Brain Tumour

Awake Craniotomy

  • Awake Craniotomy

A surgical procedure for tumour close to the functionally important part of brain

– By Dr. Manish Kumar MBBS, DNB (Neurosurgery)

An awake craniotomy is a surgical operation carried out similarly to any conventional craniotomy however in this surgery the patient is awake during the procedure. Awake Craniotomy is one of the most preferred techniques for operations for excision of tumors which involve or are close to the eloquent regions of the brain. This technique of craniotomy allows the neurosurgeons to test the brain region before incision / excision along with a regular check on the patient’s functionality during the surgery. An awake Craniotomy minimizes the risk for the patient during the operation.

Awake Craniotomy Process

A drip is inserted in patient’s body for the purpose of giving local anesthesia when the patient is in the anesthetic room. The local anesthesia comforts and relaxes the patient body after which the patient is taken to operation theatre where the Neuronavigation system is used to mark areas for incisions (cuts). Through the line incision, small amount of hair would be shaven off for clear incision and to avoid infection. The patient will be in a slightly numb state however being able to hear surrounding noises and move limbs. After the incision is done the brain area is exposed Cortical Mapping is performed.

“Establishing the relationship between various structures of the brain and their functions, Cortical Mapping is a technique used in neurosurgery to determine which parts of a diseased brain may be safely excised.”

http://medical-dictionary.thefreedictionary.com/cortical+mapping

Post operation and removal of tumour the bleeding is stopped the thick membrane around the brain is closed with the help of sutures. Mini plates are used to replace the bone flap and to close scalp. The skin is stapled to close the wound and apply a head bandage.

Post Awake Craniotomy

The recovery period is much shorter for the patients of awake craniotomy compared to conventional craniotomy. The patient is able to consume food and liquid and move around. The discharge is usually the same day after surgery or after a day once the neurosurgeon confirms. It takes few weeks to completely recover after any major surgery. In case of Awake Craniotomy, for first few weeks, the patient might suffer from headaches which can be controlled with general painkillers. There are chances of dizziness, and it is must to rest properly. A little exercise or walk is however generally preferred.

Consult your doctor in case, you see following symptoms:

  • Progressively worsening headaches
  • Fits
  • Fever & Rashes
  • Wound problems
  • Weakness or Numbness
  • Increasing drowsiness

Complications after Awake Craniotomy Surgery

The risks for the Awake Craniotomy are similar to that of conventional surgery, however there is also a chance of seizures during the surgery which might require the awake surgery to be transformed into conventional surgery with general anesthesia. Surgeries are always risky and while the awake surgery is considered to be a safer option, the slight risk involved depends on the factors like size, location and the type of tumour along with patient’s generic health and medical history.

Complications after awake surgery include, however not exclusive to:

  • Temporary or permanent paralysis of limbs or loss of speech
  • Blood clot
  • Brain swelling
  • Infection
  • Fits

Brain Craniotomy

  • Brain Craniotomy

Successful Craniotomy done with Excision of Tumor (Enplaque Maningioma): A Case Study

Dr. Anil Arya MBBS, MS, DNB (Neuro Surgeon)
Surgical Case Reports 2017 © The Park Group of Hospitals. 2017

Abstract

“En plaque meningioma refers to a specific meningioma macroscopic appearance characterised by diffuse and extensive dural involvement, usually with extracranial extension into calvarium, orbit, and soft tissues. These tumours are thought to have a collar-like or sheet-like growth along the dura mater, different from the usual globular meningioma.”* This type of brain tumour is highly vascular and involves risky operation. Being a very rare type of tumour, this needs intensive care. A 45 year old woman with a progressive increasing headache on the right side of the brain for last years, who was also misdiagnosed by a private hospital in Sonepat, visited Park Hospital Panipat. The team at Park Hospital Panipat started the treatment with MRI and brain investigations wherein the En-Plaque Meningioma was diagnosed. There was pain and bulginess in both eye balls due to the tumour and weakness on the left side. The patient was discharged after a week of intensive observation and once we saw recovery signs in her with the ability to move smoothly her limbs.

Background

En-Plaque Meningioma is a rare type of brain tumour and requires intensive care. This is one of the slow growing benign tumours which is attached to the dura and are made up of neoplastic meningothelial cells. These are more common in Western World reporting around 24-30% cases. Meningioma en plaque represents a morphological subgroup within the meningiomas defined by a carpet or sheet-like lesion that infiltrates the dura and sometimes invades the bone. Histopathological features of meningioma enplaque are similar to that of usual meningiomas; however, it is sometimes difficult to predict the behavior in individual cases. Extra-cranial meningiomas form 1-2% percentages of all meningiomas. ** The en plaque variants commonly involve fronto-parietal, juxtaorbital, sphenoid wing, diffuse calvarial or rarely spinal region. *** Due to difficulty in complete resection, the recurrence rate of en plaque meningiomas is higher than the usual counterpart. **** These tumors are also more prone to develop malignant change (11%) when compared to intracranial meningiomas.

Case Presentation

A 45 year old woman visited Park hospital Panipat for an OPD consultation with Dr. Anil Arya wherein he studied the MRI reports and after brain investigations, he diagnosed a rare brain tumour. The lady had progressive increasing headache on the right side of the brain for last 5 years. However, for last 2 years there was pain and bulginess in both eye balls. The patient visited a private hospital in Sonepat for the treatment wherein the CT head was performed and based on the same she was misdiagnosed with Subdural Hematoma. During the operation, the doctor confirmed that the case is of Brain tumour. She was then referred to GB Pant Hospital in New Delhi for further treatment. However, she did not receive any treatment or response; thereafter she contacted Dr. Anil Arya at Park Panipat. After explaining the complexity of the surgery and the poor prognosis during and after the surgery, with due permissions, the patient was operated on 27th July 2017. The tumour mass was completely removed from the brain with craniotomy. Post operation, the patient is conscious oriented with signs of difficulty in limb movement.

Discussion
As per Dr. Anil Arya, “The surgery was very complicated and could have risked the life of the patient as well.”

Conclusion

Post surgery, the patient is very well and is also not having any issues with the limbs movement and is also not experiencing any limb weakness.

Declarations

The case study is presented with the consent of the patient and his family members.

References

*Basu K, Majumdar K, Chatterjee U, Ganguli M, Chatterjee S. En plaque meningioma with angioinvasion. Indian J Pathol Microbiol 2010;53:319-21
**Perry A, Louis DN, Scheithauer BW, Budka H, von Deimling A. Meningiomas. In: Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, editors. Pathology and Genetics, World Health Organization Classification of Tumours of the Central Nervous System. 4th ed. Lyon: IARC press; 2007. p. 164-72.
**De Jesus O, Toledo MM. Surgical management of meningioma en plaque of the sphenoid ridge. Surg Neurol 2001;55:265-9.
***Muzumdar DP, Vengsarkar US, Bhatjiwale MG, Goel A. Diffuse Calvarial Meningioma: A Case Report. J Postgrad Med 2001;47:116-8. [PUBMED] Medknow Journal
***Klekamp J, Samii M. Surgical results for spinal meningiomas. Surg Neurol 1999;52:552-62. [PUBMED] [FULLTEXT]
****Akutsu H, Sugita K, Sonobe M, Matsumura A. Parasagittal meningioma en plaque with extracranial extension presenting diffuse massive hyperostosis of the skull. Surg Neurol 2004;61:165-9. [PUBMED] [FULLTEXT]
****Yamada S, Kawai S, Yonezawa T, Masui K, Nishi N, Fujiwara K. Cervical extradural en-plaque meningioma. Neurol Med Chir (Tokyo) 2007;47:36-9. [PUBMED] [FULLTEXT]
****Shuangshoti S. Primary meningiomas outside the central nervous system. In: Al-Mefty O, editor. Meningiomas. New York: Raven Press; 1991. p. 107-28.