- Department of Neurosurgery Aga Khan University Hospital, Karachi, Sindh, Pakistan.
- Department of Surgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan.
M. Shahzad Shamim
Department of Surgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan.
DOI:10.25259/SNI_635_2020Copyright: © 2020 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, tweak, 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: Bukhari SS1, Shamim MS2. Can awake glioma surgery be the new standard of care in developing countries?. Surg Neurol Int 11-Dec-2020;11:434
How to cite this URL: Bukhari SS1, Shamim MS2. Can awake glioma surgery be the new standard of care in developing countries?. Surg Neurol Int 11-Dec-2020;11:434. Available from: https://surgicalneurologyint.com/surgicalint-articles/10442/
Roberts Bartholow’s infamous experiment to map functional areas of the human brain in an awake patient in the year 1874 generated not only a lot of controversy among his contemporaries but also resulted in grand mal seizures in the unsuspecting patient Ms. Mary Rafferty. She had, what was termed as an epithelioma that had eroded her skull and exposed dura and brain over a period of 13 months.[
The advantages of awake craniotomy for surgical resection of gliomas have been supported with case series documenting the better extent of resection, lower risk of new deficits, and improved progression-free survival among certain patient sub-groups with both low-grade and high-grade gliomas. A randomized control trial (The SAFE trial) is underway to better answer certain questions regarding the utility of awake craniotomy compared to craniotomy under general anesthesia for glioblastomas. This study will look at important endpoints such as progression-free survival, overall survival, and frequency and severity of adverse effects. The trial is expected to conclude in 2024.[
Intraoperative mapping during awake craniotomy has shown significant promise in minimizing postoperative deficits which are independently associated with worse outcomes. Awake craniotomy with intraoperative mapping has been found to be useful in achieving the adequate extent of resection even in complex low-grade gliomas that several busy neuro-oncology centers do not use the navigation in such cases, with equally good or better results.[
The cost-effectiveness of awake craniotomy for glioma surgery has been suggested by many authors. The direct cost-benefit from choosing an awake procedure results from the avoidance of general anesthesia decreased hospital stay in both intensive and general care settings and early discharge. There may be an additional cost reduction by avoiding the use of navigation. Eseonu et al. showed significant savings with awake procedures with improved outcomes and reduced complication. In their experience, although the operating room cost was higher in the awake craniotomy group (primarily human resource-related), the overall inpatient costs were reduced by an average of 12000 US Dollar (USD) per case.[
Mark Bernstein has championed the philosophy of awake craniotomy as a sustainable practice in resource-limited settings through his involvement in teaching the technique in several LMICs.[
This is especially relevant in LMICs like Pakistan, where the per capita income is low, majority of patients are out of pocket payers, and especially in the wake of COVID-19 pandemic, when a large segment of population may be on the verge or below the poverty line. So can awake craniotomies be employed to reduce costs and improve outcomes for gliomas patients in Pakistan? The answer to the latter may only be answered sufficiently once we have sufficient evidence which is at least a few years away. The prior is a more complex question that is influenced heavily by the expense of training individuals in multiple roles to safely perform awake craniotomies at a certain standard. This will ultimately balloon the cost of the procedure at the patient’s end unless public health funding can be mobilized. However, one quickly realizes that this is not really saving money but rather drawing it away from other public health needs. The authors feel that awake craniotomy has significant promise that may not be realized in developing countries for the next several years at the very least.
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