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Tolerance of awake surgery for glioma: a prospective European Low Grade Glioma Network multicenter study

  • Clinical Article - Brain Tumors
  • Published:
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Abstract

Background

Gross total removal of glioma is limited by proximity to eloquent brain. Awake surgery allows for intraoperative monitoring to safely identify eloquent regions. However, data on adverse psychological effects induced in these patients is limited.

Objective

This study explored patients’ perception of awake surgery for glioma, with special focus on intraoperative pain and anxiety.

Methods

This study was conducted at five neurosurgical centers within the European Low Grade Glioma Network. Patients underwent awake surgery for glioma according to the protocol of the individual center. Pain and discomfort were measured during the awake phase. Postoperatively, patients answered a questionnaire on aspects of their operation.

Results

One hundred five patients were enrolled. Pain levels on a 10-cm visual analogue scale were 1.3 cm at the beginning, 1.9 cm the middle, and 2.1 cm at the end of awake phase. Levels of anxiety were 2.2 cm, 2.5 cm and 2.6 cm, respectively. Women and patients younger than 60 years exhibited highest mean anxiety levels. The patient questionnaire revealed that the majority of patients feel comfortable with the procedure. Discomfort resulted from head fixation or positioning on the operating table.

Conclusions

We demonstrate that awake surgery is well tolerated, as neither intraoperative nor postoperative assessment revealed major disadvantages. Concerning practical lessons learned from this study, we emphasize the importance of minimizing pain and preparing patients thoroughly to reduce anxiety and maximize cooperation. Awake surgery is an excellent treatment modality for brain tumors with very positive perception by patients.

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References

  1. Collins SL, Moore RA, McQuay HJ (1997) The visual analogue pain intensity scale: what is moderate pain in millimetres? Pain 72(1–2):95–97

    Article  PubMed  CAS  Google Scholar 

  2. De Benedictis A, Moritz-Gasser S, Duffau H (2010) Awake mapping optimizes the extent of resection for low-grade gliomas in eloquent areas. Neurosurgery 66(6):1074–1084, discussion 1084

    Article  PubMed  Google Scholar 

  3. Duffau H (2009) A personal consecutive series of surgically treated 51 cases of insular WHO Grade II glioma: advances and limitations. J Neurosurg 110(4):696–708

    Article  PubMed  Google Scholar 

  4. Duffau H (2012) Awake surgery for incidental WHO grade II gliomas involving eloquent areas. Acta Neurochir (Wien) 154(4):575–584, discussion 584

    Article  Google Scholar 

  5. Duffau H, Moritz-Gasser S, Gatignol P (2009) Functional outcome after language mapping for insular World Health Organization Grade II gliomas in the dominant hemisphere: experience with 24 patients. Neurosurg Focus 27(2):E7

    Article  PubMed  Google Scholar 

  6. Gallagher EJ, Liebman M, Bijur PE (2001) Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emerg Med 38(6):633–638

    Article  PubMed  CAS  Google Scholar 

  7. Gerbershagen HJ, Rothaug J, Kalkman CJ, Meissner W (2011) Determination of moderate-to-severe postoperative pain on the numeric rating scale: a cut-off point analysis applying four different methods. Br J Anaesth 107(4):619–626

    Article  PubMed  CAS  Google Scholar 

  8. Goebel S, Nabavi A, Schubert S, Mehdorn HM (2010) Patient perception of combined awake brain tumor surgery and intraoperative 1.5-T magnetic resonance imaging: the Kiel experience. Neurosurgery 67(3):594–600, discussion 600

    Article  PubMed  Google Scholar 

  9. Goebel S, Stark A, Kaup L, von Harscher M, Mehdorn HM (2011) Distress in patients with newly diagnosed brain tumours. Psycho-Oncology 20(6):623–630

    Article  PubMed  CAS  Google Scholar 

  10. Khu KJ, Doglietto F, Radovanovic I, Taleb F, Mendelsohn D, Zadeh G, Bernstein M (2010) Patients’ perceptions of awake and outpatient craniotomy for brain tumor: a qualitative study. J Neurosurg 112(5):1056–1060

    Article  PubMed  Google Scholar 

  11. Kindler CH, Harms C, Amsler F, Ihde-Scholl T, Scheidegger D (2000) The visual analog scale allows effective measurement of preoperative anxiety and detection of patients’ anesthetic concerns. Anesth Analg 90(3):706–712

    Article  PubMed  CAS  Google Scholar 

  12. Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, Jouvet A, Scheithauer BW, Kleihues P (2007) The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol 114(2):97–109

    Article  PubMed  Google Scholar 

  13. Manninen PH, Balki M, Lukitto K, Bernstein M (2006) Patient satisfaction with awake craniotomy for tumor surgery: a comparison of remifentanil and fentanyl in conjunction with propofol. Anesth Analg 102(1):237–242

    Article  PubMed  CAS  Google Scholar 

  14. McGirt MJ, Chaichana KL, Attenello FJ, Weingart JD, Than K, Burger PC, Olivi A, Brem H, Quinoñes-Hinojosa A (2008) Extent of surgical resection is independently associated with survival in patients with hemispheric infiltrating low-grade gliomas. Neurosurgery 63(4):700–707, author reply 707–8

    Article  PubMed  Google Scholar 

  15. Palese A, Skrap M, Fachin M, Visioli S, Zannini L (2008) The experience of patients undergoing awake craniotomy: in the patients’ own words. A qualitative study. Cancer Nursing 31(2):166–172

    Article  PubMed  Google Scholar 

  16. Sartorius C, Berger M (1998) Rapid termination of intraoperative stimulation-evoked seizures with application of cold Ringer’s lactate to the cortex: technical note. J Neurosurg 349–351

  17. Schlomer GL, Bauman S, Card NA (2010) Best practices for missing data management in counseling psychology. J Couns Psychol 57(1):1–10

    Article  PubMed  Google Scholar 

  18. Serletis D, Bernstein M (2007) Prospective study of awake craniotomy used routinely and nonselectively for supratentorial tumors. J Neurosurg 107(1):1–6

    Article  PubMed  Google Scholar 

  19. Smits A, Duffau H (2011) Seizures and the natural history of World Health Organization Grade II gliomas: a review. Neurosurgery 68(5):1326–1333

    PubMed  Google Scholar 

  20. Soffietti R, Baumert BG, Bello L, von Deimling A, Duffau H, Frénay M, Grisold W, Grant R, Graus F, Hoang-Xuan K, Klein M, Melin B, Rees J, Siegal T, Smits A, Stupp R, Wick W (2010) Guidelines on management of low-grade gliomas: report of an EFNS-EANO Task Force. Eur J Neurol Off J Eur Fed Neurol Soc 17(9):1124–1133

    CAS  Google Scholar 

  21. Stummer W, Pichlmeier U, Meinel T, Wiestler OD, Zanella F, Reulen H-J (2006) Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial. Lancet Oncol 7(5):392–401

    Article  PubMed  CAS  Google Scholar 

  22. Stummer W, Reulen H-J, Meinel T, Pichlmeier U, Schumacher W, Tonn JC, Rohde V, Oppel F, Turowski B, Woiciechowsky C, Franz K, Pietsch T (2008) Extent of resection and survival in glioblastoma multiforme: identification of and adjustment for bias. Neurosurgery 62(3):564–576, discussion 564–76

    Article  PubMed  Google Scholar 

  23. Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, Belanger K, Brandes AA, Marosi C, Bogdahn U, Curschmann J, Janzer RC, Ludwin SK, Gorlia T, Allgeier A, Lacombe D, Cairncross JG, Eisenhauer E, Mirimanoff RO (2005) Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352(10):987–996

    Article  PubMed  CAS  Google Scholar 

  24. Stupp R, Tonn J-C, Brada M, Pentheroudakis G (2010) High-grade malignant glioma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals Oncol Off J Eur Soc Med Oncol / ESMO 21 Suppl 5(Supplement 5):v190–3

    Google Scholar 

  25. Szelényi A, Bello L, Duffau H, Fava E, Feigl GC, Galanda M, Neuloh G, Signorelli F, Sala F (2010) Intraoperative electrical stimulation in awake craniotomy: methodological aspects of current practice. Neurosurg Focus 28(2):E7

    Article  PubMed  Google Scholar 

  26. Szelényi A, Joksimovic B, Seifert V (2007) Intraoperative risk of seizures associated with transient direct cortical stimulation in patients with symptomatic epilepsy. J Clin Neurophysiol Off Publ Am Electroencephalogr Soc 24(1):39–43

    Article  Google Scholar 

  27. Todd KH, Funk KG, Funk JP, Bonacci R (1996) Clinical significance of reported changes in pain severity. Ann Emerg Med 27(4):485–489

    Article  PubMed  CAS  Google Scholar 

  28. Wahab SS, Grundy PL, Weidmann C (2011) Patient experience and satisfaction with awake craniotomy for brain tumours. Br J Neurosurg 25(5):606–613

    Article  PubMed  CAS  Google Scholar 

  29. Whittle IR, Midgley S, Georges H, Pringle A-M, Taylor R (2005) Patient perceptions of “awake” brain tumour surgery. Acta Neurochir (Wien) 147(3):275–277, discussion 277

    Article  CAS  Google Scholar 

  30. Yordanova YN, Moritz-Gasser S, Duffau H (2011) Awake surgery for WHO Grade II gliomas within “noneloquent” areas in the left dominant hemisphere: toward a “supratotal” resection. Clinical article. J Neurosurg 115(2):232–239

    Article  PubMed  Google Scholar 

  31. Zabora J, BrintzenhofeSzoc K, Curbow B, Hooker C, Piantadosi S (2001) The prevalence of psychological distress by cancer site. Psycho-Oncology 10(1):19–28

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Neurosurgery, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany

    Thomas Beez, Kira Boge, Andrea Szelényi & Michael Sabel

  2. Department of Neurosurgery, CHU de Poitiers, Poitiers, France

    Michel Wager

  3. Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK

    Ian Whittle

  4. Department of Neurosurgery, Centre Hospitalier Universitaire de Nice, Nice, France

    Denys Fontaine

  5. Division of Neurosurgery, Civil Hospital, Alessandria, Italy

    Giannantonio Spena

  6. Department of Anaesthesiology, Heinrich-Heine-University, Düsseldorf, Germany

    Sebastian Braun

  7. Department of Neurosurgery, Università degli Studi di Milano, Milan, Italy

    Lorenzo Bello

  8. Department of Neurosurgery, Montpellier University Medical Center, Montpellier, France

    Hugues Duffau

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  1. Thomas Beez
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  2. Kira Boge
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  3. Michel Wager
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  7. Sebastian Braun
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  9. Lorenzo Bello
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  10. Hugues Duffau
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Correspondence to Thomas Beez.

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Beez, T., Boge, K., Wager, M. et al. Tolerance of awake surgery for glioma: a prospective European Low Grade Glioma Network multicenter study. Acta Neurochir 155, 1301–1308 (2013). https://doi.org/10.1007/s00701-013-1759-0

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  • DOI: https://doi.org/10.1007/s00701-013-1759-0

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