Planning for Awake Brain Surgery: In Light of Research Regarding Language Localization in the Brain

The Evolution of Brain Tumors Surgical Management Since the

Introduction of Neuro Navigation, Functional MRI, and Intraoperative

MRI at Abbott Northwestern Hospital

Mahmoud Nagib, M.D. , F.A.C.S. – Neurosurgical Associates, Ltd. James White, M.D. – MN Epilepsy Group, P.A. Mitchell Burke, M.D. – Northwest Anesthesia

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Disclosure

There are no conflicts of interest or relevant financial interests in making this presentation and have indicated that my presentation does not include discussion of an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose.

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The Evolution of Brain Tumors Surgical Management

• Number of patients surgically treated in the IoMRI = 1700

• Number of surgeons involved = 17

Mapping of the Brain Eloquent Cortex

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Case #1

• 71 year old male presented with a one week history of word finding difficulties. MRI shows hemorrhagic left frontal mass

Case #2

• 57 year old presented to medical attention following a seizure event preceded by speech arrest.

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Case #3

• 55 year old male presented with four week history of involuntary right hand movements

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Case #4

• 38 year old female presented with a two week history of left progressive hemiparesis

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Case #4

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Case #4

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• Over the past two decades the nihilistic approach towards the management of primary and secondary brain tumors has evolved into a more aggressive multidisciplinary management line.

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• Statistical evidence points to the fact the greater extent of tumor removal primary and secondary, the longer the progression-free survival.

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• The present statement applies to the various grades of primary brain tumors from low grade to higher grades.

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• The extent primary surgical resection remains the main prognostic factor for patient outcome.

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• Over the last decade over 1700 patients harboring a variety of brain tumors have been trusted at ANW. With the integration of neuro navigation, functional MRI, and IoMRI.

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• The innovation to be presented is the integration of awake craniotomies in the present discipline.

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• Awake craniotomies were described by Professor Horsley over 100 years ago. The techniques evidently have been refined over the years.

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• Awake craniotomies are indicated for tumors involving the “eloquent cortex”. It is therefore important to briefly discuss the language organization as a model for eloquent cortex.

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AWAKE CORTICAL MAPPING

CASE EXAMPLE

• 20 year-old healthy male presents with new-onset seizure.• Seizure description:– Seizure began with a nauseated feeling, followed by

inability to find the correct word to say. – He than had stiffening in his arms, collapsed, and had full

body convulsive seizure (= grand mal or generalized tonic clonic seizure).

– Seizure duration: 2 minutes– Took several minutes to recover language abilities.

GOAL OF TUMOR SURGERY

• Remove as much of tumor as possible.– The more tumor that is removed, the better the

outcome in terms of survival.• Avoid neurologic deficit.– The surgeon will remove as much tumor as possible, but

needs to avoid removing brain tissue critical for function.– Avoid deficits: paralysis, language impairment.

• Awake cortical mapping can provide a road map of brain function- allowing optimal surgical resection.

SURGICAL PLANNING

• Neurosurgery (Dr. Nagib)• Anesthesiology (Dr. Burke)• Neuroradiology (Dr. Gordon, Dr. Lee, Dr. Steely)• Neurophysiology (Dr. Skinner)

• Neurology/Epilepsy (Dr. White)• Neuropsychology (Dr. Risse, Dr. Doss)• MSI/EEG/Neuronavigation (Dr. Zhang, Dr. Dickens,

Dr. Doescher, Ed Carlson, Randy Danner, Brian Owens)

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The Integration of Anesthesia/Neurology/Neurosurgery

MAPPING ELOQUENT CORTEX

Minnesota Epilepsy Group, P.A.

Willey, Treatment of Epilepsy, 2011

CONCLUSIONS

A multidisciplinary approach with cutting edge brain mapping can allow for optimal removal of brain tumor:

–Remove as much of tumor as possible.–Avoid injury to critical brain structures,

including language function.

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THANK YOU!

Planning for Awake Brain Surgery: In Light of Research Regarding Language Localization in the Brain

Health & Medicine

Transcript of Planning for Awake Brain Surgery: In Light of Research Regarding Language Localization in the Brain