Awake Craniotomy for low grade tumours in Eloquent Brain Areas

1. Awake Craniotomyfor low grade tumoursin Eloquent Brain Areas Mr H El-Maghraby & Mr S Joshi

2. Eloquent Brain Areas A history of cerebral localization The brain has been known to be the center of voluntary movement, sensation, and intelligence for centuries. Nevertheless, it was not until the latter third of the 19th century that the functions of its different areas were discovered. It was the labour of several key men that made possible the accurate localization and, furthermore, the resection of brain neoplasms.

3. Paul Pierre Broca (1861) In 1861, Pierre Paul Broca was confronted by a patient who could understand language but could not speak. An autopsy in this patient revealed a lesion in the posterior region of the frontal lobe, an area now called the Broca area. Broca�s keen observations led him to identify eight patients with similar lesions by 1864. Based on this he declared �Nous parlons avec �hemisphere gauche�!� (�We speak with our �left hemisphere�!�In 1861, Pierre Paul Broca was confronted by a patient who could understand language but could not speak. An autopsy in this patient revealed a lesion in the posterior region of the frontal lobe, an area now called the Broca area. Broca�s keen observations led him to identify eight patients with similar lesions by 1864. Based on this he declared �Nous parlons avec �hemisphere gauche�!� (�We speak with our �left hemisphere�!�

4. John Hughlings Jackson (1865) He had seen 500 patients with hemiplegia by 1865, and he was intrigued by the apparent sparing of some muscle function in these individuals. Early in his career, Jackson believed that all sensorimotor function was subcortical.He had seen 500 patients with hemiplegia by 1865, and he was intrigued by the apparent sparing of some muscle function in these individuals. Early in his career, Jackson believed that all sensorimotor function was subcortical.

5. Roberts Bartholow (1874) Patient whose brain surface had been exposed by ulcer. Cortical stimulation � motor & sensory disturbance in contralateral arm & leg

6. Carl Wernicke (1876)

7. David Ferrier 1876 Used Faradic current stimulation, for the cortical functioning of many different animals He constructed one of the first detailed cortical maps. Ferrier summarized his results in the 1876 publication of The Functions of the Brain

8. Sir William Macewon 1870 1st Brain Surgery for abscess Patient survived

9. Sir Rickman Godlee 1884 1st Brain surgery to remove a brain tumour Initially patient improved but died one month later from infection

10. Sir Victor Horsely 1886 Appointed in February 1886 as a neurosurgeon by excising an epileptic scar. By the end of the year, he had performed 10 cranial cases, with only one death

11. Wilder Penfield (1928)  - Initially applied cortical stimulation to epilepsy surgery & excision of cortical scars - Galvanic current to outline motor & sensory areas Proposed map of cerebral localisation remains in use today - Established Awake Craniotomy for epilepsy surgery

12. History of Awake Craniotomy

13. History of Awake Craniotomy Egyptian Medicine: Edwin Smith Papyrus (3000 BC) 45 cases of trephination

14. History of Awake Craniotomy 600 AD Lima, Peru Early Cranioplasty with a piece of Gold Well healed by the time of this patient�s death

15. History of Awake Craniotomy

16. Modern NeurosurgeryBrain tumours 1930 - 1970 Clinical cerebral localization Improvement of General Anaesthetic Tumour debulking Avoidance of eloquent brain areas surgery

17. CT Scan Brain 1970- 1980

18. MRI Brain 1980

19. High Grade Tumour

20. High Grade Tumour

21. MRI � Low Grade Tumours - 1990

22. Low Grade Tumour

23. Low Grade Tumour

24. Low Grade Brain Tumour - 1980 Younger patients Less symptomatic Possible longer survival (5-7 years) Tumour transformation to higher grade will happen

25. Low Grade Brain Tumour - 1980 Management options: Extensive discussions with patient & family Options: Expectant approach, regular surveillance scans Biopsy for tumours in eloquent areas Resection / Debulking for tumours away from eloquent areas Radiotherapy: delays time to potential transformation, but no change to life expectancy as can only be given once.

26. Low Grade Brain Tumour - 1980 Role of Surgery Surgical biopsy is recommended in almost all cases to establish the diagnosis When herniation threatens from large tumours Tumours causing obstruction to CSF flow Large tumours in non eloquent areas (Debulking/resection)

27. Low Grade Brain Tumour 1980 - 1990 No well-designed study has shown any approach for supratentorial low grade gliomas in adults to be clearly superior These tumours are slow growing � until progression on imaging or malignant degeneration is documented it may be no worse to not treat the patient Piepmeier, 1987 Medbery, 1988 Shaw 1989 Cairncross & Laperriere, 1989

28. Low Grade Brain Tumour 1980 - 1990 Large tumours in non eloquent areas, had debulking or resection There is a trend to suggest that complete surgical removal, when possible, is associated with a better prognosis Laws, 1984 Soffietti, 1989 North et al, 1990

29. Low Grade Brain Tumour 1990 - 2000 Awake Craniotomy Intra-operative brain mapping Pre & Intra-operative Brain Navigation Favours early surgery and aggressive resction for tumours in eloquent areas

30. Low Grade Brain Tumour 1990 - 2000 Advantages of aggressive resection: Treat disease when neoplasm is smaller May decrease risk associated with malignant differentiation May decrease the risk of emergence of intractable seizure disorder

31. Low Grade Brain Tumour 1990 - 2000 Theoretical advantages of radical resection: Better chance of accurate histological diagnosis Reduced mass effect / ICP Reduced tumour burden prior to adjuvant Rx Reduced chance of transformation of LGG Prolong Survival

32. Low Grade Brain Tumour 1990 - 2000

33. Low Grade Brain Tumour 2000 - 2010 New Technologies for Imaging Functional MRI Brain Mapping MRI Spectroscopy Advances in anaesthesia for awake craniotomy Real time intra-operative Navigation

34. Low Grade Brain Tumour 1990 - 2010

35. The Journey

41. Br J Neurosurg. 2005 Feb;20(1):43-5.Awake craniotomy using stealth frameless stereotaxy without rigid skull fixation Barazi SA, El-Maghraby H, Selway R, Marsh H. Abstract The authors describe a technique using the Medtronic Stealth spinal reference array allowing awake craniotomy to be performed without cranial fixation in the Mayfield pin head rest. A Medtronic spinal reference array (four-point H-shaped LED array) is fitted to a Yasargil footplate via a three-jointed swingarm. The Yasargil footplate is directly attached to the cranium after craniotomy and following stereotactic registration the patient is awakened. The patient is free to move his head during the procedure as the reference array does not move in relation to the cranial contents and the fiducials, preserving accuracy

51. UHCW 10 months 4 cases All did well

52. Future More cases Invest in Real Time Intra-operative Navigation Research in 3D virtual reality Navigation

55. Conclusion Two things we must learn from history.... One is that we are not in ourselves superior to our seniors and that we are shamefully inferior to them if we do not advance beyond them.� The principles of awake craniotomies were established years ago. As our understanding of cerebral localization and aesthetic regimens continues to improve, awake craniotomies will continue to provide critical insights into the complexities of brain function.

56. Thank you