Transcript Prospective Observational Study on Awake Image

Awake and Day-case Neurosurgery
for Brain Tumours
SWPHO note: A number of pictures have been
removed from this presentation to preserve the
identity of the patients involved
Paul L Grundy
Wessex Neurological Centre
Aim of the Presentation

Describe the development of awake
and day-case neurosurgery @ WNC
– Awake craniotomy
– Image-guided biopsy
– Day-case neurosurgery
Awake neurosurgery

Advantages
–
–
–
–
–
–
Safety
Efficiency
Cost savings
No GA risk/side effect
Facilitates day-cases
Improved satisfaction?

Disadvantages
–
–
–
–
–
Airway/seizure risk
Specialist anaesthetist
Patient anxiety
Pain?
Increased surgeon
involvement
Introduction to the Awake
Craniotomy Technique




The awake craniotomy technique allows a safer
approach to the removal of tumours lying on/near
the eloquent cortex.
Traditionally, asleep-awake-asleep craniotomies
have been performed.
Controlled conscious sedation is key to the awake
craniotomy technique.
Advances in anaesthetic agents have enabled
development of the technique.
How Does the WNC compare to
Other Centres in the UK Performing
Awake Craniotomies?

19 centres in the UK are performing awake craniotomies.

Only 4/19 centres do more than 10 cases/year.

Indication for awakes across the centres consisted of
tumour/epilepsy surgery involving eloquent cortex.

6/19 centres occasionally use a controlled sedation technique.

No centre has reported day-case awake craniotomy.
The Study



Data collected prospectively
38 awake craniotomies performed from January 2006
to present
37 tumour resections and one drainage of an arachnoid
cyst
Demographics of the Awake
Craniotomy Patients
Age Range of Awake Craniotomy Patients
10
8
Number of 6
Patients 4
2
0
20-30
31-40
41-50
51-60
Age Range
61-70
71-80
Origin of Tumours Resected from
Awake Craniotomy Patients
Tumour Origin from Aw ake Craniotomy Patients
25
20
Number of 15
Patients 10
5
0
Primary
Secondary
Not applicable
Tumour Origin

Not applicable = Drainage of arachnoid cyst
Histological Classification of the
Resected Tumours
His tological Clas s ification of the Re s e cte d Prim ary
Tum ours
G
ra
nd
de
ro
gl
III
io
O
m
lig
a
od
G
en
ra
de
dr
og
III
lio
A
ty
m
pi
a
ca
G
ra
lT
de
er
at
II
oi
d
R
ha
bd
oi
d
om
a
oc
yt
lig
od
e
A
st
r
O
G
lio
bl
as
to
m
a
M
ul
tif
or
m
e
9
8
7
6
Number of 5
Patients 4
3
2
1
0
Histological Classification
Histological Classification of the
Secondary Resected Tumours
Histological Classification of the Resected Secondary
Tumours
3
Number of 2
Patients
1
0
a
a
a
a
a
a
m
m
m
m
m
m
o
o
o
o
o
o
n
in
ph
an r cin rcin rci
m
rc
el
a
y
a
a
a
C
L
c
M
c
C
ll
no
nt as t
no nal
e
a
e
e
C
e
d
n
e
d
Big
Br n A ic R g A
al
c
t
o
n
a
M
ti
ol
Lu
st
ta
ic
C
a
t
s
c
t
i
a
ta
tic Me
at
et
as
ta
M
st
s
a
et
a
M
et
et
M
M
Histological
Classification

The patient with B-cell lymphoma was radiologically thought to be a metastases.
Histology confirmed B-cell lymphoma.
The Indication for Awake Craniotomy
i.e. the Area of Eloquent Cortex
Affected by Tumour Presence
The Areas of Eloquent Cortex Affected by Tumour
Presence (Indication for Aw ake Craniotomy)
4
6
17
7
2
Speech
Sensory
Motor
Motor and Sensory
Motor and Speech
ANAESTHETIC ROOM
-Sedation commenced
-Remifentanyl
-Propofol target controlled infusion
- 1% Lignocaine to pin sites
- Propofol bolus
- Mayfield 3-pin head fixator applied
THEATRE
-Positioning of patient
-Image guided system registered
-Incision site prepped
-Elliptical ring block performed with 0.25 % Bupivicaine
and 1 in 200, 000 Adrenaline
-Craniotomy performed
-Cortical mapping (Ojemann cortical stimulator)
-Tumour resection
-Continuous monitoring throughout resection
+/- sub-cortical stimulation
-Dura closed and bone flap replaced
RECOVERY, FOLLOWED
BY THE WARD
-Neuro observations
-CT at 4 hours for day-cases
Theatre set-up
Intra-Operative Photos 1
Intra Operative Photos 2
Pain Management

Potential sites for pain during the operation
-
Inserting Mayfield 3-pin head fixator
Lifting bone flap
Operating close to the falx
Operating near the floor of the middle fossa dura

No patients required additional lignocaine

No patients had problems with pin sites
-
Anaesthetic Details: Propofol

TCI Propofol= Target
Controlled Infusion
Total Volume of TCI Propofol Required by Awake
Craniotomy Patients
10


No patient required more
than one syringe of propofol.
An average GA requires 6-7
syringes of propofol
8
Total Number 6
of Patients 4
2
0
0 to 10 10 to 16 to 21 to 26 to 30 to
15
20
25
30
35
Volume of Propofol (ml)
Mean TCI Propofol =13.8 mls
Range of TCI Propofol = 1.6 mls to 36 mls
Additional Drugs within the
Anaesthetic Regimen

-
-
Patients also received:
Additional Analgesia (e.g. Morphine, Paracetamol)
Anti-emetics (e.g. Cyclizine and/or Ondansetron)
Benzodiazepines (e.g. Midazolam)
Prophylactic Antibiotics (e.g. Cefuroxime)
Phenytoin (if no pre-op AED)
Intra-Operative Anaesthetic
Monitoring/ Intervention

Cannula = 16 gauge

ECG monitor

NIBP

SaO2

No DVT prophylaxis
Number of Patients
Intervention
Yes
No
Intra Venous
Cannula
38
0
Arterial Line
6
32
Urinary
Catheter
3
35
Endotracheal
Tube
0
38
Over-View of Method

Anaesthetic Time
- Mean: 20 minutes
- Range: 8 to 60 minutes

Intra-Operative Complications
Complication
Number
of
Patients
Focal Seizure
3
Generalized Seizure
2
Operative Time
- Mean: 3 hours 5 minutes
- Range: 1 hour 4 minutes
to 4 hours 50 minutes


No patients required
conversion to general
anaesthetic
Analysis of Mapping Results
Results of Mapping:
Impact of Mapping Results on
Tumour Resection:
Change to approach of tumour
resection following mapping
results:
Results of Mapping
Number of Patients
Positive
28
Negative
10
Tumour Resection
Following Mapping
Number of Patients
Increased
20
Decreased
7
No Change
10
Cancelled
1
Approach to Tumour
Resection
Number of Patients
Changed
18
No change
19
Operation
Abandoned
1
Post-Operative Complications



Nursing Post-Operatively: 1/38 patients required a bed in NICU.
Transient Complications
- 5/38 patients experienced transient neurological deficits (13%)
- One patient entered status epilepticus.
- One patient suffered severe expressive dysphasia.
Permanent Complications
- One patient experienced an internal capsule infarct (2.6%)
Number of Patients
Complication
Yes
No
Return to theatre for further surgery
1
37
DVT/PE prior to discharge *
0
38
Wound Infection/UTI prior to discharge *
0
38
Total Length of In-Patient Stay
Length of Time (Days)
Total Le ngth of Stay in Hos pital of Aw ak e
Craniotom y Patie nts
7 Days +
6 Days
5 Days
4 Days
3 Days
2 Days
1 Day
0 Days
0
2
4
6
8
10
Number of Patients

Reasons for delay in discharge:
Reason for Delay
Number of Patients
Extra Observations Required
8
Transport Issues
2
Mobilisation problems
2
Re-warfarinisation required
1
Summary of the Awake Craniotomy
Technique



Awake craniotomy creates a surgical option for the resection
of tumours lying on or adjacent to eloquent cortex.
Surgery can be offered to patients, where surgery previously
may have been deemed too high risk.
Additional benefits:
-
Reduction in cost compared to asleep-awake-asleep protocol
Low complication rate e.g. DVT and infection
Reduction in hospital stay
Reduction in need for high-dependency nursing post-operatively
Avoids risks and side-effects of GA
Potentially improved quality of life post operatively
Stereotactic biopsy

Lengthy process in theatre
– GA
– Frame and CT under GA
– Planning under GA
– Time waiting for intra-op frozen section

In-patient stay too long?
Solutions




Frameless stereotaxy
LA +/- sedation
Don’t wait for intra-operative
neuropathology?
Day-case biopsy?
Methods







Prospective study
Consecutive cohort
July 2005 – present
Stryker IGS system
Single trajectory
Multiple samples – 2-3 targets
Side-cutting cannula
Results





110 biopsies performed
Age range 14-82
Mean age 58.9yrs
Males 68
Females 42
Results

1 biopsy was non-diagnostic (0.9%)

Morbidity 1 (0.9%)
– 1 ICH that didn’t require surgery or alter
condition significantly

Deaths 2 (1.8%)
Negative biopsy
Deaths

Thalamic GBM
– Hemiplegia on admission
– Sudden deterioration after 2 days
– Not Ix/resus due to diagnosis and PS

Gliomatosis cerebri
– Severe cognitive impairment on admission
– Deterioration due to oedema after 3 days
– Died after 5 days
Diagnoses










GBM 51 (46.4%)
Lymphoma 10 (9.1%)
Mets 7 (6.4%)
AnOA 6 (5.5%)
Astrocytoma 5 (4.9%)
AnO 5 ( 4.9%)
AnA 5 (4.9%)
OA 4 (3.9%)
Oligo 3 (2.7%)
Gliomatosis 3 (2.7%)
Results comparison
Non-Diagnosis
M&M
PG (n=110)
0.9%
2.7%
WNC (n=127)
5.5%
4.7%
Hall (n=7471)
9%
4.2%
Conclusions



Frameless stereotactic biopsy using this
technique has high diagnostic yield and low
morbidity and mortality
Intra-operative neuropathology may not be
necessary
Frameless IGSBx under LA saves theatre
time, in-patient stay and money and is well
tolerated
Day-case neurosurgery
Feasability

Mobile post-op
Pain controlled

Social support

Complications

– Incidence
– Type
– timing
Previous studies

Bhardwaj RD,Bernstein M, ‘Prospective feasibility study of
outpatient stereotactic brain lesion biopsy.’, Neurosurgery.
2002 Aug;51(2):358-61
– 76 cases, 1 minimal bleed, 1 worsening of neurology and 2 stayed
overnight for IV Antibiotics & further investigations.

Bernstein M, ‘Outpatient craniotomy for brain tumour: a pilot
feasability study in 46 patients.’ Can J Neurol Sci. 2001
May;28(2):120-4
– 46 cases, 5 stayed overnight.

Kaakaji W, Barnett GH, Bernhard D, Warbel A, Valaitis K, Stamp S.
‘Clinical and economic consequences of early discharge of
patients following supratentorial stereotactic brain biopsy.’ J
Neurosurg. 2001 Jun;94(6):892-8
– 139 cases, 11 bleeds detected within 6 hours post-op, 1 went back to
theatre, rest went home same day.
WNC study


10/06 to present
26 intracranial tumour patients
– no medical condition warranting overnight
stay
– someone present at home post-discharge
– smaller tumours for awake craniotomy
Process




OPA - PAC - IGS scan
DOSA 07:30
CT scan 4 hours post-op
Discharged 6 hours post-op
– Discharge check list
– Information leaflet
Cases




Image-guided biopsy - 21
Craniotomy - 5
14 operated on by consultant
12 by SpR
Details

Age;

– Mean: 56.6
– Range: 23-86

– Lt: 13
– Rt: 8
– Bilateral: 3
Pathology;
–
–
–
–
–
–
–
–
–
–
GBM: 8
Metastatic: 4
Astrocytoma III: 3
Oligo II: 2
Lymphoma: 2
Anaplastic oligo:1
Oligo-astro grade II: 1
Oligo-astro grade III: 1
PNET: 1
Inflammatory lesion: 1
Side;

Site:
–
–
–
–
–
–
–
Frontal : 7
Parietal : 7
Temporal : 5
Insular : 2
Hippocampal : 1
Gliomatosis cerebri : 1
Butterfly lesion : 1
Results



No complications
No re-admissions
18/21 IGSBx went home same day (86%)
– 2 stayed overnight owing to patient/family anxiety
– 1 intra-operative bleed stayed 2 nights; normal CT

5/5 craniotomies went home same day
Conclusion

Day-case IGS biopsy & awake craniotomy for
tumours is safe and feasible

Day case IGS biopsy is now routine practice

There is a need for on-going larger
prospective study in UK
– Consider qualitative issues too
Overall conclusion
Awake & day-case neurosurgery are
– Feasible
– Safe
– Efficient
– Cost effective
– Well tolerated
Why aren’t we all doing it?
Thanks




Crispin Weidmann
Victoria Beasley
Colin Griffith
Amr Salem