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Awake Craniotomy in a Child: Assessment of Eligibility with a Simulated Theatre Experience
Jason Labuschagne1,2, Clover-Ann Lee3,4, Denis Mutyaba1,2
1Department of Neurosurgery, University of the Witwatersrand, Johannesburg, South Africa.
Insights
A simulated surgical experience successfully prepared a young patient for awake craniotomy, despite initial concerns about cooperation. This method helps determine eligibility for awake brain surgery in children.
Area of Science:
- Neurosurgery
- Pediatric Surgery
- Anesthesiology
Background:
- Awake craniotomy is vital for preserving eloquent brain areas during tumor resection, arteriovenous malformation surgery, and epilepsy surgery.
- Assessing a child's ability to cooperate is crucial for successful awake craniotomy.
- Preoperative screening is essential for patient safety during awake procedures.
Observation:
- A simulated surgical experience was used to evaluate an 11-year-old patient with a right motor cortex tumor.
- The simulation replicated the operating room environment, including attire, positioning, monitoring devices, and draping.
- This controlled stress aimed to assess the child's coping skills and suitability for awake surgery.
Findings:
- The patient successfully tolerated the simulated awake craniotomy, demonstrating cooperation and anxiety management.
- An asleep-awake-asleep technique was employed for tumor removal, with cortical and subcortical mapping.
- The procedure resulted in gross total removal of the lesion with the patient remaining cooperative.
Implications:
- Simulated theatre experiences can accurately assess young patients' eligibility for awake craniotomy, even with relative contraindications.
- This technique provides a reliable method for determining suitability for awake surgery in pediatric patients.
- The approach enhances patient selection for awake craniotomy, optimizing surgical outcomes.
Background:
Awake craniotomy is a useful surgical approach to identify and preserve eloquent areas during tumour resection, during surgery for arteriovenous malformation resections and for resective epilepsy surgery. With decreasing age, a child's ability to cooperate and mange an awake craniotomy becomes increasingly relevant. Preoperative screening is essential to identify the child who can undergo the procedure safely. Case Description. A 11-year-old female patient presented with a tumour in her right motor cortex, presumed to be a dysembryoplastic neuroepithelial tumour (DNET). We had concerns regarding the feasibility of performing awake surgery in this patient as psychological testing revealed easy distractibility and an inability to follow commands repetitively. We devised a simulated surgical experience to assess her ability to manage such a procedure. During the simulated theatre experience, attempts were made to replicate the actual theatre experience as closely as possible. The patient was dressed in theatre attire and brought into the theatre on a theatre trolley. She was then transferred onto the theatre bed and positioned in the same manner as she would be for the actual surgery. Her head was placed on a horseshoe headrest, and she was made to lie in a semilateral position, as required for the surgery. A blood pressure cuff, pulse oximeter, nasal cannula with oxygen flow, and calf pumps were applied. She was then draped precisely as she would have been for the procedure. Theatre lighting was set as it would be for the surgical case. The application of the monitoring devices, nasal cannula, and draping was meant not only to prepare her for the procedure but to induce a mild degree of stress such that we could assess the child's coping skills and ability to undergo the procedure. The child performed well throughout the simulated run, and surgery was thus offered. An asleep-awake-asleep technique was planned and employed for surgical removal of the tumour. Cortical and subcortical mapping was used to identify the eloquent tissue. Throughout the procedure, the child was cooperative and anxiety free. Follow-up MRI revealed gross total removal of the lesion.
Conclusion:
A simulated theatre experience allowed us to accurately determine that this young patient, despite relative contraindications, was indeed eligible for awake surgery. We will continue to use this technique for all our young patients in assessing their eligibility for these procedures.
