La chirurgie cérébrale en conditions éveillées. Une pratique historique redevenue technique de référence au 21ème siècle
Seance of wednesday 10 may 2023 (Neurochirurgie)
DOI number : 10.26299/qqa8-gd13/emem.2023.17.04
Abstract
The surgical management of intrinsic brain lesions is challenging. Postoperative morbidity, neurological, neurocognitive and behavioral outcomes, disease control and survival, epileptic seizure control, ability to work, and health-related quality-of-life are all a concern for these patients.
The development of neurosurgical techniques and methods allow for a safer and larger lesion resection. Particularly, the better understanding of the anatomo-functional organization and connectivity of brain functions has switch from an historical localisationist approach to an integrated hodotopical and dynamic approach. To minimize functional risks while maximizing the extent of resection of a particular brain lesion, a “function-based” and “connectome-guided” resection conducted under awake mapping can be proposed considering the inter-individual brain anatomo-functional variability. Intraoperative brain mapping under awake conditions allows real-time monitoring of sensorimotor, visuospatial, language, executive and behavioral functions and improves the risk-to-benefit ratio of the surgery. Such “awake surgeries” are currently considered as the neurosurgical gold standard to treat infiltrative brain neoplasms, such as diffuse gliomas in adults. Awake surgery is now incorporated in a global multi-step approach to manage cerebral gliomas and can be proposed at each step of the disease, including for incidentally discovered ones. Compensatory neural network reconfiguration, the so-called brain plasticity, allows multiple surgeries to be performed over years. In addition, awake surgery allows performing supra-marginal resection, including the removal of an additional margin around the visible part of the tumor, to improve disease control while preserving the health-related quality-of-life.
The development of neurosurgical techniques and methods allow for a safer and larger lesion resection. Particularly, the better understanding of the anatomo-functional organization and connectivity of brain functions has switch from an historical localisationist approach to an integrated hodotopical and dynamic approach. To minimize functional risks while maximizing the extent of resection of a particular brain lesion, a “function-based” and “connectome-guided” resection conducted under awake mapping can be proposed considering the inter-individual brain anatomo-functional variability. Intraoperative brain mapping under awake conditions allows real-time monitoring of sensorimotor, visuospatial, language, executive and behavioral functions and improves the risk-to-benefit ratio of the surgery. Such “awake surgeries” are currently considered as the neurosurgical gold standard to treat infiltrative brain neoplasms, such as diffuse gliomas in adults. Awake surgery is now incorporated in a global multi-step approach to manage cerebral gliomas and can be proposed at each step of the disease, including for incidentally discovered ones. Compensatory neural network reconfiguration, the so-called brain plasticity, allows multiple surgeries to be performed over years. In addition, awake surgery allows performing supra-marginal resection, including the removal of an additional margin around the visible part of the tumor, to improve disease control while preserving the health-related quality-of-life.