Awake brain surgery for autistic patients: Is it possible?

Abstract

Background: Awake neurosurgery is currently the mainstay for eloquent brain lesions. Opting for an awake operation is affected by a number of patient-related factors. We present a case of a patient with autistic spectrum disorder (ASD) that was successfully operated for a brain tumor through awake craniotomy. To the best of our knowledge, this is the first reported case in the literature.

Case description: A 42-year-old patient, with known ASD since his childhood, underwent awake craniotomy for a left supplementary motor area tumor. Detailed preoperative preparation of the patient was done to identify special requirements and establish a good patient-team relationship. Intraoperatively, continuous language and motor testing were performed. Conversation and music were the main distractors used. Throughout the operation, the patient remained calm and cooperative, even during a focal seizure. Mapping allowed for >80% resection of the tumor. Postoperatively, the patient recovered without any deficits.

Conclusion: This case shows that with growing experience and meticulous preparation, the limits of awake craniotomy can be expanded to include more patients that were previously considered unfit.

Keywords: Autism; Autistic spectrum disorder; Awake craniotomy; Brain mapping; Glioma; Neuro-oncology.

Figure 1:

Preoperative T2 FLAIR magnetic resonance imaging (MRI) scan in coronal (left) and sagittal (right) cuts. Tumor margins illustrated during preoperative planning in red. The tumor (red) is located in the supplementary motor area, with signs of extension to the cingulate gyrus. At the posterolateral border, tumor tractography shows corticospinal tract fibers (purple). (green: Brainstem, orange: Anterior commisure, yellow: Optic radiation).

Figure 2:

(a) Intraoperative ultrasound after dural opening. Hyperechoic lesion measuring 3 cm in depth. On the left, the falx is recognized by its bright white hyperechoic signal and its shape. (b) View of the posterolateral part of the resection cavity at the end of the operation. Hyperechoic residual tumor at 2 cm depth can be identified. At this area, subcortical stimulation identified the corticospinal tract.

Figure 3:

Postoperative (48-h) MRI scan T2 FLAIR (left) and T1+contrast (Right) sagittal sections, showing the resection cavity. Residual tumor can be seen at the posterolateral margins, where function was detected during subcortical stimulation.