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Two-step awake craniotomy for diffuse supratentorial gliomas
Petra Bintintan-Socaciu1,2,3,4,5, Shuroq Taju1,2,3, Angela Elia1,2,3
1Service de Neurochirurgie, GHU-Paris Psychiatrie et Neuro-sciences, Paris, France.
Background:
Maximal safe awake resection is the standard for diffuse gliomas, as it optimizes extent of resection while preserving functional integrity. Progressive loss of accuracy during neurocognitive testing may preclude completion of a maximal function-based resection. We assessed the prevalence, feasibility, safety, and efficacy of a 2-step awake craniotomy approach and identified predictors for requiring a second awake procedure to achieve maximal function-based resection.
Methods:
We conducted a retrospective single-center cohort study of 449 consecutive supratentorial diffuse glioma awake craniotomies (2009-2024). Clinical, neurocognitive, imaging, oncological, and intraoperative data were collected.
Results:
Among 449 awake craniotomies, 12 (2.8%) required a second awake procedure. The first surgeries were interrupted due to increasing spontaneous errors during intraoperative tests, fatigue, loss of participation, or pain-induced high blood pressure. The interval between procedures ranged from 1.0 to 7.5 months. Compared with all other awake surgeries, the second procedure showed no increase in intraoperative adverse events. Compared to the first awake procedure, the second awake procedure achieved a median additional resection rate of 32.3% (mean 38.6 ± 24.4%; range 8%-83.2%) across all patients. The proportion of complete resections increased from 0/12 to 6/12. Independent predictors of a 2-step awake craniotomy were preoperative attention impairment (P = .021), left-hemispheric location (P = .017), and insular involvement (P = .016).
Conclusion:
Two-step awake craniotomy is a rare but effective and safe strategy when the initial awake procedure must be prematurely stopped. Patients with attention deficits, left-sided lesions, or insular tumor involvement are more likely to require a 2-step awake craniotomy.
Insights
A two-step awake craniotomy is a safe and effective strategy for diffuse gliomas when initial surgeries are interrupted. This approach allows for maximal safe resection, particularly in patients with attention deficits or specific tumor locations.
Area of Science:
- Neurosurgery
- Oncology
- Neuroscience
Background:
- Maximal safe resection is standard for diffuse gliomas, balancing tumor removal with functional preservation.
- Neurocognitive testing can limit resection completion due to progressive accuracy loss.
- The 2-step awake craniotomy approach was assessed for prevalence, feasibility, safety, and efficacy.
Purpose of the Study:
- To evaluate the effectiveness and safety of a 2-step awake craniotomy for diffuse gliomas.
- To identify predictors for requiring a second awake procedure to achieve maximal function-based resection.
- To determine the additional resection rate and impact on complete resection in 2-step procedures.
Main Methods:
- Retrospective single-center cohort study of 449 supratentorial diffuse glioma awake craniotomies (2009-2024).
- Collection of clinical, neurocognitive, imaging, oncological, and intraoperative data.
- Analysis of factors leading to premature interruption of the first awake procedure.
Main Results:
- 12 (2.8%) of 449 awake craniotomies required a second procedure, often due to neurocognitive decline or patient fatigue.
- The second procedure demonstrated no increased intraoperative adverse events and achieved a median additional 32.3% resection.
- Complete resection rates increased from 0/12 to 6/12 in patients undergoing the 2-step approach.
- Preoperative attention impairment, left-hemispheric location, and insular involvement predicted the need for a 2-step procedure.
Conclusions:
- A 2-step awake craniotomy is a rare, effective, and safe strategy for diffuse gliomas when initial procedures are prematurely stopped.
- Patients with attention deficits, left-sided lesions, or insular tumor involvement are more likely to require this staged approach.
