Introduction: An awake craniotomy (AC) and surgery under general anesthesia (GA) present two approaches for removing perirolandic, motor area gliomas. With a reported higher prevalence of intraoperative seizures occurring during awake resections of perirolandic lesions, oftentimes, surgery under general anesthesia is chosen for these lesions. This study evaluates a single-surgeon's experience with awake craniotomies versus surgery under general anesthesia for resecting perirolandic, motor area gliomas.

Methods: A comparative univariate analysis between 31 patients who had a craniotomy under general anesthesia (GA) with neuromonitoring and direct cortical stimulation (DCS) versus 27 patients who underwent an awake craniotomy (AC) with DCS for perirolandic gliomas was conducted. Perioperative risk factors, extent of resection, complications, and discharge status were assessed.

Results: The two groups were comparable in terms of age, sex, preoperative Karnofsky Performance Status score, size of the lesions, tumor location, and postoperative neurological deficits. The postoperative KPS, months after surgery, was significantly lower for the GA patients at 81.1 compared to the AC patients at 93.3 (p=0.040). The extent of resection for GA patients was 79.6% while the AC patients had a 86.3% resection (p=0.136). There were significantly more 100% total resections in the AC patients 25.9% compared to the GA group (6.5%) (p=0.041). Patients in the GA group had a longer mean length of hospitalization of 7.9 days compared to the AC group which was 4.2 days (p=0.05). Stimulation-induced seizures occurred in 7.4% of AC cases and 16.1% of GA cases (p=0.432), with no aborted cases in either group.

Conclusions: An awake craniotomy presents a safe, viable approach for perirolandic, eloquent region glioma resections. We show that awake craniotomies can be performed with low intraoperative seizure rates, more frequent 100% total resections, better postoperative KPS, shorter hospitalizations, as well as similar perioperative complication rates compared to surgery under general anesthesia.

Patient Care: This study evaluates the efficacy and safety of awake craniotomies on perirolandic gliomas, thus allowing surgeons to choose the safest surgical approach for treating patients with eloquent region gliomas that can help improve surgical outcome and minimize length of hospitalization.

Learning Objectives: 1) To understand the postoperative outcome differences between awake craniotomies versus surgery under general anesthesia for perirolandic gliomas 2) To identify surgical risks associated with awake craniotomies and surgery under general anesthesia 3) To evaluate the best surgical approach for perirolandic gliomas

References: 1. Hervey-Jumper SL, Li J, Lau D, et al. Awake craniotomy to maximize glioma resection: Methods and technical nuances over a 27-year period. J Neurosurg. 2015;123(2):325-339. 2. Jakola AS, Myrmel KS, Kloster R, et al. Comparison of a strategy favoring early surgical resection vs a strategy favoring watchful waiting in low-grade gliomas. JAMA. 2012;308(18):1881-1888. 3. Markert JM. The role of early resection vs biopsy in the management of low-grade gliomas. JAMA. 2012;308(18):1918-1919. 4. McGirt MJ, Chaichana KL, Attenello FJ, et al. Extent of surgical resection is independently associated with survival in patients with hemispheric infiltrating low-grade gliomas. Neurosurgery. 2008;63(4):700-7; author reply 707-8. 5. Smith JS, Chang EF, Lamborn KR, et al. Role of extent of resection in the long-term outcome of low-grade hemispheric gliomas. J Clin Oncol. 2008;26(8):1338-1345. 6. Trimble G, McStravick C, Farling P, et al. Awake craniotomy for glioma resection: Technical aspects and initial results in a single institution. Br J Neurosurg. 2015:1-7. 7. Almeida JP, Chaichana KL, Rincon-Torroella J, Quinones-Hinojosa A. The value of extent of resection of glioblastomas: Clinical evidence and current approach. Curr Neurol Neurosci Rep. 2015;15(2):517-014-0517-x. 8. Chaichana KL, Jusue-Torres I, Lemos AM, et al. The butterfly effect on glioblastoma: Is volumetric extent of resection more effective than biopsy for these tumors? J Neurooncol. 2014;120(3):625-634. 9. Chaichana KL, Cabrera-Aldana EE, Jusue-Torres I, et al. When gross total resection of a glioblastoma is possible, how much resection should be achieved? World Neurosurg. 2014;82(1-2):e257-65. 10. Chaichana KL, Jusue-Torres I, Navarro-Ramirez R, et al. Establishing percent resection and residual volume thresholds affecting survival and recurrence for patients with newly diagnosed intracranial glioblastoma. Neuro Oncol. 2014;16(1):113-122. 11. McGirt MJ, Mukherjee D, Chaichana KL, Than KD, Weingart JD, Quinones-Hinojosa A. Association of surgically acquired motor and language deficits on overall survival after resection of glioblastoma multiforme. Neurosurgery. 2009;65(3):463-9; discussion 469-70. 12. Skirboll SS, Ojemann GA, Berger MS, Lettich E, Winn HR. Functional cortex and subcortical white matter located within gliomas. Neurosurgery. 1996;38(4):678-84; discussion 684-5. 13. Ojemann JG, Miller JW, Silbergeld DL. Preserved function in brain invaded by tumor. Neurosurgery. 1996;39(2):253-8; discussion 258-9. 14. Reithmeier T, Krammer M, Gumprecht H, Gerstner W, Lumenta CB. Neuronavigation combined with electrophysiological monitoring for surgery of lesions in eloquent brain areas in 42 cases: A retrospective comparison of the neurological outcome and the quality of resection with a control group with similar lesions. Minim Invasive Neurosurg. 2003;46(2):65-71. 15. Bookheimer S. Pre-surgical language mapping with functional magnetic resonance imaging. Neuropsychol Rev. 2007;17(2):145-155. 16. Mate A, Lidzba K, Hauser TK, Staudt M, Wilke M. A "one size fits all" approach to language fMRI: Increasing specificity and applicability by adding a self-paced component. Exp Brain Res. 2016;234(3):673-684. 17. Tharin S, Golby A. Functional brain mapping and its applications to neurosurgery. Neurosurgery. 2007;60(4 Suppl 2):185-201; discussion 201-2. 18. Tie Y, Rigolo L, Ozdemir Ovalioglu A, et al. A new paradigm for individual subject language mapping: Movie-watching fMRI. J Neuroimaging. 2015;25(5):710-720. 19. Walker JA, Quinones-Hinojosa A, Berger MS. Intraoperative speech mapping in 17 bilingual patients undergoing resection of a mass lesion. Neurosurgery. 2004;54(1):113-7; discussion 118. 20. Quinones-Hinojosa A, Ojemann SG, Sanai N, Dillon WP, Berger MS. Preoperative correlation of intraoperative cortical mapping with magnetic resonance imaging landmarks to predict localization of the broca area. J Neurosurg. 2003;99(2):311-318. 21. Boetto J, Bertram L, Moulinie G, Herbet G, Moritz-Gasser S, Duffau H. Low rate of intraoperative seizures during awake craniotomy in a prospective cohort with 374 supratentorial brain lesions: Electrocorticography is not mandatory. World Neurosurg. 2015. 22. De Witt Hamer PC, Robles SG, Zwinderman AH, Duffau H, Berger MS. Impact of intraoperative stimulation brain mapping on glioma surgery outcome: A meta-analysis. J Clin Oncol. 2012;30(20):2559-2565. 23. De Benedictis A, Moritz-Gasser S, Duffau H. Awake mapping optimizes the extent of resection for low-grade gliomas in eloquent areas. Neurosurgery. 2010;66(6):1074-84; discussion 1084. 24. Sacko O, Lauwers-Cances V, Brauge D, Sesay M, Brenner A, Roux FE. Awake craniotomy vs surgery under general anesthesia for resection of supratentorial lesions. Neurosurgery. 2011;68(5):1192-8; discussion 1198-9. 25. Nossek E, Matot I, Shahar T, et al. Failed awake craniotomy: A retrospective analysis in 424 patients undergoing craniotomy for brain tumor. J Neurosurg. 2013;118(2):243-249. 26. Chang SM, Parney IF, Huang W, et al. Patterns of care for adults with newly diagnosed malignant glioma. JAMA. 2005;293(5):557-564. 27. Nossek E, Matot I, Shahar T, et al. Intraoperative seizures during awake craniotomy: Incidence and consequences: Analysis of 477 patients. Neurosurgery. 2013;73(1):135-40; discussion 140. 28. Gonen T, Grossman R, Sitt R, et al. Tumor location and IDH1 mutation may predict intraoperative seizures during awake craniotomy. J Neurosurg. 2014;121(5):1133-1138. 29. Berger MS, Ojemann GA, Lettich E. Neurophysiological monitoring during astrocytoma surgery. Neurosurg Clin N Am. 1990;1(1):65-80. 30. LeRoux PD, Berger MS, Haglund MM, Pilcher WH, Ojemann GA. Resection of intrinsic tumors from nondominant face motor cortex using stimulation mapping: Report of two cases. Surg Neurol. 1991;36(1):44-48. 31. Berger MS, Rostomily RC. Low grade gliomas: Functional mapping resection strategies, extent of resection, and outcome. J Neurooncol. 1997;34(1):85-101. 32. Meyer FB, Bates LM, Goerss SJ, et al. Awake craniotomy for aggressive resection of primary gliomas located in eloquent brain. Mayo Clin Proc. 2001;76(7):677-687. 33. Duffau H, Lopes M, Arthuis F, et al. Contribution of intraoperative electrical stimulations in surgery of low grade gliomas: A comparative study between two series without (1985-96) and with (1996-2003) functional mapping in the same institution. J Neurol Neurosurg Psychiatry. 2005;76(6):845-851. 34. Picht T, Kombos T, Gramm HJ, Brock M, Suess O. Multimodal protocol for awake craniotomy in language cortex tumour surgery. Acta Neurochir (Wien). 2006;148(2):127-37; discussion 137-8. 35. Lee YJ, Chung TS, Yoon YS, et al. The role of functional MR imaging in patients with ischemia in the visual cortex. AJNR Am J Neuroradiol. 2001;22(6):1043-1049. 36. Schreiber A, Hubbe U, Ziyeh S, Hennig J. The influence of gliomas and nonglial space-occupying lesions on blood-oxygen-level-dependent contrast enhancement. AJNR Am J Neuroradiol. 2000;21(6):1055-1063. 37. Trinh VT, Fahim DK, Maldaun MV, et al. Impact of preoperative functional magnetic resonance imaging during awake craniotomy procedures for intraoperative guidance and complication avoidance. Stereotact Funct Neurosurg. 2014;92(5):315-322. 38. Wilden JA, Voorhies J, Mosier KM, O'Neill DP, Cohen-Gadol AA. Strategies to maximize resection of complex, or high surgical risk, low-grade gliomas. Neurosurg Focus. 2013;34(2):E5. 39. Duffau H. A new concept of diffuse (low-grade) glioma surgery. Adv Tech Stand Neurosurg. 2012;38:3-27. 40. Potgieser AR, de Jong BM, Wagemakers M, Hoving EW, Groen RJ. Insights from the supplementary motor area syndrome in balancing movement initiation and inhibition. Front Hum Neurosci. 2014;8:960. 41. Peruzzi P, Bergese SD, Viloria A, Puente EG, Abdel-Rasoul M, Chiocca EA. A retrospective cohort-matched comparison of conscious sedation versus general anesthesia for supratentorial glioma resection. clinical article. J Neurosurg. 2011;114(3):633-639. 42. Martino J, Gomez E, Bilbao JL, Duenas JC, Vazquez-Barquero A. Cost-utility of maximal safe resection of WHO grade II gliomas within eloquent areas. Acta Neurochir (Wien). 2013;155(1):41-50. 43. Archer DP, McKenna JM, Morin L, Ravussin P. Conscious-sedation analgesia during craniotomy for intractable epilepsy: A review of 354 consecutive cases. Can J Anaesth. 1988;35(4):338-344. 44. Conte V, Magni L, Songa V, et al. Analysis of propofol/remifentanil infusion protocol for tumor surgery with intraoperative brain mapping. J Neurosurg Anesthesiol. 2010;22(2):119-127. 45. Gignac E, Manninen PH, Gelb AW. Comparison of fentanyl, sufentanil and alfentanil during awake craniotomy for epilepsy. Can J Anaesth. 1993;40(5 Pt 1):421-424. 46. Grossman R, Nossek E, Sitt R, et al. Outcome of elderly patients undergoing awake-craniotomy for tumor resection. Ann Surg Oncol. 2013;20(5):1722-1728. 47. Serletis D, Bernstein M. Prospective study of awake craniotomy used routinely and nonselectively for supratentorial tumors. J Neurosurg. 2007;107(1):1-6. 48. Skucas AP, Artru AA. Anesthetic complications of awake craniotomies for epilepsy surgery. Anesth Analg. 2006;102(3):882-887. 49. Pereira LC, Oliveira KM, L'Abbate GL, Sugai R, Ferreira JA, da Motta LA. Outcome of fully awake craniotomy for lesions near the eloquent cortex: Analysis of a prospective surgical series of 79 supratentorial primary brain tumors with long follow-up. Acta Neurochir (Wien). 2009;151(10):1215-1230. 50. Holodny AI, Schulder M, Liu WC, Wolko J, Maldjian JA, Kalnin AJ. The effect of brain tumors on BOLD functional MR imaging activation in the adjacent motor cortex: Implications for image-guided neurosurgery. AJNR Am J Neuroradiol. 2000;21(8):1415-1422. 51. Szelenyi A, Bello L, Duffau H, et al. Intraoperative electrical stimulation in awake craniotomy: Methodological aspects of current practice. Neurosurg Focus. 2010;28(2):E7. 52. McGirt MJ, Chaichana KL, Gathinji M, et al. Independent association of extent of resection with survival in patients with malignant brain astrocytoma. J Neurosurg. 2009;110(1):156-162. 53. Sanai N, Polley MY, McDermott MW, Parsa AT, Berger MS. An extent of resection threshold for newly diagnosed glioblastomas. J Neurosurg. 2011;115(1):3-8. 54. Chaichana KL, Garzon-Muvdi T, Parker S, et al. Supratentorial glioblastoma multiforme: The role of surgical resection versus biopsy among older patients. Ann Surg Oncol. 2011;18(1):239-245. 55. Taylor MD, Bernstein M. Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: A prospective trial of 200 cases. J Neurosurg. 1999;90(1):35-41. 56. Danks RA, Aglio LS, Gugino LD, Black PM. Craniotomy under local anesthesia and monitored conscious sedation for the resection of tumors involving eloquent cortex. J Neurooncol. 2000;49(2):131-139. 57. Gupta DK, Chandra PS, Ojha BK, Sharma BS, Mahapatra AK, Mehta VS. Awake craniotomy versus surgery under general anesthesia for resection of intrinsic lesions of eloquent cortex--a prospective randomised study. Clin Neurol Neurosurg. 2007;109(4):335-343. 58. Kim SS, McCutcheon IE, Suki D, et al. Awake craniotomy for brain tumors near eloquent cortex: Correlation of intraoperative cortical mapping with neurological outcomes in 309 consecutive patients. Neurosurgery. 2009;64(5):836-45; discussion 345-6. 59. Tuominen J, Yrjana S, Ukkonen A, Koivukangas J. Awake craniotomy may further improve neurological outcome of intraoperative MRI-guided brain tumor surgery. Acta Neurochir (Wien). 2013;155(10):1805-1812. 60. Chacko AG, Thomas SG, Babu KS, et al. Awake craniotomy and electrophysiological mapping for eloquent area tumours. Clin Neurol Neurosurg. 2013;115(3):329-334. 61. Andersen JH, Olsen KS. Anaesthesia for awake craniotomy is safe and well-tolerated. Dan Med Bull. 2010;57(10):A4194. 62. Sokhal N, Rath GP, Chaturvedi A, Dash HH, Bithal PK, Chandra PS. Anaesthesia for awake craniotomy: A retrospective study of 54 cases. Indian J Anaesth. 2015;59(5):300-305.