Craniotomy Patients Research Articles

Awake craniotomy: improving the patient's experience.

Awake craniotomy patients are exposed to various stressful stimuli while their attention and vigilance is important for the success of the surgery. We describe several recent findings on the perception of awake craniotomy patients and address nonpharmacological perioperative factors that enhance the experience of awake craniotomy patients. These factors could also be applicable to other surgical patients. Proper preoperative counseling gives higher patient satisfaction and should be individually tailored to the patient. Furthermore, there is a substantial proportion of patients who have significant pain or fear during an awake craniotomy procedure. There is a possibility that this could induce post-traumatic stress disorder or related symptoms. Preoperative preparation is of utmost importance in awake craniotomy patients, and a solid doctor-patient relationship is an important condition. Nonpharmacological intraoperative management should focus on reduction of fear and pain by adaptation of the environment and careful and well considered communication.

National survey on thromboprophylaxis and anticoagulant or antiplatelet management in neurosurgical and neurocritical patients

ObjectivesTo determine the protocols used by Spanish anaesthesiologists for thromboprophylaxis and anticoagulant or antiplatelet drugs management in neurosurgical or neurocritical care patients. Materials and methodsAn online survey with 22 questions, with one or multiple options, launched by the Neuroscience Subcommittee of the Spanish Anaesthesia Society and available between June and October 2012. ResultsOf the 73 hospitals included in the National Hospitals Catalogue, a valid response to the online questionnaire was received by 41 anaesthesiologists from 37 sites (response rate 50.7%). Only one response per site was used. A specific protocol was available in 27% of these centres. Mechanical thromboprophylaxis is used, intraoperatively or postoperatively, in 80%, and pharmacological treatment is used by 75% of respondents. Enoxaparin was the most frequent heparin used in craniotomy patients (78%). Craniotomies were performed maintaining acetylsalicylic acid treatment in patients with coronary stents and double anti-platelet treatment in half of the centres. ConclusionsMechanical thromboprophylaxis is used more frequently than the pharmacological approach in neurosurgical or neurocritical populations in Spanish hospitals. Management of patients under previous anticoagulant treatment was highly heterogeneous among hospitals included in this survey. Previous antiplatelet treatment is modified depending on primary or secondary prescription.

Patient-Reported Outcomes in Elective Cranial Neurosurgery

The role of patient-reported outcomes (PROs) in elective cranial neurosurgery has been poorly studied, and their significance in reflecting complication rates is unclear. A prospective, consecutive, and unselected cohort of 418 adult patients underwent elective intracranial operations between 7 December, 2011 and 31 December, 2012 in Helsinki University Hospital, Finland. The questionnaire-based PROs included subjective postoperative assessments of overall health, cognitive function, and subjective change in functional status. Outcome measures included in-hospital major morbidity (including mortality) and in-hospital overall morbidity. We compared the usefulness of PROs with postoperative modified Rankin Scale (mRS) score. In univariable analyses, all recorded PROs and 30-day mRS scores ≥ 3 were associated with in-hospital major and overall morbidity. After multivariable analyses, postoperative deterioration of subjective functional status remained associated with in-hospital major morbidity (P = 0.001, odds ratio [OR] 4.9, confidence interval [CI] 1.9-12.0, sensitivity 71%, and specificity 70%) and overall in-hospital morbidity (P < 0.001, OR 5.7, CI 3.1-10.7, sensitivity 59%, and specificity 84%). Postoperatively impaired functional status was more sensitive but less specific in detecting in-hospital major and overall morbidity than the widely used mRS cut-off value of 2. A simple composite score combining the 3 recorded PROs was highly sensitive and specific in detecting in-hospital major (sensitivity 87%, specificity 98%) and overall (sensitivity 72%, specificity 99%) morbidity. In elective craniotomy patients, PROs seem promising patient-centered tools for outcomes reporting. Furthermore, neurosurgery-specific patient-reported outcome measures (PROMs) can perhaps be implemented to clinical use to improve patient safety and outcome comparisons in elective cranial neurosurgery.

Awake right hemisphere brain surgery

We report the indications and outcomes of awake right hemispheric brain surgery, as well as a rare patient with crossed aphasia. Awake craniotomies are often performed to protect eloquent cortex. We reviewed the medical records for 35 of 96 patients, in detail, who had awake right hemisphere brain operations. Intraoperative cortical mapping of motor and/or language function was performed in 29 of the 35 patients. A preoperative speech impairment and left hand dominance were the main indicators for awake right-sided craniotomies in patients with right hemisphere lesions. Four patients with lesion proximity to eloquent areas underwent awake craniotomies without cortical mapping. In addition, one patient had a broncho-pulmonary fistula, and another had a recent major cardiac procedure that precluded awake surgery. An eloquent cortex representation was identified in 14 patients (48.3%). Postoperatively, seven of 17 patients (41.1%) who presented with weakness, experienced improvements in their motor functions, 11 of 16 (68.7%) with seizures became seizure-free, and seven of nine (77.7%) with moderate to severe headaches and one of two with a visual field deficit improved significantly. There were also improvements in speech and language functions in all patients who presented with speech difficulties. A right sided awake craniotomy is an excellent option for left handed patients, or those with right sided cortical lesions that result in preoperative speech impairments. When combined with intraoperative cortical mapping, both speech and motor function can be well preserved.

Patient Satisfaction and Short-Term Outcome in Elective Cranial Neurosurgery.

Patient-reported experience is often used as a measure for quality of care, but no reports on patient satisfaction after cranial neurosurgery exist. To study the association of overall patient satisfaction and surgical outcome and to evaluate the applicability of overall patient satisfaction as a proxy for quality of care in elective cranial neurosurgery. We conducted an observational study on the relationship of overall patient satisfaction at 30 postoperative days with surgical and functional outcome (modified Rankin Scale [mRS] score) in a prospective, consecutive, and unselected cohort of 418 adult elective craniotomy patients enrolled between December 2011 and December 2012 at Helsinki University Hospital, Helsinki, Finland. Postoperative overall (subjective and objective) morbidity was present in 194 (46.4%) patients; yet almost 94% of all study patients reported high overall satisfaction. Low overall patient satisfaction at 30 days was not associated with postoperative major morbidity in elective cranial neurosurgery. Dependent functional status (mRS score ≥3) at 30 days, minor infections, poor postoperative subjective overall health status, and patient-reported severe symptoms (double vision, poor balance) may contribute to unsatisfactory patient experience. Overall patient satisfaction with elective cranial neurosurgery is high. Even 9 of 10 patients with postoperative major morbidity rated high overall patient satisfaction at 30 days. Overall patient satisfaction may merely reflect patient experience and subjective postoperative health status, and therefore it is a poor proxy for quality of care in elective cranial neurosurgery.

In Reply: Patient Satisfaction and Short-term Outcome in Elective Cranial Neurosurgery.

BACKGROUND Patient-reported experience is often used as a measure for quality of care, but no reports on patient satisfaction after cranial neurosurgery exist. OBJECTIVE To study the association of overall patient satisfaction and surgical outcome and to evaluate the applicability of overall patient satisfaction as a proxy for quality of care in elective cranial neurosurgery. METHODS We conducted an observational study on the relationship of overall patient satisfaction at 30 postoperative days with surgical and functional outcome (modified Rankin Scale [mRS] score) in a prospective, consecutive, and unselected cohort of 418 adult elective craniotomy patients enrolled between December 2011 and December 2012 at Helsinki University Hospital, Helsinki, Finland. RESULTS Postoperative overall (subjective and objective) morbidity was present in 194 (46.4%) patients; yet almost 94% of all study patients reported high overall satisfaction. Low overall patient satisfaction at 30 days was not associated with postoperative major morbidity in elective cranial neurosurgery. Dependent functional status (mRS score ≥3) at 30 days, minor infections, poor postoperative subjective overall health status, and patient-reported severe symptoms (double vision, poor balance) may contribute to unsatisfactory patient experience. CONCLUSION Overall patient satisfaction with elective cranial neurosurgery is high. Even 9 of 10 patients with postoperative major morbidity rated high overall patient satisfaction at 30 days. Overall patient satisfaction may merely reflect patient experience and subjective postoperative health status, and therefore it is a poor proxy for quality of care in elective cranial neurosurgery.

Awake craniotomy using electromagnetic navigation technology without rigid pin fixation

We report our institutional experience using an electromagnetic navigation system, without rigid head fixation, for awake craniotomy patients. The StealthStation® S7 AxiEM™ navigation system (Medtronic, Inc.) was used for this technique. Detailed preoperative clinical and neuropsychological evaluations, patient education and contrast-enhanced MRI (thickness 1.5mm) were performed for each patient. The AxiEM Mobile Emitter was typically placed in a holder, which was mounted to the operating room table, and a non-invasive patient tracker was used as the patient reference device. A monitored conscious sedation technique was used in all awake craniotomy patients, and the AxiEM Navigation Pointer was used for navigation during the procedure. This offers the same accuracy as optical navigation, but without head pin fixation or interference with intraoperative neurophysiological techniques and surgical instruments. The application of the electromagnetic neuronavigation technology without rigid head fixation during an awake craniotomy is accurate, and offers superior patient comfort. It is recommended as an effective adjunctive technique for the conduct of awake surgery.

Preoperative identification of neurosurgery patients with a high risk of in-hospital complications: a prospective cohort of 418 consecutive elective craniotomy patients.

Patients undergoing craniotomy are routinely assessed preoperatively, yet the role of these assessments in predicting outcome is poorly studied. This study aimed to identify preoperative factors predicting in-hospital outcome after cranial neurosurgery. The study cohort consisted of 418 consecutive adults undergoing elective craniotomy for any intracranial lesion. Apart from the age criteria (≥ 18 years), almost all patients were considered eligible for the study to increase external validity of the results. The studied preoperative assessments included various patient-related data, routine blood tests, American Society of Anesthesiologists (ASA) Physical Status Classification system, and a local modification of the ASA classification (Helsinki ASA classification). Adverse outcomes were in-hospital mortality, in-hospital systemic or infectious complications, and in-hospital CNS deficits. Resource use was defined as length of stay (LOS) in the intensive care unit and overall LOS in the hospital. The in-hospital mortality rate was 1.0%. In-hospital systemic or infectious complications and permanent or transient CNS deficits occurred in 6.7% and 11.2% of the patients, respectively. Advanced age (≥ 60-65 years), elevated C-reactive protein level (> 3 mg/L), and high Helsinki ASA score (Class 4) were associated with in-hospital systemic and infectious complications, and a combination of these could identify one-fourth of the patients with postoperative complications. Moreover, this combination of preoperative assessment parameters was significantly associated with increased resource use. In this first prospective and unselected cohort study of outcome after elective craniotomy, simple preoperative assessments identified patients with a high risk of in-hospital systemic or infectious complications as well as extended resource use. Presented risk assessment methods may be widely applicable, also in low-volume centers, as they are based on composite predictors and outcome events.

The influence of shaving and non-shaving on postoperative wound infection in craniotomy patient

within two hours of collection. In this study, we will discuss the impact of the delayed inoculation. Methods: A total of 40 consecutively collected midstream and/or catheter-catch urine samples from patients were cultured in medium. The samples were inoculated immediately, one hour, two hours and 4 hours separately. Results: The culture result yields that the difference between the immediate cultures and delayed inoculations were influenced by the period of delaying. Conclusion: Direct sample inoculation into selective growth medium may improve the likelihood of detecting real pathogen.

Encuesta nacional sobre la tromboprofilaxis y el manejo de los anticoagulantes y antiagregantes en pacientes neuroquirúrgicos y neurocríticos

ObjectivesTo determine the protocols used by Spanish anaesthesiologists for thromboprophylaxis and anticoagulant or antiplatelet drugs management in neurosurgical or neurocritical care patients. Material and methodsAn online survey with 22 questions, with one or multiple options, launched by the Neuroscience Subcommittee of the Spanish Anaesthesia Society and available between June and October 2012. ResultsOf the 73 hospitals included in the National Hospitals Catalogue, a valid response to the online questionnaire was received by 41 anaesthesiologists from 37 sites (response rate 50.7%). Only one response per site was used. A specific protocol was available in 27% of these centres. Mechanical thromboprophylaxis is used, intraoperatively or postoperatively, in 80%, and pharmacological treatment is used by 75% of respondents. Enoxaparin was the most frequent heparin used in craniotomy patients (78%). Craniotomies were performed maintaining acetylsalicylic acid treatment in patients with coronary stents and double anti-platelet treatment in a half of the centres. ConclusionsMechanical thromboprophylaxis is used more frequently than the pharmacological approach in neurosurgical or neurocritical populations in Spanish hospitals. Management of patients under previous anticoagulant treatment was highly heterogeneous among hospitals included in this survey. Previous antiplatelet treatment is modified depending on primary or secondary prescription.

Challenging Tracheostomy – A Novel Approach in a Rare Anomaly of the Brachiocephalic Artery

A 70 year old post craniotomy patient on ventilator required tracheostomy for early weaning. An anomalous Brachiocephalic trunk running across the surgical site was making the surgery challenging due to difficulty during surgery and also post operative risk of torrential bleeding due to injury to the vessel by the tracheostomy tube causing vascular rupture.

Ipilimumab and craniotomy in patients with melanoma and brain metastases: a case series.

OBJECT In patients with large or symptomatic brain lesions from metastatic melanoma, the value of resection of metastases to facilitate administration of systemic ipilimumab therapy has not yet been described. The authors undertook this study to investigate whether craniotomy creates the opportunity for patients to receive and benefit from ipilimumab who would otherwise succumb to brain metastasis prior to the onset of regression. METHODS All patients with metastatic melanoma who received ipilimumab and underwent craniotomy for metastasis resection between 2008 and 2014 at the Massachusetts General Hospital were identified through retrospective chart review. The final analysis included cases involving patients who underwent craniotomy within 3 months prior to initiation of therapy or up to 6 months after cessation of ipilimumab administration. RESULTS Twelve patients met the inclusion criteria based on timing of therapy (median age 59.2). The median number of metastases at the time of craniotomy was 2. The median number of ipilimumab doses received was 4. Eleven of 12 courses of ipilimumab were stopped for disease progression, and 1 was stopped for treatment-induced colitis. Eight of 12 patients had improvement in their performance status following craniotomy. Of the 6 patients requiring corticosteroids prior to craniotomy, 3 tolerated corticosteroid dose reduction after surgery. Ten of 12 patients had died by the time of data collection, with 1 patient lost to follow-up. The median survival after the start of ipilimumab treatment was 7 months. CONCLUSIONS In this series, patients who underwent resection of brain metastases in temporal proximity to receiving ipilimumab had qualitatively improved performance status following surgery in most cases. Surgery facilitated corticosteroid reduction in select patients. Larger analyses are required to better understand possible synergies between craniotomy for melanoma metastases and ipilimumab treatment.

Interferência e características do edema periorbital no exame pupilar após craniotomia

Objetivo Avaliar a interferência e características do edema periorbital no exame pupilar, em pacientes submetidos a craniotomia por via anterior. Métodos Estudo de coorte prospectivo realizado em pacientes no pós-operatório na unidade de terapia intensiva e internação de neurocirurgia. A interferência e características do edema periorbital no exame pupilar foram avaliados da admissão do paciente até sétimo dia de pós-operatório. O exame pupilar foi realizado por enfermeiros. Resultados Foram avaliados 100 pacientes e a incidência de edema periorbital foi de 80%. O enfermeiro não realizou o exame pupilar em 24 (30%) pacientes. As características que influenciaram na realização do exame pupilar foram coloração arroxeada e intenso edema periorbital. Conclusão O edema periorbital estava presente na maioria dos pacientes no pós-operatório de craniotomia e o exame pupilar não foi realizado em 30% dos pacientes. A presença de intenso edema periorbital e de coloração arroxeada foram características que prejudicaram o exame pupilar.

Comparison study of neuroendoscopic surgery and craniotomy in management of hypertensive intracerebral hemorrhage

Objective To investigate the therapeutic effects of neuroendoscopic surgery and craniotomy in the treatment of hypertensive intracerebral hemorrhage(HIH). Methods A total of 54 patients with hypertensive intracerebral hemorrhage treated by operation between May 2011 and June 2013 were analyzed retrospectively, 28 patients in neuroendoscopy group and 26 patients in craniotomy group.All patients were followed up for 3 months, two groups were estimated by the ADL scores, grade 1-3 of ADL was regarded as good prognosis, grade 4-5 of ADL and dead cases as poor prognosis. Results One death case in the neuroendoscopy group and 2 death cases in the craniotomy group, no statistical difference (P>0.05). The good prognosis rate of ADL was 82.1% (23/28) in the neuroendoscopy group and 53.9% (14/26) in the craniotomy group, the therapeutic effects of neuroendoscopy group were better than those of craniotomy group(P>0.05). Conclusion Neuroendoscopic surgery is a kind of method with little injury、favorable recovery of neural function in the treatment of hypertensive intracerebral hemorrhage. Key words: Hypertensive intracerebral hemorrhage; Neuroendoscope; Craniotomy

Comparison the effects of paracetamol with sufentanil infusion on postoperative pain control after craniotomy in patients with brain tumor.

Background:Patients experience severe pain after craniotomy surgery that leads to discomfort. Our target in this study that performed in interventional method is an evaluation of sufentanil and paracetamol effect on postoperative pain control in patients undergone craniotomy surgery at Urmia Imam Khomeini Hospital.Materials and Methods:Totally, 45 patients between the ages 18 and 65 were studied. The effect of sufentanil and paracetamol medicines in pain management, hemodynamic stability, and side effects compared with control group that were receiving morphine (subcutaneous [SC]) in 3 groups of 15 people at time 0, 2, 4, 12 and 24-h were evaluated. Collected data were included and monitoring blood pressure, O2 Sat, heart rate (HR) and pain, nausea, vomiting and use of morphine.Results:According to the analysis of results, there was a significant difference between 3 groups on postoperative pain (P < 0.05). In patients that used sufentanil, pain score of visual analog scale (VAS) is lowest and in the paracetamol group the highest VAS score was seen. There was a significant difference in HR between 3 groups (P < 0.05). Maximum average of HR was observed in the paracetamol group. There was a significant difference in mean arterial pressure between 3 groups (P < 0.05). In paracetamol group, there was the highest value (99.3). There was no significant difference in Glasgow Coma scale and SPO2 between 3 groups (P > 0.05).Conclusion:Sufentanil compared to morphine (which is routinely used for patients pain control after craniotomy surgery) has better pain control, less nausea and vomiting, and better hemodynamic stability. Although paracetamol has the least nausea and vomiting, it has the lowest quality of pain relief.

Anti-epileptic prophylaxis in traumatic brain injury: A retrospective analysis of patients undergoing craniotomy versus decompressive craniectomy.

Background:Seizures account for significant morbidity and mortality early in the course of traumatic brain injury (TBI). Although there is sufficient literature suggesting short-term benefits of antiepileptic drugs (AEDs) in post-TBI patients, there has been no study to suggest a time frame for continuing AEDs in patients who have undergone a decompressive craniectomy for more severe TBI. We examined trends in a level-II trauma center in southern California that may provide guidelines for AED treatment in craniectomy patients.Methods:A retrospective analysis was performed evaluating patients who underwent decompressive craniectomy and those who underwent a standard craniotomy from 2008 to 2012.Results:Out of the 153 patients reviewed, 85 were included in the study with 52 (61%) craniotomy and 33 (39%) craniectomy patients. A total of 78.8% of the craniotomy group used phenytoin (Dilantin), 9.6% used levetiracetam (Keppra), 5.8% used a combination of both, and 3.8% used topiramate (Topamax). The craniectomy group used phenytoin 84.8% and levetiracetam 15.2% of the time without any significant difference between the procedural groups. Craniotomy patients had a 30-day seizure rate of 13.5% compared with 21.2% in craniectomy patients (P = 0.35). Seizure onset averaged on postoperative day 5.86 for the craniotomy group and 8.14 for the craniectomy group. There was no significant difference in the average day of seizure onset between the groups P = 0.642.Conclusion:Our study shows a trend toward increased seizure incidence in craniectomy group, which does not reach significance, but suggests they are at higher risk. Whether this higher risk translates into a benefit on being on AEDs for a longer duration than the current standard of 7 days cannot be concluded as there is no significant difference or trend on the onset date for seizures in either group. Moreover, a prospective study will be necessary to more profoundly evaluate the duration of AED prophylaxis for each one of the stated groups.

Music is Beneficial for Awake Craniotomy Patients: A Qualitative Study.

Patients undergoing awake craniotomy may experience high levels of stress. Minimizing anxiety benefits patients and surgeons. Music has many therapeutic effects in altering human mood and emotion. Tonality of music as conveyed by composition in major or minor keys can have an impact on patients' emotions and thoughts. Assessing the effects of listening to major and minor key musical pieces on patients undergoing awake craniotiomy could help in the design of interventions to alleviate anxiety, stress and tension. Twenty-nine patients who were undergoing awake craniotomy were recruited and randomly assigned into two groups: Group 1 subjects listened to major key music and Group 2 listened to minor key compositions. Subjects completed a demographics questionnaire, a pre- and post-operative Beck Anxiety Inventory (BAI) and a semi-structured open-ended interview. RESULTS were analyzed using modified thematic analysis through open and axial coding. Overall, patients enjoyed the music regardless of the key distinctions and stated they benefitted from listening to the music. No adverse reactions to the music were found. Subjects remarked that the music made them feel more at ease and less anxious before, during and after their procedure. Patients preferred either major key or minor key music but not a combination of both. Those who preferred major key pieces said it was on the basis of tonality while the individuals who selected minor key pieces stated that tempo of the music was the primary factor. Overall, listening to music selections was beneficial for the patients. Future work should further investigate the effects of audio interventions in awake surgery through narrative means.

Clinical factors associated with venous thromboembolism risk in patients undergoing craniotomy.

OBJECT Patients undergoing craniotomy are at risk for developing venous thromboembolism (VTE). The safety of anticoagulation in these patients is not clear. The authors sought to identify risk factors predictive of VTE in patients undergoing craniotomy. METHODS The authors reviewed a national surgical quality database, the American College of Surgeons National Surgical Quality Improvement Program. Craniotomy patients were identified by current procedural terminology code. Clinical factors were analyzed to identify associations with VTE. RESULTS Four thousand eight hundred forty-four adult patients who underwent craniotomy were identified. The rate of VTE in the cohort was 3.5%, including pulmonary embolism in 1.4% and deep venous thrombosis in 2.6%. A number of factors were found to be statistically significant in multivariate binary logistic regression analysis, including craniotomy for tumor, transfer from acute care hospital, age ≥ 60 years, dependent functional status, tumor involving the CNS, sepsis, emergency surgery, surgery time ≥ 4 hours, postoperative urinary tract infection, postoperative pneumonia, on ventilator ≥ 48 hours postoperatively, and return to the operating room. Patients were assigned a score based on how many of these factors they had (minimum score 0, maximum score 12). Increasing score was predictive of increased VTE incidence, as well as risk of mortality, and time from surgery to discharge. CONCLUSIONS Patients undergoing craniotomy are at low risk of developing VTE, but this risk is increased by preoperative medical comorbidities and postoperative complications. The presence of more of these clinical factors is associated with progressively increased VTE risk; patients possessing a VTE Risk Score of ≥ 5 had a greater than 20-fold increased risk of VTE compared with patients with a VTE score of 0.

Stereotactic aspiration versus craniotomy for primary intracerebral hemorrhage: a meta-analysis of randomized controlled trials.

BackgroundA wealth of evidence based on the randomized controlled trials (RCTs) has indicated that surgery may be a better choice in the management of primary intracerebral hemorrhage (ICH) compared to conservative treatment. However, there is considerable controversy over selecting appropriate surgical procedures for ICH. Thus, this meta-analysis was performed to assess the effects of stereotactic aspiration compared to craniotomy in patients with ICH.MethodsAccording to the study strategy, we searched PUBMED, EMBASE and Cochrane Central Register of Controlled Trials. Other sources such as the internet-based clinical trial registries, relevant journals and the lists of references were also searched. After literature searching, two investigators independently performed literature screening, assessment of quality of the included trials and data extraction. The outcome measures included death or dependence, total risk of complication, and the risk of rebleeding, gastrointestinal hemorrhage and systematic infection.ResultsFour RCTs with 2996 participants were included. The quality of the included trials was acceptable. Stereotactic aspiration significantly decreased the odds of death or dependence at the final follow-up (odds ratio (OR): 0.80, 95% confidence interval (CI): 0.69–0.93; P = 0.004) and the risk of intracerebral rebleeding (OR: 0.44, 95% CI: 0.26–0.74; P = 0.002) compared to craniotomy with no significant heterogeneity among the study results.ConclusionsThe present meta-analysis provides evidence that the stereotactic aspiration may be associated with a reduction in the odds of being dead or dependent in primary ICH, which should be interpreted with caution. Further trials are needed to identify those patients most likely to benefit from the stereotactic aspiration.

Impact of Preoperative Functional Magnetic Resonance Imaging during Awake Craniotomy Procedures for Intraoperative Guidance and Complication Avoidance

Background: We wanted to study the role of functional MRI (fMRI) in preventing neurological injury in awake craniotomy patients as this has not been previously studied. Objectives: To examine the role of fMRI as an intraoperative adjunct during awake craniotomy procedures. Methods: Preoperative fMRI was carried out routinely in 214 patients undergoing awake craniotomy with direct cortical stimulation (DCS). Results: In 40% of our cases (n = 85) fMRI was utilized for the intraoperative localization of the eloquent cortex. In the other 129 cases significant noise distortion, poor task performance and nonspecific BOLD activation precluded the surgeon from using the fMRI data. Compared with DCS, fMRI had a sensitivity and specificity, respectively, of 91 and 64% in Broca's area, 93 and 18% in Wernicke's area and 100 and 100% in motor areas. A new intraoperative neurological deficit during subcortical dissection was predictive of a worsened deficit following surgery (p < 0.001). The use of fMRI for intraoperative localization was, however, not significant in preventing worsened neurological deficits, both in the immediate postoperative period (p = 1.00) and at the 3-month follow-up (p = 0.42). Conclusions: The routine use of fMRI was not useful in identifying language sites as performed and, more importantly, practiced tasks failed to prevent neurological deficits following awake craniotomy procedures.