الفهرس 
Introduction and Aim of the workOnly 14 pages are availabe for public view
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Abstract
One of the biggest challenges in Neurosurgery is the good and accurate localization of different brain lesions specially those related to eloquent brain and cerebral cortex. Extent of resection is believed to be a key prognostic factor in Neurosurgery. Image guided surgery using a variety of tools or technologies to help achieve this goal had become a great need. With the Growing evidence in the literature, which suggests that a greater extent of resection positively affects overall survival, progression-free survival with better performance, It is believed that image guided surgery and mapping of eloquent brain areas offers advantages in terms of extent of resection and more effective in preventing damage to surrounding normal brain matter, minimizing the postoperative morbidity and ensuring a good quality of life.
from 2016 to 2018, 19 patients underwent surgical excision of intra-axial lesions under TIVA and 6 patients underwent awake craniotomy aided with fMRI and IONM, to find out the surgical outcomes of these techniques in tumors in eloquent areas. The study took place in Nasser Institute Hospital, Egypt.
from those 25 patients, 10 males and 15 females with mean age 36.08 years. Fourteen patients were low-grade lesions, [one patient (DNET GI, Hemangiopericytoma GI, and Pilocytic Astrocytoma GI), two patients Pleomorphic Xanthoastrocytoma
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GI, one patient (Diffuse Astrocytoma-Gemistocytic GII, Oligo-astrocytoma GII and LGG GII), two patients Oligodendroglioma GII and four patients Fibrillary Astrocytoma GII].
One patient was Granuloma (Tuberculoma).
Ten patients were high-grade lesions, [three patients Metastatic Adenocarcinoma GIII, three patients Anaplastic Oligo-astrocytoma GIII, one patient (Anaplastic Ganglio-glioma GIII, Anaplastic Astrocytoma- Gemistocytic) and two patients were Glioblastoma Multiforme].
Pre-operative detailed examination, assessment of the karnofsky performance scale, cognitive functions and ability of the patient to cooperate during awake surgery are very crucial before recruiting the patient for awake surgery. Meeting with a member of the monitoring team for detailed explanation of the hospital course, nature of the surgical procedure, possible complications in details, postoperative course and expected prognosis and outcome is very valuable and important for decreasing failure rate and encouraging the patient for more co-operation.
The procedure was successful and provided the main aim of increasing the extent of resection with minimal neurological complications. Preoperative KPS ranged from 70 to 90 with median (76.8%). 9 patients (36%) presented with KPS 70, 15 patients (60%) presented with KPS 80, 1 patient (4%) had KPS of 90. Immediate Post-operative, 14 patients (56%) were KPS
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70, 4 patients (16%) were KPS 80 and 7 patients (28%) were KPS 90. 3 Months post-operative, 1 patient died KPS was 0, 6 patients (24%) were KPS 80 and 18 patients (72%) had KPS 90. One Year post-operative, one patient (4%) was KPS 80, 15 patients (60%) were KPS 90 and 8 patients (32%) were KPS 100. Gross total resection >95% achieved in 19 patients (76%), 4 patients (16%) had subtotal resection >75%% and 2 patients (8%) had partial resection >65%. In our study the technique was associated with early postoperative worsened deficit in 32%, which improved permanently after 3 months and this was in agreement with the reported range in the literature.
Intraoperative seizures and lack of communication and agitations are the most important factors in awake surgeries. In our study intraoperative seizures happened in 4 patients (16%), and was easily controlled by ice-cold saline irrigation in all of them.
Overall our study added more evidence of the importance of such technique when dealing with tumors related to eloquent areas, and from our initial experience surgical excision of intra-axial lesions related to eloquent brain areas under TIVA and awake craniotomy can be easily introduced and achieved with reasonable operation time, complications rates and high patient satisfaction.