Awake Surgery for Brain Vascular Malformations and Moyamoya Disease

Rami James N. Aoun, Mithun G. Sattur, Chandan Krishna, Amen Gupta, Matthew E. Welz, Allan D. Nanney, Antoun Koht, Matthew Christopher Tate, Katherine H. Noe, Joseph I. Sirven, Barrett J. Anderies, Patrick B. Bolton, Terry L. Trentman, Richard S. Zimmerman, Kristin R. Swanson, Bernard R. Bendok*

*Corresponding author for this work

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Objective Although 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 neurologic monitoring during surgery for lesions in eloquent areas, avoidance of potential hemodynamic instability, and possible faster recovery. It also opens the window for perilesional epileptogenic tissue resection with potentially less risk for iatrogenic injury. Methods Institutional review board 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 Eight consecutive patients underwent 9 intracranial neurovascular awake procedures conducted by the senior author. A standardized “sedated–awake–sedated” protocol was used in all 8 patients. For the 2 patients with arteriovenous malformations and the 3 patients with cavernoma, awake brain surface and white matter mapping was performed before and during microsurgical resection. A neurological examination was obtained periodically throughout all 5 procedures. There were no intraoperative or perioperative complications. Hypotension was avoided during the 2 Moyamoya revascularization procedures in the patient with a history of labile blood pressure. Postoperative imaging confirmed complete arteriovenous malformation and cavernoma resections. No new neurologic deficits or new-onset seizures were noted on 3-month follow-up. Conclusions 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.

Original languageEnglish (US)
Pages (from-to)659-671
Number of pages13
JournalWorld Neurosurgery
Volume105
DOIs
StatePublished - Sep 1 2017

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Central Nervous System Vascular Malformations
Moyamoya Disease
Vascular Diseases
Arteriovenous Malformations
Brain Mapping
Research Ethics Committees
Neurologic Examination
Neurologic Manifestations
Brain Neoplasms
Hypotension
Nervous System
Epilepsy
Length of Stay
Seizures
Hemodynamics
Databases
Pathology
Blood Pressure
Safety
Costs and Cost Analysis

Keywords

  • Arteriovenous malformation
  • Awake surgery
  • Cavernomas
  • Direct cortical stimulation
  • Moyamoya
  • Neurovascular surgery
  • fMRI

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Aoun, R. J. N., Sattur, M. G., Krishna, C., Gupta, A., Welz, M. E., Nanney, A. D., ... Bendok, B. R. (2017). Awake Surgery for Brain Vascular Malformations and Moyamoya Disease. World Neurosurgery, 105, 659-671. https://doi.org/10.1016/j.wneu.2017.03.121
Aoun, Rami James N. ; Sattur, Mithun G. ; Krishna, Chandan ; Gupta, Amen ; Welz, Matthew E. ; Nanney, Allan D. ; Koht, Antoun ; Tate, Matthew Christopher ; Noe, Katherine H. ; Sirven, Joseph I. ; Anderies, Barrett J. ; Bolton, Patrick B. ; Trentman, Terry L. ; Zimmerman, Richard S. ; Swanson, Kristin R. ; Bendok, Bernard R. / Awake Surgery for Brain Vascular Malformations and Moyamoya Disease. In: World Neurosurgery. 2017 ; Vol. 105. pp. 659-671.
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abstract = "Objective Although 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 neurologic monitoring during surgery for lesions in eloquent areas, avoidance of potential hemodynamic instability, and possible faster recovery. It also opens the window for perilesional epileptogenic tissue resection with potentially less risk for iatrogenic injury. Methods Institutional review board 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 Eight consecutive patients underwent 9 intracranial neurovascular awake procedures conducted by the senior author. A standardized “sedated–awake–sedated” protocol was used in all 8 patients. For the 2 patients with arteriovenous malformations and the 3 patients with cavernoma, awake brain surface and white matter mapping was performed before and during microsurgical resection. A neurological examination was obtained periodically throughout all 5 procedures. There were no intraoperative or perioperative complications. Hypotension was avoided during the 2 Moyamoya revascularization procedures in the patient with a history of labile blood pressure. Postoperative imaging confirmed complete arteriovenous malformation and cavernoma resections. No new neurologic deficits or new-onset seizures were noted on 3-month follow-up. Conclusions 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.",
keywords = "Arteriovenous malformation, Awake surgery, Cavernomas, Direct cortical stimulation, Moyamoya, Neurovascular surgery, fMRI",
author = "Aoun, {Rami James N.} and Sattur, {Mithun G.} and Chandan Krishna and Amen Gupta and Welz, {Matthew E.} and Nanney, {Allan D.} and Antoun Koht and Tate, {Matthew Christopher} and Noe, {Katherine H.} and Sirven, {Joseph I.} and Anderies, {Barrett J.} and Bolton, {Patrick B.} and Trentman, {Terry L.} and Zimmerman, {Richard S.} and Swanson, {Kristin R.} and Bendok, {Bernard R.}",
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Aoun, RJN, Sattur, MG, Krishna, C, Gupta, A, Welz, ME, Nanney, AD, Koht, A, Tate, MC, Noe, KH, Sirven, JI, Anderies, BJ, Bolton, PB, Trentman, TL, Zimmerman, RS, Swanson, KR & Bendok, BR 2017, 'Awake Surgery for Brain Vascular Malformations and Moyamoya Disease', World Neurosurgery, vol. 105, pp. 659-671. https://doi.org/10.1016/j.wneu.2017.03.121

Awake Surgery for Brain Vascular Malformations and Moyamoya Disease. / Aoun, Rami James N.; Sattur, Mithun G.; Krishna, Chandan; Gupta, Amen; Welz, Matthew E.; Nanney, Allan D.; Koht, Antoun; Tate, Matthew Christopher; Noe, Katherine H.; Sirven, Joseph I.; Anderies, Barrett J.; Bolton, Patrick B.; Trentman, Terry L.; Zimmerman, Richard S.; Swanson, Kristin R.; Bendok, Bernard R.

In: World Neurosurgery, Vol. 105, 01.09.2017, p. 659-671.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Awake Surgery for Brain Vascular Malformations and Moyamoya Disease

AU - Aoun, Rami James N.

AU - Sattur, Mithun G.

AU - Krishna, Chandan

AU - Gupta, Amen

AU - Welz, Matthew E.

AU - Nanney, Allan D.

AU - Koht, Antoun

AU - Tate, Matthew Christopher

AU - Noe, Katherine H.

AU - Sirven, Joseph I.

AU - Anderies, Barrett J.

AU - Bolton, Patrick B.

AU - Trentman, Terry L.

AU - Zimmerman, Richard S.

AU - Swanson, Kristin R.

AU - Bendok, Bernard R.

PY - 2017/9/1

Y1 - 2017/9/1

N2 - Objective Although 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 neurologic monitoring during surgery for lesions in eloquent areas, avoidance of potential hemodynamic instability, and possible faster recovery. It also opens the window for perilesional epileptogenic tissue resection with potentially less risk for iatrogenic injury. Methods Institutional review board 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 Eight consecutive patients underwent 9 intracranial neurovascular awake procedures conducted by the senior author. A standardized “sedated–awake–sedated” protocol was used in all 8 patients. For the 2 patients with arteriovenous malformations and the 3 patients with cavernoma, awake brain surface and white matter mapping was performed before and during microsurgical resection. A neurological examination was obtained periodically throughout all 5 procedures. There were no intraoperative or perioperative complications. Hypotension was avoided during the 2 Moyamoya revascularization procedures in the patient with a history of labile blood pressure. Postoperative imaging confirmed complete arteriovenous malformation and cavernoma resections. No new neurologic deficits or new-onset seizures were noted on 3-month follow-up. Conclusions 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.

AB - Objective Although 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 neurologic monitoring during surgery for lesions in eloquent areas, avoidance of potential hemodynamic instability, and possible faster recovery. It also opens the window for perilesional epileptogenic tissue resection with potentially less risk for iatrogenic injury. Methods Institutional review board 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 Eight consecutive patients underwent 9 intracranial neurovascular awake procedures conducted by the senior author. A standardized “sedated–awake–sedated” protocol was used in all 8 patients. For the 2 patients with arteriovenous malformations and the 3 patients with cavernoma, awake brain surface and white matter mapping was performed before and during microsurgical resection. A neurological examination was obtained periodically throughout all 5 procedures. There were no intraoperative or perioperative complications. Hypotension was avoided during the 2 Moyamoya revascularization procedures in the patient with a history of labile blood pressure. Postoperative imaging confirmed complete arteriovenous malformation and cavernoma resections. No new neurologic deficits or new-onset seizures were noted on 3-month follow-up. Conclusions 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.

KW - Arteriovenous malformation

KW - Awake surgery

KW - Cavernomas

KW - Direct cortical stimulation

KW - Moyamoya

KW - Neurovascular surgery

KW - fMRI

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Aoun RJN, Sattur MG, Krishna C, Gupta A, Welz ME, Nanney AD et al. Awake Surgery for Brain Vascular Malformations and Moyamoya Disease. World Neurosurgery. 2017 Sep 1;105:659-671. https://doi.org/10.1016/j.wneu.2017.03.121