements, wherein CNS neoplasm related mortality has remained unchanged for the last 30 years [1].…”