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Technical Considerations in Awake Craniotomy with Cortical and Subcortical Motor Mapping in Preadolescents: Pushing
Vishwaraj Ratha1, Nishanth Sampath2, Sudhakar Subramaniam3
1Department of Neurosurgery, Institute of Neurosciences, SIMS Hospital, Chennai, India, thinkvishwaraj@gmail.com.
Insights
Awake craniotomy with intraoperative neurophysiological monitoring (IONM) is safe and feasible for preadolescent children undergoing surgery for eloquent region gliomas (ERG). This approach enables maximal safe resection without postoperative deficits.
Area of Science:
- Pediatric Neurosurgery
- Neuro-oncology
- Anesthesiology
Background:
- The efficacy of awake anesthesia combined with intraoperative neurophysiological monitoring (IONM) for maximal safe resection of eloquent region gliomas (ERG) is established in adults but not yet in pediatric populations.
- This combined approach remains unexplored in preadolescent children (under 11 years old).
Observation:
- Two preadolescent patients (8 and 9 years old) underwent awake craniotomy with IONM for ERG resection.
- Preoperative familiarization with the OR and procedures was conducted.
- Conscious sedation, cortical/subcortical mapping, and electrocorticography were employed.
Findings:
- Gross total resection was achieved in both cases.
- No postoperative neurological deficits or perioperative complications were observed.
- This represents the first successful use of awake IONM for ERG resection in the preadolescent age group.
Implications:
- Awake IONM is a safe and feasible technique for maximal safe resection of ERGs in preadolescent children.
- Careful preoperative planning and anesthetic titration are crucial for success.
- The exclusion of preadolescents from awake mapping should be reconsidered on a case-by-case basis.
Introduction:
Unlike adult gliomas, the utility of combined application of awake anesthesia and intraoperative neurophysiological monitoring (IONM) for maximal safe resection in eloquent region gliomas (ERG) has not been established for pediatric population while it remains unexplored in preadolescents (below 11 years old).
Case Presentation:
We report 2 cases of awake craniotomy with IONM in an 8 and 9 year old for safe maximal resection of ERG. In both the cases, repeated preoperative visits of the operating room was performed to familiarize and educate the children about intraoperative communication, comfortable positioning, and neurological assessment. Under conscious sedation protocol, cortical and subcortical mapping, and electrocorticography, gross total resection was achieved. In both the cases, there were no postoperative neurodeficits or perioperative complications.
Conclusion:
Our 2 cases illustrate the first instance of successful use of awake IONM for maximal safe resection of ERG in preadolescent age-group. We believe, with proper preoperative planning and careful titration of anesthetics, it is safe and feasible. The blanket notion that preadolescent age-group should be excluded from awake mapping needs to be challenged, rather curated on a case basis.
