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      Awake Craniotomy in a Child: Assessment of Eligibility with a Simulated Theatre Experience

      case-report

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          Abstract

          Background

          Awake craniotomy is a useful surgical approach to identify and preserve eloquent areas during tumour resection, during surgery for arteriovenous malformation resections and for resective epilepsy surgery. With decreasing age, a child's ability to cooperate and mange an awake craniotomy becomes increasingly relevant. Preoperative screening is essential to identify the child who can undergo the procedure safely. Case Description. A 11-year-old female patient presented with a tumour in her right motor cortex, presumed to be a dysembryoplastic neuroepithelial tumour (DNET). We had concerns regarding the feasibility of performing awake surgery in this patient as psychological testing revealed easy distractibility and an inability to follow commands repetitively. We devised a simulated surgical experience to assess her ability to manage such a procedure. During the simulated theatre experience, attempts were made to replicate the actual theatre experience as closely as possible. The patient was dressed in theatre attire and brought into the theatre on a theatre trolley. She was then transferred onto the theatre bed and positioned in the same manner as she would be for the actual surgery. Her head was placed on a horseshoe headrest, and she was made to lie in a semilateral position, as required for the surgery. A blood pressure cuff, pulse oximeter, nasal cannula with oxygen flow, and calf pumps were applied. She was then draped precisely as she would have been for the procedure. Theatre lighting was set as it would be for the surgical case. The application of the monitoring devices, nasal cannula, and draping was meant not only to prepare her for the procedure but to induce a mild degree of stress such that we could assess the child's coping skills and ability to undergo the procedure. The child performed well throughout the simulated run, and surgery was thus offered. An asleep-awake-asleep technique was planned and employed for surgical removal of the tumour. Cortical and subcortical mapping was used to identify the eloquent tissue. Throughout the procedure, the child was cooperative and anxiety free. Follow-up MRI revealed gross total removal of the lesion.

          Conclusion

          A simulated theatre experience allowed us to accurately determine that this young patient, despite relative contraindications, was indeed eligible for awake surgery. We will continue to use this technique for all our young patients in assessing their eligibility for these procedures.

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          Most cited references31

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          Cortical language localization in left, dominant hemisphere. An electrical stimulation mapping investigation in 117 patients.

          The localization of cortical sites essential for language was assessed by stimulation mapping in the left, dominant hemispheres of 117 patients. Sites were related to language when stimulation at a current below the threshold for afterdischarge evoked repeated statistically significant errors in object naming. The language center was highly localized in many patients to form several mosaics of 1 to 2 sq cm, usually one in the frontal and one or more in the temporoparietal lobe. The area of individual mosaics, and the total area related to language was usually much smaller than the traditional Broca-Wernicke areas. There was substantial individual variability in the exact location of language function, some of which correlated with the patient's sex and verbal intelligence. These features were present for patients as young as 4 years and as old as 80 years, and for those with lesions acquired in early life or adulthood. These findings indicate a need for revision of the classical model of language localization. The combination of discrete localization in individual patients but substantial individual variability between patients also has major clinical implications for cortical resections of the dominant hemisphere, for it means that language cannot be reliably localized on anatomic criteria alone. A maximal resection with minimal risk of postoperative aphasia requires individual localization of language with a technique like stimulation mapping.
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            Prevention and intervention strategies to alleviate preoperative anxiety in children: a critical review.

            Preoperative anxiety (anxiety regarding impending surgical experience) in children is a common phenomenon that has been associated with a number of negative behaviors during the surgery experience (e.g., agitation, crying, spontaneous urination, and the need for physical restraint during anesthetic induction). Preoperative anxiety has also been associated with the display of a number of maladaptive behaviors postsurgery, including postoperative pain, sleeping disturbances, parent-child conflict, and separation anxiety. For these reasons, researchers have sought out interventions to treat or prevent childhood preoperative anxiety and possibly decrease the development of negative behaviors postsurgery. Such interventions include sedative premedication, parental presence during anesthetic induction, behavioral preparation programs, music therapy, and acupuncture. The present article reviews the existing research on the various modes of intervention for preoperative anxiety in children. Clinical implications and future directions are discussed.
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              Tolerance of awake surgery for glioma: a prospective European Low Grade Glioma Network multicenter study.

              Gross total removal of glioma is limited by proximity to eloquent brain. Awake surgery allows for intraoperative monitoring to safely identify eloquent regions. However, data on adverse psychological effects induced in these patients is limited.
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                Author and article information

                Contributors
                Journal
                Case Rep Anesthesiol
                Case Rep Anesthesiol
                CRIA
                Case Reports in Anesthesiology
                Hindawi
                2090-6382
                2090-6390
                2020
                5 July 2020
                : 2020
                : 6902075
                Affiliations
                1Department of Neurosurgery, University of the Witwatersrand, Johannesburg, South Africa
                2Department of Paediatric Neurosurgery, Nelson Mandela Children's Hospital, Johannesburg, South Africa
                3Department of Anaesthesiology, University of the Witwatersrand, Johannesburg, South Africa
                4Department of Paediatric Anaesthesiology, Nelson Mandela Children's Hospital, Johannesburg, South Africa
                5University of the Witwatersrand, Johannesburg, South Africa
                6Department of Speech Therapy, Nelson Mandela Children's Hospital, Johannesburg, South Africa
                Author notes

                Academic Editor: Alparslan Apan

                Author information
                https://orcid.org/0000-0002-6567-0131
                Article
                10.1155/2020/6902075
                7361895
                32695521
                c457e1d0-4f08-460e-9e10-fa0f7eb55bd7
                Copyright © 2020 Jason Labuschagne et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 11 March 2020
                : 8 June 2020
                : 11 June 2020
                Categories
                Case Report

                Anesthesiology & Pain management
                Anesthesiology & Pain management

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