Awake Craniotomy Image demonstrating grid and sensors at the surface of the brain following tumor resection.
Figure 1: Intraoperative photo of brain following awake craniotomy tumor removal; the numbers shown represent electrode contacts for the subdural grid coverage.
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.1,2

During 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 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 surgical technologies required in these brain tumor cases.

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.

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

Penn Neurosurgery Pennsylvania Hospital
Pennsylvania Hospital
Spruce Building, 3rd Floor
801 Spruce Street
Philadelphia, PA 19107

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

Clinical Research in Glioblastoma at Penn Medicine

O’Rourke Laboratory - Led by neurosurgeon Donald M. O’Rourke, MD, the O’Rourke Laboratory at Penn Medicine is devoted to neuro-oncology and has, for several years, been home to a series of vibrant investigations in immunotherapy for glioblastoma multiforme (GBM). The laboratory is fully integrated into the Center for Cellular Immunotherapies and The Parker Institute for Cancer Immunotherapy at the Perelman Center for Advanced Medicine and the Abramson Cancer Center (ACC).In addition to CAR T therapy, researchers in the O’Rourke Lab are currently focusing upon targeted antibodies and novel proof of concept studies, with the ultimate goal of reversing the immunosuppression native to glioblastoma and stimulating immune activity in the tumor microenvironment. The overarching goal is to create a pipeline of new clinical trials to be used in the care of GBM patients.

Penn Neurosurgery recently partnered with the Abramson Cancer at Penn for the newest Translational Center of Excellence (TCE) for the treatment of Glioblastoma Multiforme. The Center is specifically focused on researching new, innovative immune therapies to treat gliomas, and to design and test engineer autologous T-cells with chimeric antigen receptor (CAR-T) therapies -- alone or in combination with other immuno-oncology approaches -- and incorporates research with cores available through the HumanBrain Tumor Tissue Bank at Penn.

Published on: October 11, 2010

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, et al. 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

M. Sean Grady, MD

Chairman, Department of Neurosurgery

Charles Harrison Frazier Professor of Neurosurgery

John Y. K. Lee, MD, MSCE

Medical Director, Gamma Knife Center

Associate Professor of Neurosurgery at the Pennsylvania Hospital

Timothy H. Lucas, II, MD, PhD

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

Director, Translational Neuromodulation Laboratory

Assistant Professor of Neurosurgery

Donald M. O'Rourke, MD

Director, Human Brain Tumor Tissue Bank

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

James M. Schuster, MD, PhD

Residency Program Diector, Director of Neurotrauma

Associate Professor of Neurosurgery at the Hospital of the University of Pennsylvania

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