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Image shows the brain of a patient during awake craniotomy surgery.
Figure 1: Intraoperative image of brain following tumor resection. The margins of safe resection were confirmed during surgery by awake speech testing.
Surgeons with the Penn Medicine Department of Neurosurgery are performing awake craniotomy surgery for patients with infiltrative glial tumors to preserve functional tissue within the motor and speech cortex with greater reliability and promote better tumor resection.Awake craniotomy surgery is the gold standard of care for glial tumors, and has the twin objects of removing as much of the tumor as possible to improve survival while preserving the motor and sensory regions of the brain.To achieve this end, awake craniotomy surgery uses intraoperative functional MR imaging to delineate the relationship between lesions and the speech and motor pathways of the brain. Patients having awake craniotomy have been found to have better early postoperative motor outcomes, fewer late minor complications and shorter hospitalizations compared to patients having surgery under general anesthesia.1,2During awake craniotomy, the patient is sedated while electrical stimuli are induced by the operating neurosurgeon from a grid of sensors or electrodes at the brain surface. The patient is then wakened and his or her conscious reactions to stimulation of the cortical and deep areas of the brain are used to tailor a motor and speech map of the brain in real time. This map permits the surgeon to maximize tumor removal while preserving functional tissue during surgery with minimal neurologic risk to the patient.The benefits of multidisciplinary care at Penn Medicine are  p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 9.5px Times; color: #58595b} especially evident in awake craniotomy surgery, which requires a seamless coordination between surgeon and anesthesiologist to achieve the interaction of surgeon and patient and the balance of states of waking and sedation.Other team members include a neuroradiologist, who provides functional MRI scans during the procedure, neurologists/neurophysiologists to assess functional speech and brain electrical recordings, and nurse practitioners and trained operating room nurses, who facilitate the use of the surgical technologies required of open craniotomy surgery.

Case Study

Mr. S, a 61-year-old male, was first referred to Penn Neurosurgery after experiencing several seizures at age 42, and had a resection of an oligodendroglial brain tumor of the left temporal lobe followed by standard radiation therapy. Following his surgery, he was highly functional with only rare seizures and was able to return to work without issue. Nineteen years later, however, he noted an increase in his seizure frequency and returned to Penn for a repeat MRI. This showed an increased infiltrative left temporal tumor with close proximity to the language cortex. Mr. S then had a functional MRI that allowed mapping of his speech center in a non-invasive manner, and a concurrent image-guided MRI, which allowed for precise intraoperative localization of the tumor with an accuracy of <1mm.

The cumulative data indicated that Mr. S would be ideal for awake surgery with intraoperative speech mapping, and after counseling, he agreed to this approach. In the operating room, direct cortical stimulation was performed by the surgical team and the data were analyzed by anesthesiologists and neurophysiologists. The surgical team was able to maximize tumor resection while at the same time minimizing manipulation of critical language cortex.

Post-operatively, Mr. S was without a speech deficit and the post-resection MRI scan indicated a near complete tumor removal in a highly infiltrative recurrent oligodendroglial brain tumor. The resected tumor tissue was then subjected to cytogenetic and molecular analysis to allow for a more rational treatment selection.

Access

Penn Neuroscience Center
Perelman Center for Advanced Medicine
South Pavilion, 2nd Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104

Penn Neurosurgery

Pennsylvania Hospital
Washington Square West Building
235 South 8th Street
Philadelphia, PA 19106

Penn Medicine University City
8th Floor
3737 Market Street
Philadelphia, PA 19104

Published on: January 1, 0001

References

1. Zelitzki R, Korn A, Arial E, Ben-Harosh C, Ram Z, Grossman R. Comparison of Motor Outcome in Patients Undergoing Awake vs General Anesthesia Surgery for Brain Tumors Located Within or Adjacent to the Motor Pathways. Neurosurgery. 2019;2:1-7. doi: 10.1093/neuros/nyz007.

2. Gerritsen JKW, Viëtor CL, Rizopoulos D, Schouten JW, Klimek M, Dirven CMF, Vincent AJE. Awake craniotomy versus craniotomy under general anesthesia without surgery adjuncts for supratentorial glioblastoma in eloquent areas: a retrospective matched case-control study. Acta Neurochir (Wien). 2019;161:307-315. doi: 10.1007/s00701-018-03788-y.


About Penn Neurosurgery

As part of Penn Neurosciences, Penn Neurosurgery cooperates and collaborates with multiple departments including neurology (medical treatment of nervous disorders including stroke, epilepsy, Parkinson’s disease and others), otorhinolaryngology-head and neck surgery (cranial base tumors, hearing and balance problems), anesthesia (pain medicine) and psychiatry (depression, obsessive compulsive disorders). Advances in research are directly translated into patient care to provide the latest and safest approach for surgical treatment of nervous system disorders. The Department of Neurosurgery at Penn is recognized internationally for excellence in patient care, resident education and scientific research. The faculty includes highly experienced neurosurgeons, each of whom has a subspecialty focus in addition to neurosurgery.

Penn Faculty Team

John Y. K. Lee, MD, MSCE

Medical Director, Gamma Knife Center

Clinical Director, Center for Precision Surgery

Professor of Neurosurgery at the Pennsylvania Hospital

Timothy H. Lucas, II, MD, PhD

Director, Translational Neuromodulation Laboratory

Co-Director, Penn Center for Neuro-Engineering and Therapeutics

Director, Laser Neurosurgery Center

Associate Professor of Neurosurgery

Donald M. O'Rourke, MD

Director, Human Brain Tumor Tissue Bank

Director, Glioblastoma Translational Center of Excellence

John Templeton, Jr., M.D. Professor in Neurosurgery

James M. Schuster, MD, PhD

Chief of Neurosurgery, Penn Presbyterian Medical Center

Residency Program Director, Director of Neurotrauma

Professor of Neurosurgery at the Hospital of the University of Pennsylvania

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