Awake Craniotomy Treatment
During surgery to remove brain tumors, University of Miami neurosurgeons and neurologists have the ability to use brain-mapping techniques to identify and avoid injury to sites of language, motor, and sensory function during surgery. For example, when a tumor is near critical speech areas of the brain, it may be important to determine the exact location of these speech-related areas. Although functional MRI can show the various areas of activation during speech, it does not pinpoint the most important areas. These critical areas must be located using special speech mapping techniques while the patient is awake in the operating room. Awake speech mapping involves applying mild electrical current to the surface of the exposed brain while the patient performs various tasks, such as reading. If the stimulation hinders the task, then that area of the brain is marked and preserved.
A similar procedure may be done for tumors located near the motor region. In these cases, the cortex is stimulated and movement is recorded in order to carefully delineate the eloquent regions to be preserved during resection. Stimulation may be performed throughout the resection to continually monitor functional tissue, with the patient also being asked to perform simple movements.
The general technique for awake craniotomies with mapping is performed as follows – the operation is begun while the patient is deeply asleep. This is for the comfort of the patient and is safe. When the brain is exposed and the neurosurgeon is ready to begin mapping, neuroanesthesiologists carefully lighten the sedation to allow the patient to talk, move, and interact with the neurologists. Typically, the patients feel minimal or no discomfort while awake. As stated previously, stimulation is used to tailor a motor and/or speech map of the brain. This map permits surgeons to maximize tumor removal while preserving functional tissue during surgery with minimal neurologic risk to the patient. Once the mapping is complete, often the tumor is removed while the speech and/or motor testing continues. The anesthesiologist places the patient back under deep anesthesia after tumor resection to allow the neurosurgeon to complete the operation safely with no discomfort to the patient.
Brain mapping permits the surgeon to remove tumor and focal points of epileptic activity from the brain to the maximum extent possible, while minimizing ill effects from surgery. They also use the most advanced surgical navigation systems, which permit confirmation of tumor location under the scalp and bone during incision planning and under the brain surface during the operation. These image-guided systems are used throughout the surgery to assist the surgeon in achieving excision of as much tumor as possible.
The benefits of multidisciplinary care at Miami are especially evident in awake craniotomy surgery, which requires a seamless coordination between neurosurgeon and neurologist. Drs. Roberto Heros, Jacques Morcos, Ronald Benveniste, and Ricardo Komotar from the Department of Neurosurgery and Drs. Bruno Gallo and Deborah Heros from the Department of Neurology work together as a team to conduct this technique. Other team members include an experienced neuroanesthesiologist to achieve a fine balance of wakefulness and sedation, and neuroradiologist, who provides functional MRI scans as part of the preoperative workup.
Treatments may also include radiotherapy, chemotherapy and immunotherapy. The care is coordinated by a multidisciplinary team including Neurosurgery, Neuro-Oncology, Radiation Oncology, Neuropathology, and Neuroradiology. These specialists meet regularly for a tumor board to determine the most appropriate therapy for each patient.
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