The past few years have seen increasing support for gross total resection in the management
of low-grade gliomas (LGGs), with a greater extent of resection correlated with better
overall survival, progression-free survival, and time to malignant transformation.
There is consistent evidence in literature supporting extent of safe resection as
a good prognostic indicator as well as positively affecting seizure control, symptomatic
relief in pressure symptoms, and longer progression-free and total survival. The operative
goal in most LGG cases is to maximize the extent of resection for these benefits while
avoiding postoperative neurologic deficits. Several advanced invasive and noninvasive
surgical techniques such as intraoperative magnetic resonance imaging (MRI), fluorescence-guided
surgery, intraoperative functional pathway mapping, and neuronavigation have been
developed in an attempt to better achieve maximal safe resection. We present a case
of LGG in a young patient with a 5-year history of refractory seizures and gradual
onset walking difficulty. Serial MRI brain scans revealed a progressive increase in
right frontal tumor size with substantial edema and parafalcine herniation. Noninvasive
brain mapping by functional MRI (fMRI) and sleep-awake-sleep type of anesthesia with
endotracheal tube insertion was utilized during an awake craniotomy. Histopathology
confirmed a Grade II oligodendroglioma, and genetic analysis revealed no codeletion
at 1p/19q. Neurological improvement was remarkable in terms of immediate motor improvement,
and the patient remained completely seizure free on a single antiepileptic drug. There
is no radiologic or clinical evidence of recurrence 6 months postoperatively. This
is the first published report of an awake craniotomy for LGG in Pakistan. The contemporary
concept of supratotal resection in LGGs advocates generous functional resection even
beyond MRI findings rather than mere excision of oncological boundaries. This relatively
aggressive approach is only possible with an awake craniotomy, which ensures preservation
of functional status and thus less postoperative morbidity and better outcomes. Noninvasive
mapping for intracranial space-occupying lesions, including fMRI and blood-oxygen-level
dependent (BOLD) imaging modality, is an essential tool in a resource-limited setting
such as Pakistan.
Key-words: Awake craniotomy - brain mapping - low-grade glioma - oligodendroglioma - Pakistan
