Course of the intervention
The intervention takes place in three stages:
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Opening
The patient is under hypno-sedation. The tissues are locally anesthetized. The surgeon accesses the lesion.
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Awake phase — determining functional limits
The patient is awake and performs continuous tests under the supervision of a speech-language pathologist: motor, language, visual, spatial, and executive functions... The surgeon uses an electrical probe that transiently disrupts the stimulated area. If the patient can no longer perform the task during stimulation, the area is preserved. Limits are thus identified on the surface and in depth.
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Closing
The patient is placed under sedation again for the closure of the surgical approach.
Cognitive disorders in the immediate post-operative period are frequent—as the excision goes as close as possible to functional areas. An early speech-language assessment allows them to be identified and guides rehabilitation, first in the department of Prof. Beaudreuil (Fernand-Widal Hospital), then as an outpatient. Recovery is most often complete in about 4 months (between 1 month and 1 year). In the Lariboisière series, 85% of patients resumed their professional activity after awake surgery for low-grade glioma.
Role of surgery
The goal is to remove as much of the tumor as possible, as all studies have shown that the more extensive the excision, the better the prognosis. When the tumor is in a highly functional area, a biopsy may be performed first to determine its exact nature before considering a resection.
The extent of the resection is planned during the preoperative discussion with the patient—an essential moment to analyze the predictable impact on their socio-professional life. For example, for the same frontal location, the limits will not be identical depending on whether the patient is a sports teacher (motor coordination circuits) or an English teacher (language circuits in French and English).
A follow-up MRI is performed within 48 hours post-operatively to confirm the extent of the excision. Histopathology results are available within 5 to 10 days, and complete molecular analyses (chromosomal abnormalities, gene mutations, etc.) within a few weeks.
The awake surgery team
Led by Prof. Emmanuel Mandonnet, an internationally recognized expert, the team is multidisciplinary:
Anesthesia
Prof. Etienne Gayat, Dr. Jona Joachim, Nurse Anesthetists Sylvie Aubrun, Séverine Levavasseur, Astrid Letertre. Preoperative hypnotic relaxation sessions to approach the intervention in the best possible conditions.Electrophysiology
Dr. Chassoux and Dr. Zanin (neurosurgery / epilepsy), François Bonnetblanc and Olivier Rossel (INRIA-Montpellier). Localization of the epileptogenic zone and study of brain connectivity via intracerebral evoked potentials.Speech-Language Pathology
Ms. Isabelle Poisson, Ms. Marion Barberis, Ms. Cécile Prevost, Ms. Sophie Letrange. The preoperative assessment guides the relevant tests for the intraoperative phase.Neuroradiology
Team of Prof. Houdart (Lariboisière) and Dr. Mellerio (Centre Cardiologique du Nord). Notably allows for the certain determination of the patient's dominant language hemisphere.Rehabilitation
Dr. Tlili and Dr. Heslot, PM department of Prof. Beaudreuil (Fernand-Widal Hospital). Individualized rehabilitation program defined for each patient.Neuropathology
Prof. Homa Adle-Biassette and Dr. Chiara Villa. Analysis of each tumor sample, results available within one week.References
- Network-level causal analysis of set-shifting during trail making test part B: A multimodal analysis of a glioma surgery case. Cortex 2020; 132: 238–49.
- Verbal fluency predicts work resumption after awake surgery in low-grade glioma patients. Acta Neurochir (Wien) 2024; 166: 88.
- Patterns of axono-cortical evoked potentials: an electrophysiological signature unique to each white matter functional site? Acta Neurochir (Wien) 2021; 163: 3121–30.
- When Right Is on the Left (and Vice Versa): A Case Series of Glioma Patients with Reversed Lateralization of Cognitive Functions. J Neurol Surg A Cent Eur Neurosurg 2020; 81: 138–46.
Skull base surgery treats lesions deep between the skull base and the brain, or in the skull base itself. The most common pathologies affecting the base of the skull are tumors. These tumors can be histologically "benign" (e.g. meningiomas, acoustic neurinomas, pituitary adenomas, craniopharyngiomas) or malignant (cancerous) (e.g. originating in the sinuses, bone, cartilage, ear or salivary glands).
- MENINGIOME
- NEURINOME or SCHWANNOME
- CHORDOME
- CHONDROSARCOMA
- EPIDERMOID CYSTS
- ESTHESIONEUROBLASTOMA
- CHOLESTERINE GRANULOMA
- TUMORS OF THE JUGULAR FORAMEN
- TUMORS OF THE CAVERNOUS SINUS
- ROCK TUMORS
- TUMORS OF THE ORBIT
Early diagnosis and multidisciplinary management is the key to effective treatment of these tumors.
Because of their location, injuries to the base of the skull can cause a wide range of symptoms, including visual, hearing, smell, balance and swallowing disorders, headaches, facial asymmetry, sensitivity disorders and/or facial pain, nasal obstruction, vertigo...
Cerebral CT andMRI scans are the main tests used to identify the lesion. CT scans enable precise assessment of bone structures, but lack spatial resolution for soft tissues. MRI enables precise assessment of the soft tissues, the lesion and its relationship with surrounding structures. Other tests may be ordered depending on the type and location of the suspected lesion:
- cerebral angioscan, MRI angiography and/or arteriography to assess the vascularity of the lesion, its relationship with the major vessels supplying the brain, such as the internal carotid and vertebral arteries, and the anatomy of the cerebral drainage veins, in order to preserve them as much as possible,
- an ophthalmological check-up
-an ENT check-up to assess hearing, balance and swallowing skills
-an endocrinological check-up to assess any possible repercussions of the lesion on the functioning of the pituitary gland, a small gland connected to the brain and located at the center of the skull base
etc...
- Operating microscope with integrated neuronavigation and endoscopy
- High-definition (HD) endoscope
- Ultrasonic scalpel
- Neuronavigation
- Intraoperative cranial nerve monitoring
- Intraoperative somaesthetic and motor evoked potentials
- Intraoperative CT scan being acquired
These surgeries are performed in dedicated operating rooms that integrate all the latest imaging, visualization, monitoring, and guidance technologies.
The department also has highly qualified paramedical staff.
Our common goal is to provide the best possible surgical outcome with the fewest side effects and maximum preservation of function.
Our department maintains close relationships with numerous neurosurgery teams specialized in this field abroad, and we welcome many visiting neurosurgeons from other countries who come to train in these techniques.
Guide
Your stay is our priority, and we have established a patient pathway program for your surgical schedule, admission and intervention, through to your discharge. Please do not hesitate to contact us if you have any questions.