Minimally Invasive Awake Craniotomy using Steiner-Lindquist Stereotactic Laser Guidance

Abstract

Introduction: Awake craniotomy permits the continuous assessment of intraoperative neurological functions. In addition, stereotactic laser guidance aids in performing minimally invasive procedures related to the radical resection of lesions located in eloquent and non-eloquent brain regions.

Methods: Between May 2000 and October 2006, 117 consecutive patients with various intracranial tumoral lesions underwent 141 resection procedures. The eloquent areas were determined with the aid of anatomic landmarks and/or functional MRI (fMRI) examinations. The resection of the lesions was performed under continuous neurological examination. In all cases, postoperative MRI was performed within 24–72 h.

Results: Seventy-seven males and 40 females were included in this study. The mean age of the patients was 52.0±12.6 years. Most of the lesions were located within the parietal lobe. Of the lesions, 33 (23.4%) were located within the cortex, whereas 108 (76.5%) were subcortical. The most common pathologies were metastasis (70 cases) and glioblastome multiforme (27 cases). In 20 (14.2%) of the patients, fMRI was performed preoperatively. Of 21 patients with multiple lesions, 18 underwent 2 craniotomies and 3 underwent 3 craniotomies. The mean operation time was 72±0.3 min, and the mean hospital stay was 3.26±1.82 d. The average lesion size was 11.92±15.26 cm³. In 7 cases (4.9%), the surgery caused either new neurological deficits or a worsening of the existing deficits; these deficits were permanent in 2 (1.4%) cases. One patient (0.7%) died due to the development of postoperative intracerebral hemorrhage.

Conclusions: Awake craniotomy with the aid of stereotactic laser guidance is a safe procedure that assists in performing minimally invasive resection of lesions in eloquent and non-eloquent brain regions. Although direct intraoperative stimulation was not performed, detection of the functioning areas of the brain with fMRI decreased additional postoperative neurological deficits. Overall, this method decreased the operation time and hospital stay.

stereotactic surgery - awake craniotomy - cerebral tumors - cerebral metastasis

References

• 1 Ammirati M, Vick N, Liao YL. et al . Effect of the extent of surgical resection on survival and quality of life in patients with supratentorial glioblastomas and anaplastic astrocytomas.  Neurosurgery. 1987;  21 201-206
• 2 Keles GE, Anderson B, Berger MS. The effects of extent of resection on time to tumor progression and survival in patients with glioblastome multiforme of the cerebral hemisphere.  Surg Neurol. 1999;  52 371-379
• 3 Meyer FB, Bates LM, Georss SJ. et al . Awake craniotomy for aggressive resection of primary gliomas located in eloquent brain.  Mayo Clin Proc. 2001;  76 677-687
• 4 Jaaskelainen J. Awake craniotomy in glioma surgery.  Acta Neurochir Suppl. 2003;  88 31-35
• 5 Sarang A, Dinsmore J. Anaesthesia for awake craniotomy-evolution of a technique that facilitates awake neurosurgical testing.  Survey Anesthesiol. 2003;  47 324-325
• 6 Blanshard HJ, Chung F, Manninen PH. et al . Awake craniotomy for removal of intracranial tumor: considerations for early discharge.  Anesth Analg. 2001;  92 89-94
• 7 Serletis D, Bernstein M. Prospective study of awake craniotomy used routinely and nonselectively for supratentorial tumors.  J Neurosurg. 2007;  107 1-6
• 8 Kurimoto M, Hayashi N, Kamiyama H. et al . Impact of neuronavigation and image-guided extensive resection for adult patients with supratentorial malignant astrocytomas: a single-institution retrospective study.  Minim Invas Neurosurg. 2004;  47 278-283
• 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
• 10 Bekar A, Korfalıç E, Çalışır B. et al . Minimally invasive craniotomy using the Steiner-Lindquist stereotaxic guide.  Minim Invas Neurosurg. 2001;  44 13-16
• 11 Steiner L, Lindquist C. A stereotactic guide for microneurosurgery: technical note.  Acta Neurochir (Wien). 1994;  129 82-84
• 12 Mathiesen T, Lindquist C, Kihlström L. Microsurgery with the Steiner-Lindquist stereotaxic guide.  Br J Neurosurg. 1996;  10 155-160
• 13 Bernstein M. Outpatient craniotomy for brain tumor: a pilot feasibility study in 46 patients.  Can J Neurol Sci. 2001;  28 120-124
• 14 Muragaki Y, Iseki H, Maruyama T. et al . Usefulness of intraoperative magnetic resonance imaging for glioma surgery.  Acta Neurochir Suppl. 2006;  98 67-75
• 15 Işlekel S. Keyhole tumor removal under local anesthesia.  J Neurol Sci [Turk]. 2006;  23 108-115
• 16 Whittle IR, Borthwick S, Haq N. Brain dysfunction following ‘awake’ craniotomy, brain mapping, and resection of glioma.  Br J Neurosurg. 2003;  17 130-137
• 17 Costello TG, Cormack JR. Anaesthesia for awake craniotomy: a modern approach.  J Clin Neurosci. 2004;  11 19
• 18 Shinoura N, Yamada R, Kodama T. et al . Preoperative fMRI, tractography and continuous task during awake surgery for maintenance of motor function following surgical resection of metastatic tumor spread to the primary motor area.  Minim Invas Neurosurg. 2005;  48 85-90
• 19 Ganslandt O, Steinmeier R, Kober H. et al . Magnetic source imaging combined with image guided frameless stereotaxy: A new method in surgery around the motor strip.  Neurosurgery. 1997;  41 621-627
• 20 Puce A, Constable RT, Luby ML. et al . Functional magnetic resonance imaging of sensory and motor cortex: Comparison with electrophysiological localization.  J Neurosurg. 1995;  83 262-270
• 21 Yetkin FZ, Mueller WM, Morris GL. et al . Functional MR activation correlated with intraoperative cortical mapping.  Am J Neuroradiol. 1997;  18 1311-1315
• 22 Ebeling U, Schmid UD, Ying H. et al . Safe surgery of lesions near the motor cortex using intra-operative mapping techniques: A report on 50 patients.  Acta Neurochir (Wien). 1992;  119 23-28
• 23 Ulmer JL, Hacein-Bey L, Mathews VP. et al . Lesion-induced pseudo-dominance at functional magnetic resonance imaging: Implications for preoperative assessments.  Neurosurgery. 2004;  55 569-579
• 24 Roux FE, Boetto S, Sacko O. et al . Writing, calculating, and finger recognition in the region of the angular gyrus: a cortical stimulation study of Gersmann syndrome.  J Neurosurg. 2003;  99 716-727
• 25 Kral T, Kurthen M, Schramm J. et al . Stimulation mapping via implanted grid electrodes prior to surgery for gliomas in highly eloquent cortex.  Neurosurgery. 2006;  58 36-43

Correspondence