The course of awake surgery
Today, “awake surgery” is the most reliable technique for assisting the surgeon in the intraoperative determination of personalized functional limits, thus giving the patient the best chance of neurocognitive recovery.
It is particularly indicated for the resection of low-grade glial lesions and epileptogenic zones, but can also be applied to other types of lesions (high-grade gliomas, cavernomas, metastases), depending on their location.
An intervention in “awake conditions” takes place in three stages:
First, the lesion. The patient is under hypno-sedation; the tissues are locally anesthetized.
determining the functional limits of the resection. This is the phase during which the patient is awakened and performs continuous tests, under the supervision of a speech therapist.
In this way, motor, language, visual, spatial and executive functions can be continuously monitored 1 ….
The surgeon uses an electrical probe to transiently disturb the stimulated area: if the patient can no longer perform the task during stimulation, the area must be preserved (see video http://www.college-de-france.fr/site/nicholas-ayache/seminar-2014-05-27-17h30.htm). Limits are thus identified, both on the surface and at depth, then the approach is closed. The patient is again sedated (put back to sleep).
Given that excision is performed as close as possible to functional areas, it is not uncommon for patients to experience cognitive problems in the immediate postoperative period.
An early speech and language assessment helps to identify them, and to direct the rehabilitation sessions, initially in Pr Beaudreuil’s rehabilitation department at Fernand-Widal Hospital, then on an outpatient basis, with a speech and language therapist.
Recovery is usually complete, after a variable period of around 4 months (between 1 month and 1 year). Overall, in the Lariboisière 2 series, 85% of patients were able to return to work after awake surgery for low-grade glioma.
What is the role of surgery?
The aim is to remove as much of the tumour as possible, as all studies have shown
the more extensive the excision, the better the prognosis. However, exeresis
is not always possible, particularly for tumours in highly populated areas.
functional. In this case, we prefer to start with a
biopsy to determine the exact nature of the tumour, before considering
surgery to remove the tumor if necessary and possible.
In all cases, the sample is analyzed by neuropathologists (Prof. Homa
Adle-Biassette and Dr Chiara Villa) and results are achieved in around a week.
The extent of excision is planned during the preoperative discussion with the patient.
patient, an essential moment for analysing the foreseeable impact of the resection.
on the patient’s socio-professional life. For example, for tumors of the same
frontal localisations, the limits will not be the same depending on whether the patient is
sports teacher (which requires respecting the circuits of the
movements) or English teacher (which requires respecting the circuits of the
two spoken and written languages, French and English).
Awake surgery” is currently the most reliable technique.
to assist the surgeon in locating these functional limits. The Pr
Emmanuel Mandonnet, referent for this type of surgery, is an expert in the field.
internationally recognized in awake surgery and management
gliomas.
A post-procedure MRI scan is performed within 48 hours of the procedure.
after surgery to confirm the extent of tumor removal.
It then takes 5 to 10 days to obtain the final results of the analysis of the
tumor removed, and a few weeks before obtaining the full analysis of the
tumor at molecular level (chromosomal abnormalities, gene mutations, etc.)
Depending on the type and grade of the tumour, additional treatment with
radiotherapy, chemotherapy or targeted therapy may be proposed. In tumors
such as glioblastoma, radiotherapy and chemotherapy are required.
and/or targeted therapy is almost systematic.
The surgical team awake
The surgical activity relies on the cohesion of an entire team, including surgeons, anesthetists, nurse anesthetists, neuroradiologists, speech therapists, neuropsychologists and rehabilitation physicians. The team, led by Professor Mandonnet, includes :
anesthesia, with Pr Etienne Gayat, Dr Jona Joachim and nurse anesthetists Sylvie Aubrun, Séverine Levavaseur and Astrid Letertre. Preoperative hypnotic relaxation sessions enable patients to approach surgery in the best possible conditions of relaxation;
an electrophysiological section with neurologists from the neurosurgery department specializing in surgical epilepsy (Dr Chassoux and Dr Zanin) and electrophysiologists from INRIA-Montpellier (François Bonnetblanc and Olivier Rossel).
This unique intraoperative expertise makes it possible both to help localize the epileptogenic zone, and to use new methods (intra-cerebral evoked potentials) to better understand brain connectivity, and thus conserve it 3;
a speech therapy section, with Isabelle Poisson, Marion Barberis, Cécile Prevost and Sophie Letrange. The preoperative workup provides guidance on the tests that are relevant to the intraoperative phase;
a neuroradiological section, with Pr Houdart’s team at Lariboisière and Dr Mellerio at the northern cardiology center. This makes it possible to define with certainty the language hemisphere of patient 4 (which is the left hemisphere in 99% of right-handers and 90% of left-handers);
a rehabilitation section, with Dr Tlili and Dr Heslot, in Pr Beaudreuil’s physical medicine and rehabilitation department at the Fernand Widal hospital. An individualized rehabilitation program is defined for each patient;
1 Mandonnet E, Vincent M, Valero-Cabré A, et al. 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.
2 Barberis M, Poisson I, Prévost-Tarabon C, et al. Verbal fluency predicts work resumption after awake surgery in low-grade glioma patients. Acta Neurochir (Wien) 2024; 166: 88.
3 Boyer A, Stengel C, Bonnetblanc F, et al. Patterns of axono-cortical evoked potentials: an electrophysiological signature unique to each white matter functional site? Acta Neurochir (Wien) 2021; 163: 3121-30.
4 Mandonnet E, Mellerio C, Barberis M, Poisson I, Jansma JM, Rutten G-J. 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.