Awake craniotomy for left frontal high-grade glioma: A multidisciplinary case report

Monisha *

Anesthesia Technician, Kauvery Hospital, Hosur, Tamil Nadu

*Correspondence

Abstract

Anaplastic astrocytoma is a World Health Organization (WHO) Grade III malignant glioma characterized by aggressive growth and progressive neurological deterioration. Lesions located in the left frontal lobe pose significant surgical challenges due to their proximity to eloquent cortical areas responsible for speech and motor function. Awake craniotomy enables intraoperative neurological monitoring, facilitating maximal safe resection while minimizing postoperative deficits. Left frontal space-occupying lesions (SOLs) located near eloquent brain areas require meticulous surgical planning to prevent neurological deficits. Awake craniotomy is a specialized technique that allows continuous intraoperative neurological monitoring, enabling safe and maximal tumor resection.

Key words: Anaplastic astrocytoma; Space-occupying lesions (SOLs); Craniotomy

Introduction

Space-occupying lesions (SOLs) of the brain encompass neoplastic, infectious, vascular, and inflammatory etiologies. Left frontal lobe SOLs are clinically significant due to their association with speech production, executive functions, motor control, and behaviour. Tumors in this region often present with expressive aphasia, right-sided motor deficits, cognitive decline, and altered personality. High-grade gliomas remain one of the most common malignant SOLs affecting the frontal lobe. Their infiltrative nature poses considerable challenges in achieving complete resection without inducing neurological deficits. Awake craniotomy with real-time speech and motor mapping has become the preferred surgical technique for lesions near eloquent cortex, allowing maximal tumor clearance with functional preservation.

Case Presentation

History of present illness

A 69-year-old male, known case of Type II diabetes mellitus and systemic hypertension for 15 years, presented to the Emergency Department with:

  • Slurring of speech for 4 days
  • Deviation of the mouth toward the left
  • Altered sensorium
  • Associated right-sided weakness
  • No history of seizures or vomiting

Past medical and surgical History

  • Type II Diabetes Mellitus
  • Hypertension
  • History of Guillain–Barré Syndrome (2007), treated with IVIG at a tertiary care centre
  • No significant surgical history

Clinical findings

General examination

  • Conscious, oriented to pain: GCS E4 V4 M6
  • Pupils: Bilaterally equal and reactive

Vitals

BP130/80 mmHg
Pulse78/min
RR18/min
Temperature97.2°F
SpO₂99% on room air

Systemic examination

CVSS1, S2 normal
RSBilateral air entry present

Neurological examination

  • Right-sided UMN facial palsy
  • Slurred speech (expressive aphasia)
  • Motor: Moves all four limbs with mild weakness on the right side
  • No meningeal signs

Investigations

Blood tests

Blood testResult
Hb10.9 g/dL
RBC count3.23 million/µL
Platelet Count2.51 lakh/µL
Total Count5,670 cells/µL
Urea40.6 mg/dL
Creatinine0.6 mg/dL
SerologyNegative

Radiological findings

CT Cerebral angiogram (27/02/26)

  • Large heterogeneously enhancing intra-axial mass
  • Left fronto-parietal region
  • Surrounding perilesional edema
  • Suggestive of high-grade glioma

MRI Brain

  • Size: 3.7 × 4.6 cm
  • Peripheral enhancement with central necrosis
  • Mass effect on left lateral ventricle

MRI Spectroscopy

  • Elevated choline
  • Reduced NAA→ Features consistent with high-grade glioma

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Diagnosis

Provisional diagnosis

  • Anaplastic Astrocytoma (WHO Grade III)

Final Diagnosis

  • Left Frontal Space-Occupying Lesion – likely high-grade glioma (HPE awaited)
  • Type II Diabetes Mellitus
  • Hypertension

Management

Surgical plan

  • Left Frontal Parasagittal Awake Craniotomy
  • Neuro navigation-guided
  • Neuro monitoring-assisted
  • Goal: Near-total excision

Anaesthesia plan

Techniques used

  • Monitored Anaesthesia Care (MAC)
  • Asleep–Awake–Asleep Method

Airway and preoperative assessment

  • Mallampati Grade IV
  • Limited neck extension
  • Mouth opening: 2 fingers

Scalp block

Nerves blocked:

  • Supraorbital, Supratrochlear
  • Zygomaticotemporal, Auriculotemporal
  • Greater & Lesser Occipital

Drugs Used

  • 0.5% Bupivacaine – 30 ml
  • 2% Lignocaine + Adrenaline – 30 ml

Sedation and intraoperative medications

  • Dexmedetomidine infusion
  • Propofol 30 mg (repeated)
  • Fentanyl 50 mcg (multiple doses)

Oxygenation: High Flow Nasal Cannula (HFNC): 40 L/min

Surgical course

Positioning: Supine; head in Mayfield clamp

Craniotomy: Scalp incision → bone flap elevation → dura opened

Awake phase

  • Sedation off
  • Speech and motor testing performed

Cortical mapping

  • Motor cortex
  • Sensory cortex
  • Broca’s area

Tumor resection

  • Near-total removal achieved
  • No new neurological deficits

Re-sedation and closure

  • Dura closed → bone flap replaced → scalp sutured

Outcome

The patient tolerated the awake craniotomy remarkably well, with no episodes of intraoperative seizures or hemodynamic instability. The immediate postoperative period remained uneventful, and the patient demonstrated steady neurological improvement. Speech function began to improve gradually over the following days, and the previously noted facial deviation showed a significant reduction. Motor strength in all limbs was preserved without any new deficits, reflecting the effectiveness of intraoperative mapping and the success of maximal safe tumor resection.

Discharge

On discharge, the patient was clinically stable and recovering well following the awake craniotomy. Neurologically, he demonstrated improved speech clarity with intact motor functions, and no new focal deficits were noted. Postoperative medications included corticosteroids for cerebral edema control, prophylactic antiepileptic drugs, broad-spectrum antibiotics, antihypertensives, and antidiabetic agents for optimal comorbidity management. The patient was advised to continue regular follow-up with the neurosurgery team, monitor blood glucose and blood pressure closely, and await the final histopathology report for definitive tumor characterization.

Discussion – Medical aspects

Anaplastic astrocytoma is a high-grade glioma with infiltrative margins, making surgical excision challenging. Lesions in the left frontal lobe risk affecting:

  • Broca’s area → expressive aphasia
  • Precentral gyrus → contralateral motor deficits
  • Premotor/SMA → impaired coordination and movement initiation

Awake craniotomy is the gold standard for lesions near eloquent cortex because:

  • Allows real-time neurological testing
  • Minimizes postoperative morbidity
  • Enhances extent of resection → improves survival outcomes

Neuro monitoring (MEP, SSEP, EEG) is critical in preventing irreversible neurological injury.

Discussion – Nursing Aspects

Nursing care played a pivotal role throughout the perioperative period of the awake craniotomy. Preoperatively, comprehensive neurological assessment was essential to establish a baseline, along with ensuring optimal blood pressure and glycemic control to reduce perioperative risk. The nurse provided detailed explanations about the awake craniotomy procedure to alleviate anxiety and assisted in preparing the patient for the scalp block and airway evaluation. Intraoperatively, the nursing team closely monitored vital signs, patient comfort, and sedation depth while assisting the anesthesiologist with adjustments. Continuous reassurance and therapeutic communication were crucial to keeping the awake patient calm and cooperative, alongside vigilant observation for warning signs such as seizures, respiratory distress, or hypoxia. Postoperatively, nursing responsibilities included frequent neurological assessments and close monitoring for potential complications such as increased intracranial pressure, seizures, or infection. Effective pain management, strict blood sugar and blood pressure monitoring, and meticulous wound care were maintained. Additionally, education for the patient and family regarding postoperative expectations and home care formed an integral part of the recovery process.

Conclusion

This case demonstrates the effectiveness of awake craniotomy in managing left frontal high-grade gliomas located near eloquent cortical regions. Through meticulous surgical planning, neuro monitoring, and coordinated anaesthetic and nursing care, near-total excision was achieved while preserving neurological function. Awake craniotomy remains an invaluable technique in maximizing tumor removal and minimizing postoperative deficits in eloquent brain tumors.

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