Seguridad y tolerabilidad de la craneotomía vigíl para tumores cerebrales y otras lesiones supratentoriales / Safety and Tolerability of Vigil Craniotomy for Brain Tumors and Other Supratentorial Lesions

Objetivos: describir la seguridad y tolerabilidad de craneotomía vigíl en la resección de lesiones supratentoriales. Introducción: La craneotomía vigíl es útil para poder remover tumores cercanos, o en áreas elocuentes con seguridad; potencialmente reduce complicaciones, al igual que costos y estancia intrahospitalaria. Material y métodos: Se revisaron los registros desde enero del 2007 a julio del 2018. En el caso de los pacientes con gliomas o tumores intraaxiales se analizó déficit neurológico en base a áreas de elocuencia antes y después del procedimiento, y su recuperabilidad a los 30 días, al igual que volumen de resección. Resultados: Se intentaron 218 craneotomías vigiles, 213 (98.1%) se realizaron con éxito. La edad media fue de 64 años (8-92), 117 (54.9%) hombres, 96 (45%) mujeres. La cantidad de pacientes con lesiones tumorales fueron 171 (80%), las lesiones no tumorales fueron 42 (20%). El volumen de resección en área elocuente fue 73%, cercano a elocuencia 94% y no elocuente 100%. El empeoramiento neurológico ocurrió en el 30%, 16%, 2%, con recuperabilidad a los 30 días en comparación al déficit preoperatorio del 24%, 75% y 100% por área respectivamente. Las convulsiones se presentaron en 11 pacientes (5.1%). La mortalidad previa al alta fue de un paciente (0.5%), complicaciones cardiacas o pulmonares que requirieron intubación posterior a la cirugía fue cero. Conclusión: La técnica de craneotomía vigíl ha mostrado ser segura y tolerable en la mayoría de los pacientes, ha evitado las complicaciones pulmonares en el postoperatorio, posee una baja mortalidad y ha mostrado ser importante para la resección de tumores en áreas elocuentes.

Introduction: Awake craniotomy is a useful technique for removing tumors in or near eloquent cortex, potentially reducing systemic complications, monetary costs and hospital stays. Objective: To describe the security and tolerability profiles of awake craniotomies to resect supratentorial lesions. Methods: Registries from January 2007 to July 2018 were analyzed. In patients with intra-axial tumors, neurological deficits corresponding to areas of eloquent cortex were recorded before and after surgery, as were levels of improvement 30 days post-operatively, and the volume of resection. Results: Over that time period, 218 awake craniotomies were attempted, among which 213 (98.1%) were successfully completed. Mean age was 64 (8-92) years, and there were 117 (54.9%) males, 96 (45%) females. One hundred seventy-one patients had a tumor 171 (80%); 42 (20%) some other disease. The volume of resection based on eloquent cortex was 73%, near-eloquent 94% and non-eloquent 100%. Neurological worsening after surgery was 30%, 16%, 2%, with a resolution of preoperative deficits at 30 days in 24%, 75% and 100% of the patients, respectively, by anatomical area. During surgery, seizures occurred in 11 patients (5.1%). One patient (0.5%) died prior to discharge, but no systemic complications arose that required post-operative mechanical ventilation. Conclusions: Awake craniotomy appears to be a safe and well-tolerated procedure in the majority of patients. In our study, it completely avoided pulmonary complications, had a very low mortality rate, and proved to be useful for removing tumors in eloquent cortex.

Awake craniotomy - for management of intracranial lesions safely in eloquent areas of brain.

The awake craniotomy is a procedure where the craniotomy and excision of the lesion is done in awake patient without general anaesthesia. This surgical technique enable surgeons to avoid damaging normal cerebral regions and allow real-time patient feedback while operating on important functional areas of brain like motor cortex and speech areas (motor, somatosensory, and language areas). Such surgical interventions would not be possible without anesthesia. This technique was originally introduced for the surgical treatment of epilepsy and has subsequently been used in patients undergoing surgical management of supratentorial tumours, deep brain stimulation and near critical brain regions. This surgical approach aims to maximize lesion resection while sparing important areas of the brain.

Cortical stimulation of language fields under local anesthesia: optimizing removal of brain lesions adjacent to speech areas / Mapeamento cortical da fala com o paciente acordado: optimização para ressecção de lesões intracranianas localizadas próximas a área da fala

OBJECTIVE: The main objective when resecting benign brain lesions is to minimize risk of postoperative neurological deficits. We have assessed the safety and effectiveness of craniotomy under local anesthesia and monitored conscious sedation for the resection of lesions involving eloquent language cortex. METHODS: A retrospective review was performed on a consecutive series of 12 patients who underwent craniotomy under local anesthesia between 2001 and 2004. All patients had lesions close to the speech cortex. All resection was verified by post-operative imaging. Six subjects were male and 6 female, and were aged between 14 and 52 years. RESULTS: Lesions comprised 7 tumour lesions, 3 cavernomas and 1 dermoid cyst. Radiological gross total resection was achieved in 66 percent of patients while remaining cases had greater than 80 percent resection. Only one patient had a post-operative permanent deficit, whilst another had a transient post-operative deficit. All patients with uncontrollable epilepsy had good outcomes after surgery. None of our cases subsequently needed to be put under general anesthesia. CONCLUSION: Awake craniotomy with brain mapping is a safe technique and the "gold standard" for resection of lesions involving language areas.

OBJETIVO: O presente estudo visa discutir as vantagens e as limitacões do uso da técnica de mapeamento cortical da área da fala com o paciente acordado. MÉTODO: esta é uma revisão retrospectiva dos casos em que foi realizado monitoramento cortical intraoperatório em cirurgias para ressecção de lesões intracranianas localizadas próximas à área da fala. Todos os pacientes foram submetidos a avaliação neuropsicológica no pré e intra-operatório. O grau das ressecções foi verificado através de exames de imagem pós-operatórios. Foram avaliados um total de 12 pacientes. Destes, 6 eram do sexo masculino e 6 do feminino. RESULTADOS: 7 lesões eram tumorais. A ressecção total foi atingida em 66 por cento e ressecção subtotal nos remanescentes. Apenas 1 paciente apresentou déficit motor permanente no pós-operatório e todos os pacientes com quadro prévio de epilepsia refratária obtiveram bom controle das crises no pós-operatório. Em nenhum caso houve necessidade de conversão da anestesia para geral. CONCLUSÃO: O mapeamento funcional intraoperatório na craniotomia com o paciente acordado otimiza a extensão da ressecção da lesão minimizando morbidade permanente. Esta é uma técnica eficaz no manejo de lesões em íntimo contato com o córtex eloqüente, que outrora, seriam designadas inoperáveis.

Mapeo cortical que muestra el efecto de las encefalinas en un foco epiléptico

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Abstract: Introduction. Epileptic activity modifies the endogenous opioid system by increasing its levels at the end of the ictal phase, and in post-ictal and interictal phases. This increase originates a cortical excitatory effect which suppresses both slow wave sleep and REM. The epileptic activity is initiated with the presence of interictal epileptiform activity, which may be induced through penicillin administration into amygdaline nuclei. Interictal epileptiform activity is a widely employed tool used to determine the localization of epileptic foci characterized by the sudden presence of spikes or acute waves in an electroencephalogram (EEG). In the present work, this tool was used to study the participation of the opioid system in the installation and propagation of epileptic activity induced in temporal lobe amygdala. In the epiloptogenetic study, amygdaline interictal epileptiform activity was used to assess changes induced by opioids and an antagonist in the occurrence of interictal activity using an event histogram. Propagation was studied with the cortical topographic mapping technique, which shows EEG frequency components in a power spectrum, as well as the rhythmic EEG patterns. The aim of the present study was to analyze the effect of enkephalins on epileptiform activity induced with penicillin in tem poral lobe amygdala and its propagation to the cerebral cortex. Method. Fifteen male Wistar rats were submitted to an acute preparation; they were anesthetized with urethane (1.2 g/kg, i.p.). A stainless steel bipolar electrode provided with a cannula was directed toward the left amygdaline basolateral nucleus and a second concentric bipolar electrode to the right amygdaline basolateral nucleus. Two types of cortical recordings were carried out: global mapping and restricted areas. The first consisted of the placement of a 16 stainless steel electrode matrix (in which the electrodes from the vertex were removed) on the scalp, taking care that the tips of the electrodes were in contact with the cortex; this arrangement covered the whole cerebral cortex. The second involved a 4x4mm square matrix consisting of 16 equidistant electrodes placed on the cerebral cortex. The cortical recording was a result of placing this matrix in four different positions so that the whole cerebral cortex was monitored. To monitor cortical recordings, experimental groups were injected penicillin into the amygdaline nuclei. To perform global mapping, enkephalins, [D-ala]-methionine and [D-ala]-leucine, were topically applied into the amygdaline nuclei and naloxone was administered systemically. Analogical signals were recorded in a video-tape and were digitized in parallel with an HP workstation. Off-line analysis was carried as follows: a) information recorded in video-tapes was acquired in a computer designed for this purpose, using amygdaline interictal epileptiform activity to plot event histograms; b) EEG digitized signal, obtained from global mapping, was used to obtain a spectral analysis, consisting of color images maps in time and frequency domains, using RBEAM software. The recording of electrical activity obtained with the square matrix was visually analyzed only. At the end of each experiment, animals were perfused and each brain was fixed intracardially with 10% formaldehyde. To verify the recording and sub-cortical injection sites, the rapid procedure was used. Results. During control stages, cortical records showed slow activity in the form of spindles in all the recording channels; this was due to urethane. Penicillin administration in amygdaline nuclei induced epileptiform activity with a specific pattern: immediate appearance after penicillin application with a gradual increase in amplitude until stabilization was reached within 5-10 minutes of administration. Analyses of global mapping in the frequency domain showed a specific mode of amygdaline interictal epileptiform activity propagation, starting in ipsilateral temporal, prefrontal and fron tal cortices, appearing subsequently in contralateral prefrontal and frontal cortices, and finally in temporal cortex. In the time domain spectrum, an electric dipole generating an interictal spike was found in cerebral cortex. Restricted areas mapping approach showed interictal epileptiform activity and its propagation along the ipsilateral fronto-temporal region. Data revealed an antero-posterior medial cortical activation spreading with decreasing intensity toward occipital regions. Application of enkephalins-[D-ala]-methionine and [D-ala]-leucine produced no epileptic activity, but an increase in basal EEG of cortical epileptiform activity was detected, as well as a decrease in amplitude and frequency of amygdaline epileptiform activity. Naloxone originated a facilitatory effect, since its administration induced focal and generalized electrocorticographic seizures. Conclusions. Focal penicillin is a reliable model of interictal spikes, paroxysms and generalized seizures. The study in rats showed a propagation of epileptic activity to prefrontal cortices prior to contralateral amygdala. Our results showed that enkephalins produced a double effect. First, they originated an increase in basal EEG in temporal cortical areas, as well as a putative participation in propagation mechanisms. Second, they exerted an inhibitory effect on epilepsy installation mechanisms. The inhibitory effect originated by enkephalins was reverted by naloxone.