Awake Surgery for Brain Vascular Malformations and Moyamoya Disease

• Published in: World neurosurgery 2017-09, Vol.105, p.659-671
• Main Authors: Aoun, Rami James N., MD, MPH, Sattur, Mithun G., MBBS, Krishna, Chandan, MD, Gupta, Amen, MBBS, Welz, Matthew E., MS, Nanney, Allan D., MD, Koht, Antoun H., MD, Tate, Matthew C., MD, PHD, Noe, Katherine H., MD, PhD, Sirven, Joseph I., MD, Anderies, Barrett J, Bolton, Patrick B., MD, Trentman, Terry L., MD, Zimmerman, Richard S., MD, Swanson, Kristin R., PhD, Bendok, Bernard R., MD, MSCI, FACS
• Format: Article
• Language: English
• Subjects: Adult; Arteriovenous malformation; Awake surgery; Cavernomas; Central Nervous System Vascular Malformations - diagnostic imaging; Central Nervous System Vascular Malformations - surgery; Direct cortical stimulation; Female; fMRI; Humans; Magnetic Resonance Imaging - methods; Male; Middle Aged; Monitoring, Intraoperative - methods; Moyamoya; Moyamoya Disease - diagnostic imaging; Moyamoya Disease - surgery; Neurosurgery; Neurosurgical Procedures - methods; Neurovascular surgery; Wakefulness; Young Adult
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2017.03.121

Abstract Objective While a significant amount of experience has accumulated for awake procedures for brain tumor, epilepsy and carotid surgery, its utility for intracranial neurovascular indications remains largely undefined. Awake surgery, for select neurovascular cases, offers the advantage of precise brain mapping and robust neurological monitoring during surgery for lesions in eloquent areas, avoidance of potential hemodynamic instability, and possible faster recovery. Additionally, it opens the window for perilesional epileptogenic tissue resection with potentially less risk for iatrogenic injury. Methods IRB approval was obtained for a retrospective review of awake surgeries for intracranial neurovascular indications over the past 36 months from a prospectively maintained quality database. We reviewed patients’ clinical indications, clinical and imaging parameters, and postoperative outcomes. Results 8 consecutive patients underwent 9 intracranial neurovascular awake procedures conducted by the senior author. A standardized “Sedated-Awake-Sedated” protocol was utilized in all eight patients. For the two AVM patients and the three cavernoma patients, awake brain surface and white matter mapping was performed before and during microsurgical resection. A neurological exam was obtained periodically throughout all 5 procedures. There were no intra-operative or peri-operative complications. Hypotension was avoided during the two Moyamoya revascularization procedures in the patient with a history of labile blood pressure. Postoperative imaging confirmed complete AVM and cavernoma resections. No new neurological deficits or new onset seizures were noted on 3-month follow-up. Conclusion Awake surgery appears to be safe for select patients with intracranial neurovascular pathologies. Potential advantages include greater safety, shorter length of stay and reduced cost.