Advanced frailty assessment tool predicts successful awake craniotomy in a 92-year-old patient: A case report
- Department of Neurosurgery, University of New Mexico, University of New Mexico Health Sciences Center, Albuquerque, United States.
Christian A. Bowers, MD, Associate Professor and Vice Chair for Clinical Affairs, Program Director - Neurosurgery Residency, Medical Director -Clinical Neuroscience Center Neurosurgery Clinic, Department of Neurosurgery, University of New Mexico Health Sciences Center, University New Mexico, Albuquerque, NM, 81731, United States.
DOI:10.25259/SNI_542_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Kyril L. Cole, Samantha Varela, Kavelin Rumalla, Syed Faraz Kazim, Ryan W. Rebbe, Michael Carvajal, Karen S. SantaCruz, Rohini McKee, Cheryl Willman, Meic H. Schmidt, Christian A. Bowers. Advanced frailty assessment tool predicts successful awake craniotomy in a 92-year-old patient: A case report. 09-Sep-2022;13:404
How to cite this URL: Kyril L. Cole, Samantha Varela, Kavelin Rumalla, Syed Faraz Kazim, Ryan W. Rebbe, Michael Carvajal, Karen S. SantaCruz, Rohini McKee, Cheryl Willman, Meic H. Schmidt, Christian A. Bowers. Advanced frailty assessment tool predicts successful awake craniotomy in a 92-year-old patient: A case report. 09-Sep-2022;13:404. Available from: https://surgicalneurologyint.com/surgicalint-articles/11862/
Background: The awake craniotomy (AC) procedure allows for safe and maximal resection of brain tumors from highly eloquent regions. However, geriatric patients are often viewed as poor candidates for AC due to age and medical comorbidities. Frailty assessments gauge physiological reserve for surgery and are valuable tools for preoperative decision-making. Here, we present a novel case illustrating how frailty scoring enabled an elderly but otherwise healthy female to undergo successful AC for tumor resection.
Case Description: A 92-year-old right-handed female with history of hypertension and basal cell skin cancer presented with a 1-month history of progressive aphasia and was found to have a ring-enhancing left frontoparietal mass abutting the rolandic cortex concerning for malignant neoplasm. Frailty scoring with the recalibrated risk analysis index (RAI-C) tool revealed a score of 30 (of 81) indicating low surgical risk. The patient and family were counseled appropriately that, despite advanced chronological age, a low frailty score predicts favorable surgical outcomes. The patient underwent left-sided AC for resection of tumor and experienced immediate improvement of speech intraoperatively. After surgery, the patient was neurologically intact and had an unremarkable postoperative course with significant improvements from preoperatively baseline at follow-up.
Conclusion: To the best of our knowledge, this case represents the oldest patient to undergo successful AC for brain tumor resection. Nonfrail patients over 90 years of age with the proper indications may tolerate cranial surgery. Frailty scoring is a powerful tool for preoperative risk assessment in the geriatric neurosurgery population.
Keywords: Awake craniotomy, Frailty, Malignant tumor, Risk analysis index, Tumor resection
Techniques utilized by neurosurgeons to maximize resection of brain tumors, while minimizing morbidity has improved significantly over time.[
History and examination
A 92-year-old right-handed female with a history of hypertension and basal cell skin cancer presented with a 1-month history of progressively worsening speech difficulties. The patient was brought to clinic by her daughter who first noticed the mild changes in sentence syntax. The patient is a retired schoolteacher who at baseline takes no medication, exercises daily, and lives independently. The progressive speech symptoms prompted medical workup including magnetic resonance imaging (MRI) of the brain and subsequent referral to our institution for neurosurgical evaluation. Symptoms at time of consultation included speech difficulties and intermittent right-hand numbness. Neurological examination was positive for expressive aphasia and otherwise unremarkable.
MRI brain with/without contrast revealed a T1 hypointense, rim-enhancing, and intra-axial mass centered in the left precentral gyrus concerning for a malignant neoplasm involving the eloquent rolandic cortex [
Preoperative neuroimaging. (a) Axial magnetic resonance imaging (MRI)-brain T1 image showing hypointense left frontoparietal mass centered in the left precentral gyrus with Gadolinium-enhanced T1 MRI axial (b), sagittal (c), and coronal (d) images demonstrating rim-enhancement concerning for malignant intracranial neoplasm. Green arrows represent tumor.
Preoperative assessment and patient counseling
The clinical symptoms and imaging findings were strongly suggestive of intermediate to high grade tumor involving the eloquent motor cortex responsible for speech expression. AC would be offered as a primary treatment option given acceptable surgical risk. The risks associated with surgery in the patient’s age group were considered. However, frailty assessment as measured by the recalibrated RAI-C scoring system deemed her a low-risk surgical candidate.[
A left-sided frontoparietal temporal AC was performed for resection of tumor with the use of the operative microscope and Medtronic Stealth neuronavigation. Awake speech mapping with intraoperative electrophysiology mapping was also performed with assistance from neuropsychology colleagues. Gross-total resection with achieved without any speech arrest. Speech improved intraoperatively on removal of the cystic portion of tumor.
Samples taken during tumor resection were sent to pathology, where microscopic examination of the tissue sections demonstrated a poorly differentiated population of cells with multiforme cytologic features and abundant atypical mitotic figures with vascular proliferation and necrosis, providing a histopathological diagnosis of the WHO Grade IV glioblastoma.
Histopathology of grade IV glioblastoma multiforme tumor. (a-c) Hematoxylin and eosin staining showing a poorly differentiated population of cells with multiforme cytologic features and some vaguely astrocytic features. There are abundant, often atypical mitotic figures, vascular proliferation, and necrosis. (d) Positive for GFAP immunoreactivity.
Postoperative imaging and course
Postoperatively, the patient was admitted to the neurosurgical ICU for routine monitoring. The patient was neurologically intact with exception of mild expressive aphasia that improved compared to preoperative assessment. The postoperative MRI with and without contrast was negative for acute complications and showed no residual mass [
With current life expectancy trends, octogenarians are expected to triple globally by 2050.[
Based on traditional preoperative evaluations, our patient may have been refused elective AC due to advanced chronological age alone. Similar to chronological age, older comorbidity-based indices[
The RAI is a powerful frailty tool developed and validated to improve the selection of patients for surgery.[
Outcomes data in elderly patients undergoing AC are scarce. A single study by Grossman et al., in 2013, reported outcomes after AC for tumor resection in a series of 334 young (45.4 ± 13.2 years, mean ± SD) and 90 elderly (71.7 ± 5.1 years) patients.[
The present case represents the first successful AC for tumor resection in a 92 years old. The case illustrates how robust frailty scoring tools can be integrated into the clinical workflow to select elderly but otherwise healthy patients for surgery. Nonfrail patients over 90 years of age with the proper indications may tolerate cranial surgery. Frailty scoring is a powerful tool for preoperative risk assessment in the geriatric population.
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest.
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