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December 2022, Volume 72, Issue 12

Evidence Based Neuro-Oncology

Feasibility of awake craniotomy for brain tumours in children

Mujtaba Khalil  ( Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan. )
Izza Tahir  ( Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan )
Ahmer Baig  ( Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan. )
Muhammad Shahzad Shamim  ( Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi. )

Awake craniotomy (AC) is routinely performed in adult patients for tumours near eloquent areas of the brain. It improves outcomes and reduces complications. However, its use is limited in children. However, several authors have reported good results of AC in a highly selective group of relatively older children. Fundamental to the success of AC is a co-operative child and thorough pre-operative preparation with a truly multidisciplinary approach.


Keywords: Awake Craniotomy, Brain Tumours, Children.






In children, brain tumours are the second most common malignancy, and the leading cause of cancer-related deaths.1 Surgery is the initial treatment of choice for most paediatric brain tumours.2 Awake craniotomy (AC) with intraoperative electrocortical mapping is a reliable method to maximize the extent of resection while preserving neurological function in adult patients.3,4 However, its use is limited in children primarily because the fundamental pre-requisite for an awake procedure is a co-operative patient.5 Furthermore, AC is best utilized in supratentorial lesions, and in children, only 30% of the brain tumours are supratentorial and these are mostly diagnosed before 2 years of age.6 In this article, we have reviewed the relevant literature on the feasibility of AC in children.


Review of literature


We did a thorough literature search on Google Scholar and PubMed and found that most studies were either case reports or case series. Tejedor et al.5 retrospectively studied one of the largest cohorts of 28 children who underwent AC for brain tumour resection. The mean age of the study population was 15 years (range7-17 years). The lesions were mostly left-sided (70%) [frontal (50%), temporal (36.7%), and parietal (13.3%)] and gross total resection was achieved in 64% of cases and subtotal resection was achieved in the remaining 36% cases. Twenty-four (80%) cases had no serious complications whereas the remaining 20% patients experienced serious complications [agitation (6.7%), seizures (3.3%), increased intracranial pressure (3.3%), respiratory depression requiring naloxone (3.3%), and bradycardia (3.3%)]. All complications were resolved quickly without any major consequences. For agitation, a 1 mg/kg propofol bolus was administered in one of the patients, while the other required conversion to general anaesthesia. New neurological deficits were seen in 6 (20%) patients; 2 patients experienced mild aphasia, 2 had mild peripheral sensory deficits, 1 had hemiparesis, and 1 had ataxia. All postoperative neurological deficits were resolved within 6 months follow-up period.5

Balagoun et al.7 studied 7 children who had underdone AC for gliomas. The male to female ratio of the study population was 1:1 with a mean age of 14.6 years and seizure was the most common presenting symptom. There were a few minor unexpected intraoperative events, but overall patients tolerated AC well with complete resection of the tumour. One patient became combative and uncooperative during speech mapping which resulted in the abandonment of the procedure. Two (20%) patients had speech arrest during mapping with consequent subtotal resection of the tumour in one patient to spare language. The follow-up period was 6-27 months and only one patient had a tumour over the anatomical language area and with neurological deficits. This patient's word-finding problem worsened postoperatively, but this progressively improved and was barely noticeable at her last clinic visit. No patient developed a new neurologic deficit.7 Lohkamp et al.8 studied a cohort of 17 children comprising 5 males and 12 females with a median age of 14.8 years. Complete tumuor removal was achieved in 11 patients (65%). Post-operative neurological deficits were transiently observed in 2 patients, whereas severe psychological reactions occurred in only 1 child. Two children experienced persistent attention deficits postoperatively. Patients were followed up for 22.2 months postoperatively and all children did well except 2 patients who died due to tumour progression.8

Riquin et al.,1 studied the psychological aspects of AC in 7 children. The preoperative assessment for any psychiatric condition was done by a psychiatrist using DSM 4 or DSM 5. Children were conditioned to the procedure and operating room by giving a chance to meet other children who had undergone AC to explain their psychological experiences. Pictures and a video describing the atmosphere of the operating room were also used. Finally, the children visited the operating room and met the surgery and anaesthesia team before surgery to get acquainted with the atmosphere. Postoperatively only one child had symptoms of depression which improved with psychotherapeutic follow-up without any need for medication. No patient showed symptoms of PTSD or acute stress. The children talked about the surgery without any anxiety or difficulty and, their memories were pleasant.1

For AC individual assessment of patients should be done to assess their level of development and to decide if the child is suitable for awake brain surgery. Psychological support for the child is of immense importance as well and cannot be neglected, as it can have an impact on the overall outcome of the patient. For an awake craniotomy, especially in the paediatric population, a great degree of understanding and cooperation is required. Neurosurgeons, anaesthesiologists, neuropsychologists, and neurophysiologists must come together to work in sync to ensure the best patient outcome. It is also, at the same time, essential for the operative team, including the neurosurgeons, anaesthesiologists, and neuropsychiatrists, to build trust with the patient and the family.




Awake craniotomy comes with many challenges, especially in paediatric patients, and requires a multidisciplinary approach. With sufficient preparation and a great degree of understanding and cooperation between the physicians, family, and patients, along with good assessment it is not only feasible in the paediatric population but also a safe and well-tolerated procedure.




1.       Riquin E, Dinomais M, Malka J, Lehousse T, Duverger P, Menei P, Delion M. Psychiatric and psychologic impact of surgery while awake in children for resection of brain tumors. World Neurosurg. 2017; 102:400-5.

2.       Ojemann GA. Individual variability in cortical localization of language. J. Neurosurg. 1979; 50:164-9.

3.       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.

4.       Hamer PD, Robles SG, Zwinderman AH, Duffau H, Berger MS. Impact of intraoperative stimulation brain mapping on glioma surgery outcome: a meta-analysis. J Clin Oncol. 2012; 30:2559-65.

5.       Alcaraz García?Tejedor G, Echániz G, Strantzas S, Jalloh I, Rutka J, Drake J, Der T. Feasibility of awake craniotomy in the pediatric population. Pediatr. Anesth.2020; 30:480-9.

6.       Desandes E, Guissou S, Chastagner P, Lacour B. Incidence and survival of children with central nervous system primitive tumors in the French National Registry of Childhood 7. Solid Tumors. Neuro-Oncol.2014; 16:975-83.

7.       Balogun JA, Khan OH, Taylor M, Dirks P, Der T, Snead III OC, Weiss S, Ochi A, Drake J, Rutka JT. Pediatric awake craniotomy and intraoperative stimulation mapping. J. Clin. Neurosci. 2014; 21:1891-4.

8.       Lohkamp LN, Beuriat PA, Desmurget M, Cristofori I, Szathmari A, Huguet L, Di Rocco F, Mottolese C. Awake brain surgery in children-a single-center experience. Childs Nerv Syst. 2020; 36:967-74.

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