Awake Craniotomy for a Frontal Astrocytoma: A Case Report

Abstract

Awake craniotomy is a surgical procedure that has been gaining significance over the past decades. Neuronavigation is an intraoperative technology that locates tumors and monitors the brain cortex during awake craniotomy. The presence of cerebral low-grade gliomas in the frontal lobe creates a risk of affecting vital centers of the brain cortex during surgery. We present a clinical case of a 42-year-old male patient who entered the neurosurgery clinic with a clinical manifestation of headache for two months. MRI showed evidence of the recurrence of a left frontal glioma. Differential diagnoses of frontal gliomas include metastases, abscesses, and cysts. The pathophysiologic background of the disease is the mutation of neuroglial cells, which leads to an abnormal and uncontrollable proliferation. Under sleep-awake anesthesia, operative treatment was performed through left frontal awake craniotomy under neuronavigation. As a result, a total excision was achieved. Motor functions of the right limbs and speech have been preserved. The patient was mobilized on the day after the intervention. Surgery-related complications were not observed. The patient had relief from the symptoms and was discharged on the fifth day. Awake craniotomy combined with neuronavigation was the most efficient and the least harmful method for the excision of the tumor. For low-grade gliomas localized in the frontal area of the encephalon, awake craniotomy is the only secure option for surgery.

Keywords: astrocytoma; awake craniotomy; case report; frontal tumour; low-grade gliomas; neuronavigation guidance.

Figure 1. Preoperative MRI of left frontal glioma.

(A) Axial plane; (B) sagittal plane; (C) coronal plane. Notice the tumor formation in the left frontal region of the cerebrum.

Figure 2. Cerebral cortex in places with infiltration from astroglial tumor with diffuse growth and well-defined neuropil. Minimal cellular and nuclear atypism. Poorly expressed vascular proliferation. Absence of necrosis and hemorrhage. The mitotic index (Ki 67) is less than 4%.

(A) Cerebral cortex; (B) white matter.

Figure 3. Intraoperative photography.

(A) Awake craniotomy with sleep-awake anesthesia. (B & C) Evaluation of the fine motor skills of the right upper limb of the patient.

Figure 4. Materials (pictures) used for evaluating the cognitive skills of the patient during awake craniotomy of the left frontal region.

Figure 5. Postoperative CT after surgical exertion of a left frontal glioma.

Axial plane. Notice the exerted part in the left frontal region of the cerebrum.