The Merits of Awake Craniotomy for Glioblastoma in the Left Hemispheric Eloquent Area: One Institution Experience

Ying-Ching Li,Hsiao-Yean Chiu,Ya-Jui Lin,Ko-Ting Chen,Peng-Wei Hsu,Yin-Cheng Huang,Pin-Yuan Chen,Kuo-Chen Wei

doi:10.1016/j.clineuro.2020.106343

Ying-Ching Li, Hsiao-Yean Chiu + Show 6 more

Open Access

https://doi.org/10.1016/j.clineuro.2020.106343

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Abstract

ObjectiveAwake craniotomy (AC) with intraoperative stimulation mapping is the standard treatment for gliomas, especially those on the eloquent cortex. Many studies have reported survival benefits with the use of AC in patients with glioma, however most of these studies have focused on low-grade glioma. The aim of this study was to evaluate the experience of one treatment center over 10 years for resection of left hemispheric eloquent glioblastoma. MethodsThis retrospective analysis included 48 patients with left hemispheric eloquent glioblastoma who underwent AC and 61 patients who underwent surgery under general anesthesia (GA) between 2008 and 2018. Perioperative risk factors, extent of resection (EOR), preoperative and postoperative Karnofsky Performance Score (KPS), progression-free survival (PFS) and overall survival (OS) were assessed. ResultsThe postoperative KPS was significantly lower in the GA patients compared to the AC patients (p = 0.002). The EOR in the GA group was 90.2% compared to 94.9% in the AC group (p = 0.003). The mean PFS was 18.9 months in the GA group and 23.2 months in the AC group (p = 0.001). The mean OS was 25.5 months in all patients, 23.4 months in the GA group, and 28.1 months in the AC group (p < 0.001). In multivariate analysis, the EOR and preoperative KPS independently predicted better OS. ConclusionThe patients with left hemispheric eloquent glioblastoma in this study had better neurological outcomes, maximal tumor removal, and better PFS and OS after AC than surgery under GA. Awake craniotomy should be performed in these patients if the resources are available.

Highlights

Awake craniotomy (AC) with intraoperative stimulation mapping is the standard treatment for gliomas, especially those on the eloquent cortex
We aimed to evaluate the experience of one treatment center over 10 years for resection of left hemispheric eloquent glioblastoma using direct brain stimulation and neuromonitoring with either AC or surgery under general anesthesia (GA)
One-hundred and nine patients were treated for left hemispheric eloquent gyrus, glioblastoma between 2008 and 2018 at our institution, of whom 61 underwent surgery under GA and 48 underwent AC

Summary

Introduction

Awake craniotomy (AC) with intraoperative stimulation mapping is the standard treatment for gliomas, especially those on the eloquent cortex. The traditional method of debulking a tumor from within, which has been used for a long time in glioma surgery in order to avoid new neurological deficits, can still lead to such deficits due to functional tissue being contained inside the tumor.[11,12] To overcome this problem, awake craniotomy (AC) allows for surgical mapping of sensorimotor and language functions by directly stimulating the cortical and subcortical areas that are in proximity to or even inside the tumor, and it has been shown to enhance safety and maximize the extent of resection of tumors in eloquent regions of the brain.[13,14,15] AC has enabled removal of tumors from highly functional eloquent regions that were once considered to be inoperable.[16] Surgical resection reduces tumor burden, relieves symptoms caused by the tumor mass effect, and has been proven to be a prognostic factor for survival in glioma patients. The improved survival in glioma patients treated with AC has been attributed to a maximized extent of resection (EOR)

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