Eligibility – go or no go?

MICHIEL WAGEMAKERS: So we are here to talk about the possible case for awake surgery. Concerns a 31-year-old male who has had some episodes of language disturbance the last couple of years. And he’s been analysed in a different hospital where they found a tumour in the brain. And we have it here on the scan. You can see that on the left– in the left hemisphere, in the insular region, there’s a large tumour with some of the temporal lobe overlaying the tumour. So I think that, from a surgical point of view, he may be a candidate. There’s no real problem with intracranial pressure. He does have possibly some tendency to epilepsy but not too bad.

TONY ABSALOM: So they’re well-controlled?

MICHIEL WAGEMAKERS: They’re well controlled. So I was wondering what you think about it.

WENCKE VEENSTRA: Well, I’ve seen him for a neuropsychological assessment, and he had, for 10 years, progressive word-finding difficulties, and memory complaints, mental slowness, and complains of fatigue. Very unusual for his age. He’s only 31 years old. And he also had complaints of anxiety and obsessive compulsive disorder. And he received treatment for that, but not very successfully. And we did a neuropsychological assessment–

TONY ABSALOM: Can I just interrupt though?

WENCKE VEENSTRA: Of course.

TONY ABSALOM: So that anxiety and obsessive compulsive disorder, it wasn’t successfully treated, but how is it now? Has he got a lot of problems with anxiety?

WENCKE VEENSTRA: Well, It’s mainly the problems of the OCD– so washing his hands excessively and controlling things.

He still has sessions with a psychologist, but he says, well, I can live with it, but it’s–

TONY ABSALOM: Do you think that he would cope with several hours of not having control of himself when there’s surgery and these things happening to him?

WENCKE VEENSTRA: Yeah. It’s a good question. But I talked with him, and we also did some questionnaires. And actually, he scored in the normal range for anxiety and depression. He has these controlling behaviour. But I think he can manage, and he thinks that as well.

On the other hand, we also did extensive neuropsychological assessment. Also, because he had these memory complaints. And indeed, he has deficits in his working memory capacity and verbal memory. And also, the mental slowness, especially for verbal information, not for auditory and visual information. And also, I tested his executive functions were a little bit below average. His social cognition was intact. And his linguistic functions, I did the DULIP protocol. He had his word-finding difficulties. Also, his phonological fluency is very weak. His semantic fluency was OK. And actually, on all the linguistic tests of the DULIP, he performed on average. So I think he’s eligible for awake surgery.

The only thing he found a bit hard was the phoneme deletion task, which taps very into working memory. So I think that’s the problem there. But I think he can do it. Yeah.

MICHIEL WAGEMAKERS: OK. What do you think, Tony?

TONY ABSALOM: Well, ordinarily, I’d be a little bit worried about an awake procedure or parts of the procedure awake in someone with this history. But firstly, what you’re saying is reassuring. And secondly, you can also see, with the position of the tumour, that the surgery would be really putting his speech areas at risk. So obviously, there’s big benefits here. So from that point of view of coping with the awake bit, sounds like he’ll be fine, and we wouldn’t have any objections. It looks like a big tumour. So probably the mapping and awake bit will be quite long and the resection, so it’s probably worth doing our usual and doing the general anaesthetic in the beginning, so asleep.

And from that point of view, I have assessed his– done a usual anaesthetic assessment, and I’ve got no concerns there. He was fit and well before this. He’s got no heart or lung problems. He takes some medicines for the epilepsy but nothing else. He’s got no allergies. And he’s had an anaesthetic before, and he’s tolerated that well. So I’m not worried about his fitness for anaesthesia or sedation.

MICHIEL WAGEMAKERS: OK. So I guess we should go ahead with the procedure. And if we perform this, we should talk about a strategy. If we look at the scan, we see that the tumour’s in the insular part, so we’re concerned about the arcuate fasiculus. And also, the temporal lobe may be the entry for us to move into the tumour. So we might want to remove part of the superior temporal gyrus. So these two areas are our main concern. Do you think you could select some tests to monitor these functions?

WENCKE VEENSTRA: Yep. That won’t be a problem. And also, for the arcuate fasiculus, we can monitor that. Yeah.

MICHIEL WAGEMAKERS: OK. OK.

TONY ABSALOM: So there’s no surgical contraindications to awake craniotomy.

MICHIEL WAGEMAKERS: I think not. Like I said, the intracranial pressure, he’s fine at the moment. I think that won’t be a problem. And epileptic seizures. But we’ll have to see, of course, what happens during surgery.

TONY ABSALOM: We can deal with them, though.

MICHIEL WAGEMAKERS: Yeah. OK.