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Awake craniotomy in developing countries

review of hurdles

Khan, Saad A; Nathani, Karim R; Enam, Syed A; Shafiq, Faraz

doi: 10.4103/2468-7332.200557
Review Article

Awake craniotomy is a neurosurgical approach, in which patient is operated under local anesthesia to assess his neurological function intraoperatively. It has multiple advantages over craniotomy under general anesthesia, mainly including improved postoperative neurological status, lower length of hospital, and lower overall cost of hospital stay. Awake craniotomy is commonly practiced in the developed world; however, its role in developing country is limited. Considering the benefits that awake craniotomy offers, it can contribute significant socioeconomic benefits to a developing country, especially with reduce expenditure on health care as well as maintenance of functional capacity of patients to continue work. Development of awake craniotomy in a developing country is a challenge. Multiple hurdles must be overcome before considering the possibility of the procedure. One of the key hurdles is limitation of resources. Others include neuroanesthesia training, extent of disease, and patient selection. Patient's awareness or literacy rate is also a factor to be considered, especially in developing countries where it can be difficult to explain the procedure to the patient. The authors have successfully implemented awake craniotomy in Pakistan recently and have shared how they managed to overcome the hurdles in their case. The hurdles are considerable, but they can be overcome with efforts. The program will be highly beneficial to a developing country and should be attempted for betterment of health-care facilities available to the population.

Department of Neurosurgery, Memon Medical Institute Hospital, Karachi, Pakistan

Student, Medical College, The Aga Khan University Hospital, Karachi, Pakistan

Department of Surgery, The Aga Khan University, Karachi, Pakistan

Department of Anesthesia, The Aga Khan University Hospital, Karachi 74800, Pakistan

Address for correspondence:Syed Enam, Department of Surgery, The Aga Khan University, Karachi, Pakistan

Awake craniotomy is a neurosurgical procedure of performing craniotomy under local anesthesia. The patient is conscious and maintains interaction with the surgery team. It is now the preferred technique of surgery in eloquent areas considering reduced postoperative deficits and improved quality of life. 1 , 2 , 3

The documentation of awake craniotomy procedure dates back to the 17 thcentury for epilepsy treatment. 4 The idea of brain mapping with the use of electrical stimulation in humans was expressed in 1874 by Bartholow, who using an electrode stimulated the regions of cerebral cortex through a defect in the skull due to infiltration of epithelioma. 5 In late 1920s, Penfield used mild current to map brain of patients with intractable epilepsy. 6 He intended to reproduce the aura, his patient observed before seizure activity. This would allow him to locate the source of seizure, which he could then remove or destroy. He documented his experiences with the awake craniotomy, and his operating technique was successful and reproducible. 7 , 8 , 9 Awake craniotomy has played a key role in modern neurosurgery moreover in the developed countries. 10 , 11

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Socioeconomic benefits

Patients undergoing primitive craniotomy under general anesthesia, especially for the lesion in an eloquent area, face a very high risk of postoperative neurological deficits due to iatrogenic damage while excision. 12 , 13 , 14 , 15 Awake craniotomy offers an advantage of intraoperative assessment of neurological functions, which allows surgeons to restrict the resection if the neurological status of the patient is deteriorating. Hence, the surgeon is able to avoid postoperative neurological deficits. Awake craniotomy has, therefore, contributed significantly to the art of safe neurosurgery, especially by ensuring the adequate functional capacity of the patient. 2 , 1016 , 17 , 18 , 19 , 20 , 21 , 22 Furthermore, awake craniotomy avoids risks for general anesthesia, with significantly reduced operative time, Intensive Care Unit admissions, number of arterial lines and catheters, and overall length of hospital stay. 10 , 1123 , 24 , 25 , 26 , 27

Postoperative neurological deficits in a patient after craniotomy under general anesthesia lead to reduced functionality, hence compromised the quality of life. The patient is very likely to discontinue his employment and hence becomes functionally and financially dependent on his family. 28 , 29 , 30 The situation is much worse if the patient was a bread earner for the family, in which postoperatively, the family suffers not only loss of a source of income but also an extra financial burden, compromising the quality of life of an entire family. This aspect is really important in developing countries where limited or no financial support is provided by the government for individuals with the functional disability. Developing country suffers significant economic burden due to neurosurgical diseases. It worsens when the affected patients suffer permanent neurological deficits, which lead to their inability to perform employment or self-care. 28 , 29 , 30 This compromises the overall workforce of the nation as well as places more burdens on the society. 28 , 29 , 30 , 31

Therefore, awake craniotomy does not only contribute advantages at an individual level but also at national level. It reduces the overall economic burden in case of neurosurgical diseases due to its decrease utilization of resources and overall lower cost at individual level. Reduced postoperative deficits in patients after awake craniotomy allow continuance of employment, thereby causing minimal compromise in the working force of the country.

Additional benefits

Awake craniotomy is more effective in preventing postoperative motor deficits with the use of modern equipment, such as neuronavigation and tractography. 3 , 32 Therefore, the program of developing awake craniotomy in a hospital will also lead to introduction of such modern equipment. These can then also be used for craniotomy under general anesthesia, like to reduce the size for craniotomy. The entire neurosurgery team of the hospital can be trained for it and then operated patients with more sophisticated equipment to obtain better future results.

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Awake Craniotomy in Developed Countries

Awake craniotomy is a common practice in the developed part of the world, hence extensive studies are available on it from the developed countries. 10 , 11 As early as 1988, anesthetic experience of 327 awake craniotomies was published by Archer et al. 33 Large series of 200 cases who underwent awake craniotomy surgery for brain tumor over a period of 7 years was published in 1999. 11 Awake craniotomy has been a popular technique of surgery in developed countries since then. 34 , 35

In the developed world, awake craniotomy is now being practiced for a range of patient characteristics. There have been recent articles about the performance of awake craniotomy in pregnant women for brain tumor as well as in children. 36 , 37 The developed world is also using the technique for infratentorial lesions and even nontumor lesions, such as arteriovenous malformation and for clipping aneurysms. 38 , 39 , 40 , 41 Awake craniotomy has also been reported to be used as an outpatient procedure. 25 , 26

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Awake Craniotomy in Developing Countries

Availability of awake craniotomy in developing countries is rare, yet successful programs have been documented. To the best of author's knowledge, the first case of awake craniotomy in a developing country was documented in India, where surgeons performed awake craniotomy on a 32-year-old male in 1998. 42 First series of awake craniotomy in Thailand and Iran was reported in 2000 and 2013, respectively. 24 , 43 In 2013, Howe et al. discussed their experience of the initial cases after developing awake craniotomy in Indonesia, Ghana and Nigeria, and also in parts of China. 23

The authors of this article had recently published their case series of awake craniotomy in Pakistan. 44 Our article is the first publication regarding awake craniotomy from the country, which discussed the first 16 cases of awake craniotomy and their outcomes. It is an initial report of our experience of awake craniotomy and mainly focuses on the hurdles of developing awake craniotomy in Pakistan. 44 The senior author now performs awake craniotomy for all eligible patients and has moved away from craniotomy under general anesthesia for supratentorial craniotomy for tumor excision. To the date of this article, the senior author has performed around forty awake craniotomies, and so far, none has been converted to craniotomy under general anesthesia. Figure 1shows a picture of a patient undergoing awake craniotomy at our institution.

Figure 1

Figure 1

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Hurdles for Awake Craniotomy in Developing Countries

Limitation of resources

Pioneering the procedure in a developing country is not an easy task. Many hurdles have to be overcome before the technique can be offered to patients as shown in Figure 2. The restriction of resources is the primary barrier in a developing country. Awake craniotomy demands significant advance training and equipment, mainly availability of neuronavigation to perform accurate and smaller craniotomy for brain tumors. An example of operative settings can be visualized in Figure 1. It improves safety, decreases the overall time of surgery, and indirectly reduces the cost as well. Efficiency is further improved by the use of tractography to preserve important white matter tracts. Furthermore, availability of preoperative functional imaging and intraoperative mapping of the brain further improves the postoperative neurological status of the patients. 3 , 32 In Pakistan, only a few centers have all these facilities available because such installations increase the overall cost of developing awake craniotomy. Therefore, most locally trained neurosurgeons are not trained to use these important adjuncts, hence reluctant for the initiating step. Since the patient is awake throughout the procedure, it also requires for the main operating surgeon to be present throughout the procedure because the patient expects to communicate with the surgeon.

Figure 2

Figure 2


Comparing awake craniotomy and craniotomy under general anesthesia, surgical technique in either case is not of much difference. The primary difference is due to the anesthetic management. Various techniques have been reported which include monitored anesthesia care, asleep-awake-asleep, or awake-awake-awake approach. 45 Depending on the expertise and available resources, one can adopt any one of them. Therefore, the anesthesiology team requires sufficient training for the procedure in a high volume center, especially to control any intraoperative pain and complications. One of the most common complications includes intraoperative seizures, 46 which if not controlled can lead to induction of general anesthesia. Other possible issues include settling patient anxiety, managing hypertension, tachycardia, cerebral edema, and respiratory distress. 18 Such training could not be achieved in our country due to nonavailability of this procedure until recently. This requires exposure of the anesthesia team to a high volume center performing awake craniotomy, further increasing the cost for the program. In addition, many times, all the required medications and equipment are not readily available at a center in the developing country, leaving the anesthesiologist with fewer drug options to optimize patient care intraoperatively. In our program, a team comprising the neurosurgeon, anesthesiologist, and support staff was sent abroad for the necessary exposure required. The team trained for awake-awake-awake approach and successfully implemented it into our setup. The results were commendable, and the technique proved to be an example for transfer of knowledge and skills across the globe for health-care development.

Patient awareness

Patient-related factors also play a significant role in availing the benefits of awake craniotomy. The low literacy rate of the country contributes to reducing awareness of the procedure in population and understanding its need. The reluctance of patients increases immediately when they hear about a “brain surgery with patient awake.” Patients doubt the safety of the surgery and fear the intraoperative stress. The patient psychology is, therefore, a challenge for the surgeon, to ensure the patient is able to acquire benefits of awake craniotomy. In addition, the low level of education of patients in a developing country may make the task more difficult. The patient must, therefore, be provided counseling and special sessions for information regarding the surgery where the patient is made aware of the procedure with visits to the operative room. In our experience in Pakistan, patients were counseled by the neurosurgeon, anesthesiologist, and their teams regarding the benefits of the program. All the concerns of the patients were answered. Special sessions were conducted by the neurosurgery and anesthesiology team, which included presentations, visits to the operating room, and showing the drapes with which the patient will be covered and different noises they will hear mainly including the monopolar, bipolar, and drills. The senior author believes that this exercise helps on the day of the surgery with reduce anxiety and increase compliance of the patient.

Another issue faced in our setting was the language barrier in case of few patients, in which case a translator was called, whether a relative from patient's family or a professional hired. Similar protocol was followed in terms of counseling and special sessions. Intraoperatively, the translator was allowed to sit next to the patient, and he used to translate the surgeon's commands to the patient.

Disease extent

The extent of the disease is also a concern in the developing country. Due to financial constraints being common, patients tend to visit a neurosurgeon much later in course of the disease. This causes significant neurological deficits, especially in the case of invasive brain tumors, before the patient can be offered awake craniotomy. In these cases, the awake craniotomy is less likely to be beneficial as the patient will not be able to perform the requested neurological assessment intraoperatively, like due to dysphasia or confusion. Furthermore, it is a difficult decision for the surgeon to let the patient suffer the stress of an awake surgery.

Patient selection

Even after setting up the facility, patient selection is one of the key aspects to be a concern for. The developed world is now performing awake craniotomy on a variety of patient's characteristics such as children or pregnant women or lesions such as infratentorial tumors. 37 , 38 , 47 Such is not preferred in a developing country during the early period primarily due to the risks involved and lack of experience of the surgical team. The patients preferred should be alert and oriented adults, who are willing and possess an adequate understanding of the procedure. It is extremely important that the patient selected for the surgery must be compliant. Conversion of awake craniotomy into craniotomy under general anesthesia due to patient noncompliance has been widely reported in the literature of the developed countries. Although the low risk of it will always be present in all patients, it should be avoided as much as possible by ensuring adequate counseling and a special session for information on the surgery.

The hurdles are significant but manageable. If these are overcome, awake craniotomy shows significantly improved results in terms of its socioeconomic benefits in the developing countries. 23 , 44 The technique may initially be started at a single institution of a developing country. That institution can then further develop the program in other institutions, ensuring transfer of technology and benefit to entire population.

A recent study by Howe et al. presented their experience about teaching and implementing awake craniotomy in six neurological centers of low- to middle-income regions of Indochina and Africa. 23 The study included 38 cases of brain tumors and discussed about majority of our mentioned issues, which included limitation of resources and training for the procedure. It also concluded awake craniotomy to be very beneficial for a developing country in terms of postoperative deficits, hospital stay length and overall cost for a patient, and the national economical burden of surgical diseases. In /1, few studies on awake craniotomy from the developing countries, including Pakistan, are described.{Table 1}

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Developing awake craniotomy is a daunting challenge in developing country like Pakistan, especially due to its high initial cost and training of the surgery and anesthesia teams. The task is yet achievable and should be pursued due to its overwhelming long-term better outcomes for a developing country. The team performing awake craniotomy at our institute has evolved with time by gaining valuable experience and now is shifting focus to training other teams from developing country interested in starting awake craniotomy at their institute.

Financial support and sponsorship


Conflicts off interest

There are no conflicts of interest. 49

1. Duffau H. Intraoperative cortico-subcortical stimulations in surgery of low-grade gliomas Expert Rev Neurother. 2005;5:473–85
2. Sacko O, Lauwers-Cances V, Brauge D, Sesay M, Brenner A, Roux FE. Awake craniotomy vs surgery under general anesthesia for resection of supratentorial lesions Neurosurgery. 2011;68:1192–8
3. Sanai N, Mirzadeh Z, Berger MS. Functional outcome after language mapping for glioma resection N Engl J Med. 2008;358:18–27
4. Marshall C. Surgery of epilepsy and motor disorders.A History of Neurological Surgery New York: Hafner Publishing Co.;: Surgery of epilepsy and motor disorders A History of Neurological Surgery New York: Hafner Publishing Co; 1967 p 288-305
5. Bartholow R. Art I.– Experimental investigations into the functions of the human brain Am J Med Sci. 1874;66:305–13
6. Penfield W. No Man Alone: A Neurosurgeon's Life Canada: Little, Brown and Company;. 7;: No Man Alone: A Neurosurgeon's Life Canada: Little, Brown and Company; 1977
7. Penfield W, Boldrey E. Somatic motor and sensory representation in the cerebral cortex of man as studied by electrical stimulation Brain. 7;: Somatic motor and sensory representation in the cerebral cortex of man as studied by electrical stimulation Brain 1937
8. Penfield W, Erickson TC. Epilepsy and Cerebral Localization . 1;: Epilepsy and Cerebral Localization 1941
9. Penfield W, Rasmussen T. The Cerebral Cortex of Man: A Clinical Study of Localization of Function . 0;: The Cerebral Cortex of Man: A Clinical Study of Localization of Function 1950
10. Serletis D, Bernstein M. Prospective study of awake craniotomy used routinely and nonselectively for supratentorial tumors J Neurosurg. 2007;107:1–6
11. Taylor MD, Bernstein M. Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: A prospective trial of 200 cases J Neurosurg. 1999;90:35–41
12. Cabantog AM, Bernstein M. Complications of first craniotomy for intra-axial brain tumour Can J Neurol Sci. 1994;21:213–8
13. Cedzich C, Taniguchi M, Schäfer S, Schramm J. Somatosensory evoked potential phase reversal and direct motor cortex stimulation during surgery in and around the central region Neurosurgery. 1996;38:962–70
14. Fadul C, Wood J, Thaler H, Galicich J, Patterson RH Jr. , Posner JB.Morbidity and mortality of craniotomy for excision of supratentorial gliomas Neurology. 1988;38:1374–9
15. Sawaya R, Hammoud M, Schoppa D, Hess KR, Wu SZ, Shi WM, et al Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors Neurosurgery. 1998;42:1044–55
16. Blanshard HJ, Chung F, Manninen PH, Taylor MD, Bernstein M. Awake craniotomy for removal of intracranial tumor: Considerations for early discharge Anesth Analg. 2001;92:89–94
17. Bulsara KR, Johnson J, Villavicencio AT. Improvements in brain tumor surgery: The modern history of awake craniotomies Neurosurg Focus. 2005;18:e5
18. Conte V, Baratta P, Tomaselli P, Songa V, Magni L, Stocchetti N. Awake neurosurgery: An update Minerva Anestesiol. 2008;74:289–92
19. De Benedictis A, Moritz-Gasser S, Duffau H. Awake mapping optimizes the extent of resection for low-grade gliomas in eloquent areas Neurosurgery. 2010;66:1074–84
20. Khu KJ, Doglietto F, Radovanovic I, Taleb F, Mendelsohn D, Zadeh G, et al Patients' perceptions of awake and outpatient craniotomy for brain tumor: A qualitative study J Neurosurg. 2010;112:1056–60
21. Boetto J, Bertram L, Moulinié G, Herbet G, Moritz-Gasser S, Duffau H. Low rate of intraoperative seizures during awake craniotomy in a prospective cohort with 374 supratentorial brain lesions: Electrocorticography is not mandatory World Neurosurg. 2015;84:1838–44
22. Meyer FB, Bates LM, Goerss SJ, Friedman JA, Windschitl WL, Duffy JR, et al Awake craniotomy for aggressive resection of primary gliomas located in eloquent brain Mayo Clin Proc. 2001;76:677–87
23. Howe KL, Zhou G, July J, Totimeh T, Dakurah T, Malomo AO, et al Teaching and sustainably implementing awake craniotomy in resource-poor settings World Neurosurg. 2013;80:e171–4
24. July J, Manninen P, Lai J, Yao Z, Bernstein M. The history of awake craniotomy for brain tumor and its spread into Asia Surg Neurol. 2009;71:621–4
25. Bernstein M. Outpatient craniotomy for brain tumor: A pilot feasibility study in 46 patients Can J Neurol Sci. 2001;28:120–4
26. Bernstein M. Outpatient brain tumour surgery A new paradigm in healthcare delivery Oncol Exch. 2004;5:20–3
27. Bhattacharyya A, Bernstein M. Outpatient neurosurgery: State of the art, feasibility, and relevance Adv Clin Neurosci. 2003;13:15–26
28. Adeleye AO, Fasunla JA, Young PH. Skull base surgery in a large, resource-poor, developing country with few neurosurgeons: Prospects, challenges, and needs World Neurosurg. 2012;78:35–43
29. Ozgediz D, Jamison D, Cherian M, McQueen K. The burden of surgical conditions and access to surgical care in low- and middle-income countries Bull World Health Organ. 2008;86:646–7
30. Samad L, Jawed F, Sajun SZ, Arshad MH, Baig-Ansari N. Barriers to accessing surgical care: A cross-sectional survey conducted at a tertiary care hospital in Karachi, Pakistan World J Surg. 2013;37:2313–21
31. Kaptigau WM, Rosenfeld JV, Kevau I, Watters DA. The establishment and development of neurosurgery services in Papua New Guinea World J Surg. 2016;40:251–7
32. Duffau H, Lopes M, Arthuis F, Bitar A, Sichez JP, Van Effenterre R, et al Contribution of intraoperative electrical stimulations in surgery of low grade gliomas: A comparative study between two series without (1985-1996) and with (1996-2003) functional mapping in the same institution J Neurol Neurosurg Psychiatry. 2005;76:845–51
33. Archer DP, McKenna JM, Morin L, Ravussin P. Conscious-sedation analgesia during craniotomy for intractable epilepsy: A review of 354 consecutive cases Can J Anaesth. 1988;35:338–44
34. Reulen HJ, Schmid UD, Ilmberger J, Eisner W, Bise K. Tumor surgery of the speech cortex in local anesthesia.Neuropsychological and neurophysiological monitoring during operations in the dominant hemisphere Nervenarzt. 1997;68:813–24
35. Danks RA, Aglio LS, Gugino LD, Black PM. Craniotomy under local anesthesia and monitored conscious sedation for the resection of tumors involving eloquent cortex J Neurooncol. 2000;49:131–9
36. Balogun JA, Khan OH, Taylor M, Dirks P, Der T, Carter Snead Iii O, et al Pediatric awake craniotomy and intra-operative stimulation mapping J Clin Neurosci. 2014;21:1891–4
37. Handlogten KS, Sharpe EE, Brost BC, Parney IF, Pasternak JJ. Dexmedetomidine and mannitol for awake craniotomy in a pregnant patient Anesth Analg. 2015;120:1099–103
38. deipolyi AR, Han SJ, Sughrue ME, Litt L, Parsa AT. Awake far lateral craniotomy for resection of foramen magnum meningioma in a patient with tenuous motor and somatosensory evoked potentials J Clin Neurosci. 2011;18:1254–6
39. Abdulrauf SI, Vuong P, Patel R, Sampath R, Ashour AM, Germany LM, et al “Awake” clipping of cerebral aneurysms: Report of initial series.J Neurosurg 2016:1-8 [Epub ahead of print].;: “Awake” clipping of cerebral aneurysms: Report of initial series J Neurosurg 2016:1-8 [Epub ahead of print]
40. Tolly BT, Kosky JL, Koht A, Hemmer LB. A case report of onyx pulmonary arterial embolism contributing to hypoxemia during awake craniotomy for arteriovenous malformation resection A A Case Rep. 6;: A case report of onyx pulmonary arterial embolism contributing to hypoxemia during awake craniotomy for arteriovenous malformation resection A A Case Rep 2016
41. Gamble AJ, Schaffer SG, Nardi DJ, Chalif DJ, Katz J, Dehdashti AR. Awake craniotomy in arteriovenous malformation surgery: The usefulness of cortical and subcortical mapping of language function in selected patients World Neurosurg. 2015;84:1394–401
42. Chelani R, Borges E. Awake craniotomy has an edge over general anaesthesia Express Healthc Manag. 5;: Awake craniotomy has an edge over general anaesthesia Express Healthc Manag 2005
43. Attari M, Salimi S. Awake craniotomy for tumor resection Adv Biomed Res. 2013;2:63
44. Khan SA, Nathani KR, Ujjan BU, Barakzai MD, Enam SA, Shafiq F. Awake craniotomy for brain tumours in Pakistan: An initial case series from a developing country J Pak Med Assoc. 2016;66 Suppl 3:S68–71
45. Stevanovic A, Rossaint R, Veldeman M, Bilotta F, Coburn M. Anaesthesia management for awake craniotomy: Systematic review and meta-analysis PLoS One. 2016;11:e0156448
46. Szelényi A, Joksimovic B, Seifert V. Intraoperative risk of seizures associated with transient direct cortical stimulation in patients with symptomatic epilepsy J Clin Neurophysiol. 2007;24:39–43
47. Hervey-Jumper SL, Li J, Lau D, Molinaro AM, Perry DW, Meng L, et al Awake craniotomy to maximize glioma resection: Methods and technical nuances over a 27-year period J Neurosurg. 2015;123:325–39
48. Mohd Nazaruddin WH, Mohd Fahmi L, Laila AM, Zamzuri I, Abdul Rahman IZ, Hardy MZ. Awake craniotomy: A case series of anaesthetic management using a combination of scalp block, dexmedetomidine and Remifentanil in Hospital Universiti Sains Malaysia Med J Malaysia. 2013;68:64–6
49. Gupta DK, Chandra PS, Ojha BK, Sharma BS, Mahapatra AK, Mehta VS. Awake craniotomy versus surgery under general anesthesia for resection of intrinsic lesions of eloquent cortex – A prospective randomised study Clin Neurol Neurosurg. 2007;109:335–43
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    Awake craniotomy; craniotomy under local anesthesia; developing countries; hurdles

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