Clinical Neuropsychology in the Evaluation and Preparation for Awake Neurosurgery

In this post, psychologist Cristian Francisco Liébanas Vega talks about intraoperative brain mapping and its contributions to diagnosing disease.

Intraoperative brain mapping is a specialized technique used during brain surgery to optimize the balance between removing the tumor and preserving important brain functions. It is mainly used in patients with tumors or lesions located near important functional brain regions, such as those for language, movement, vision, and emotion. The main goal of intraoperative brain mapping is to identify and avoid critical brain areas while removing the tumor.

How is brain mapping carried out?

Intraoperative brain mapping uses electrodes to stimulate different parts of the brain while the patient is awake. During the procedure, the patient performs different language, movement, visual field, and emotional expression tasks designed specifically for them by neuropsychologists.

These tasks allow neurosurgeons and clinical neuropsychologists to evaluate the patient’s responses and create a personalized map of the brain areas whose functions must be preserved. This functional map is compared with the anatomical map of the tumor obtained through intraoperative ultrasound and neuronavigation, which provides a better understanding of how higher brain functions work and allows for more extensive surgical resections with a lower risk of neurological damage.

Diseases that can be detected through brain mapping

In addition to brain tumors, brain mapping can also be used in the diagnosis and treatment of other neurological diseases, such as epilepsy and movement disorders. Intraoperative brain mapping can provide crucial information about the brain areas responsible for seizures in patients with epilepsy, allowing precise surgical removal of the affected area to be planned.

The neuropsychologist’s role in brain mapping

The neuropsychologist plays a key role in intraoperative brain mapping. They are responsible for designing and carrying out the specific neuropsychological tasks used to assess the patient’s brain functions during the procedure.

The neuropsychologist works closely with the surgeon and the medical team to identify critical brain areas and create a personalized map of the functions that must be preserved during surgery. The neuropsychologist may also carry out pre- and postoperative assessments to evaluate possible changes in brain function after surgery.

Contributions of brain mapping to diagnosis

Intraoperative brain mapping has proven to be a valuable tool in diagnosing neurological diseases.

In addition to determining the anatomical and functional boundaries of tumors, as we have just seen, brain mapping can also be used to diagnose and treat other neurological diseases. In epilepsy, for example, it helps identify the areas responsible for seizures and guides the planning of surgery to remove the affected areas.

Clinical psychological and neuropsychological assessment

In patients who are candidates for awake neurosurgery, identifying changes in mood, cognition, behavior, and personality is challenging, and only a thorough, comprehensive assessment process can determine whether they are caused by the tumor or are a psychological response to stress, the diagnosis, or the treatment (Madhusoodanan, Ting, Farah, & Ugur, 2015). In this regard, the literature emphasizes careful, individualized patient selection through a thorough, objective preoperative neuropsychological assessment, which can reduce risks and increase the chances of a good outcome.

Neuropsychological predictors of high surgical risk

1. Personal factors

It’s important to consider all the personal factors that can positively or negatively influence the person’s performance during surgery. Personal resources include personality type, emotional maturity, coping strategies, and previous experiences. Previous experiences related to cancer or the death of a family member from a tumor are associated with a greater emotional burden for the patient at the start of the process, while social and family resources are considered protective factors as the disease progresses.

Variables such as excessive alcohol or drug use and chronic pain disorders are known risk factors for sedation failure (Chui, 2015). In addition, stress levels, the patient’s expectations, and how they cope with frightening situations are taken into account in various studies and considered important variables.

2. Decision-making capacity

Assessing the ability to understand the treatment is a necessary part of the care process. According to Palmer & Harmell (2016) and Lutters & Broekman (2019), a formal assessment of decision-making capacity is not only an ethical and legal obligation of the team in charge but also part of the patient’s right to autonomy. Palmer & Harmell (2016) state that the patient’s decision-making capacity should be defined based on four dimensions:

• Understanding: the ability to accept and understand the disease, the information provided, and the risks, benefits, and possible treatments.
• Appreciation: the ability to apply the information provided to oneself and one’s own situation.
• Reasoning: evidence that decisions reflect a process of comparing and manipulating information.
• Expressing a choice: the ability to communicate a clear, consistent decision.

It’s important to keep in mind that, during illness, the ability to choose becomes more complex, so it’s common for both the patient and the family to have difficulty making decisions about the patient’s health (Mattavelli, Casarotti, Forgiarini, Riva, Bello, & Papagno, 2012). In addition, patients with brain tumors often have cognitive impairment, which in some cases is associated with severe impairments in everyday decision-making skills (Ouerchefani, Ouerchefani, Allain, Rejeb, & Le Gall, 2017; Lutters & Broekman, 2019).

As a result of the disease itself, many patients have only limited awareness of their symptoms and tend to underestimate their impact on their lives. A lack of self-awareness, whether caused by the tumor itself or by a psychological defense mechanism, makes it difficult to make informed decisions about their health, which has been identified as a limitation for patient participation in this type of procedure (Boele et al., 2015).

3. Emotional and psychiatric disorders

According to the literature, a highly anxious patient will tend to make more mistakes and lose attention, concentration, and memory, so neither the baseline nor the real-time results would be reliable, which would affect both the plan of action and the extent of the resection (Ruis et al., 2017; Huget et al., 2019). In awake neurosurgery, it’s very important for the patient to be able to manage their anxiety and their own movements, ensuring that they have self-containment skills. Self-containment is understood as the patient’s ability to voluntarily regulate their behavior during the procedure (Rughani, Rintel, Desai, Cushing & Florman, 2011; Howie et al., 2016).

4. Neurocognitive disorders

Neuropsychological assessment is an essential procedure that not only establishes a baseline of cognitive functioning but also identifies significant neuropsychological deficits that would prevent the patient from performing the tasks required during brain mapping (Ruis, Wajer, Robe, & van Zandvoort, 2014).

According to Hervey-Jumper & Berger (2016), severe impairment of preoperative cognitive functioning, the presence of aphasia, pronounced neurological disorders, and the inability to be tested because of attention or consciousness problems are considered exclusion criteria, since they make it difficult for the patient to cooperate in the operating room.

Becker (2016) mentions some basic cognitive functions that the person must retain to take an active role during awake neurosurgery:

• language that is fluent enough to express themselves and communicate cognitive and physical changes and discomfort during the procedure;
• verbal comprehension for cooperating and following instructions;
• memory to ensure that information and instructions about the surgery are retained;
• attention to carry out the intraoperative tasks;
• and visual skills in case they need to name images.

5. Considerations for presurgical preparation

In addition to passing the clinical psychological and neuropsychological assessment, the patient must meet the requirements of the presurgical preparation assessment to be ready for the demands of surgery (Rughani et al., 2011). The experience gained at HM has allowed the team to identify that this preparation should involve the family or social network and include the two basic aspects described below:

A. Information about the surgery

This type of surgery requires the coordinated participation of every member of the team. As an active participant, the patient needs to know in detail their role, the procedures carried out during surgery, and what to expect at each step. Beyond knowing this information, they also need to understand it.

Authors such as Beez et al. (2013) and Ruis et al. (2014) believe that if the patient is reluctant to receive or refuses details about the surgery, they cannot undergo surgery in this way, since the patient must understand the advantages and the need to stay awake at key moments of the operation.

However, clinical practice shows that the way information is provided should match the patient’s coping style, and some patients need more details than others.

The team should explain what will happen in the operating room, including the procedure, possible complications, the desired level of cooperation, and the tasks to be performed (Carbone et al., 2019). To achieve this, psychoeducation and preparation sessions with both the patient and the family are essential.

Psychological preparation for surgery also requires sensory familiarization with the operating room environment and with the sensations in the body. A prior visit to the operating room or the presentation of visual and auditory stimuli that get the person used to the procedure, the physical space, and the instruments are a good tool and help dispel the patient’s misconceptions about the procedure (Ortega, 2013; Ortiz, 2014; Quesada, 2015; Molinari, 2015; Acuña, 2017). Being able to anticipate in some way what will happen or what they will feel gives them a sense of control during the procedure.

B. Bond with the neuropsychologist and the surgical team

One of the most important aspects that sets awake surgery apart from other types of surgery is the importance of the patient building a bond of trust with the neuropsychologist.

Because the procedure is so demanding, studies have shown that patients need a familiar person who is available to support them emotionally throughout the entire surgical procedure (Ruis et al., 2014).

Actions such as explaining what is happening before and during surgery, training them for moments of discomfort or anxiety, offering words of encouragement, and holding their hand during surgery are seen as highly valuable by patients (Molinari, 2015; Acuña, 2017; Ruis et al., 2014).

For this kind of interaction between the patient and the clinician to be possible, time must be invested in preparation, and the patient must be willing to work together (Ruis et al., 2014). As part of the preparation, the neuropsychologist can try to extend this bond of trust to the entire surgical team, which would be the ideal situation in the operating room.

References

• Duffau, H. (2017). Mapping the connectome in awake surgery for gliomas: an update. Journal of neurosurgical sciences, 61(6), 612-630.
• Feigl, G. C., Luerding, R., & Milian, M. (2015). Awake Craniotomies: Burden or Benefit for the Patient? In Handbook of Neuroethics (pp. 949-962). Springer Netherlands. 
• Freyschlag, C. F., & Duffau, H. (2014). Awake brain mapping of cortex and subcortical pathways in brain tumor surgery. Journal of neurosurgical sciences, 58(4), 199-213.
• Howie, E., Bambrough, J., Karabatsou, K., & Fox, J. R. (2016). Patient experiences of awake craniotomy: An Interpretative Phenomenological Analysis. Journal of health psychology, 21(11), 2612-2623.
• Kelm, A., Sollmann, N., Ille, S., Meyer, B., Ringel, F., & Krieg, S. M. (2017). Resection of Gliomas with and without Neuropsychological Support during Awake Craniotomy—Effects on Surgery and Clinical Outcome. Frontiers in Oncology, 7, 176.
• Klimek, M., van der Horst, P. H., Hoeks, S. E., & Stolker, R. J. (2018). Quality and Quantity of Memories in Patients Who Underg Awake Brain Tumor Resection. World neurosurgery, 109, e258-e264.
• Khu, K. J., Doglietto, F., Radovanovic, I., Taleb, F., Mendelsohn, D., Zadeh, G., & Bernstein, M. (2010). Patients’ perceptions of awake and outpatient craniotomy for brain tumor: a qualitative study. Journal of neurosurgery, 112(5), 1056-1060.
• Leal, R. T. M., da Fonseca, C. O., & Landeiro, J. A. (2017). Patients’ perspective on awake craniotomy for brain tumors—single center experience in Brazil. Acta neurochirurgica, 159(4), 725-731.
• Lutters, B., & Broekman, M. L. (2019). Evaluating Awake Craniotomies in Glioma Patients: Meeting the Challenge. In Ethics of Innovation in Neurosurgery (pp. 113-118). Springer, Cham.
• Madhusoodanan, S., Ting, M. B., Farah, T., & Ugur, U. (2015). Psychiatric aspects of brain tumors: A review. World journal of psychiatry, 5(3), 273.
• Mattavelli, G., Casarotti, A., Forgiarini, M., Riva, M., Bello, L., & Papagno, C. (2012). Decision-making abilities in patients with frontal low-grade glioma. Journal of neuro-oncology, 110(1), 59-67.
• Ouerchefani, R., Ouerchefani, N., Allain, P., Rejeb, M. R. B., & Le Gall, D. (2017). Contribution of different regions of the prefrontal cortex and lesion laterality to deficit of decision-making on the Iowa Gambling Task. Brain and cognition, 111, 73-85.
• Palese, A., Skrap, M., Fachin, M., Visioli, S. y Zannini, L. (2008). La experiencia de los pacientes sometidos a craneotomía despierta: en las propias palabras de los pacientes. Un estudio cualitativo. Enfermería noncológica, 31 (2), 166-172.
• Palmer, B. W., & Harmell, A. L. (2016). Assessment of healthcare decisionmaking capacity. Archives of Clinical Neuropsychology, 31(6), 530-540.
• Pichierri, A., Bradley, M., & Iyer, V. (2019). Intraoperative Magnetic Resonance Imaging–Guided Glioma Resections in Awake or Asleep Settings and Feasibility in the Context of a Public Health System. World neurosurgery: X, 3, 100022.
• ughani, A. I., Rintel, T., Desai, R., Cushing, D. A., & Florman, J. E. (2011). Development of a safe and pragmatic awake craniotomy program at Maine Medical Center. Journal of neurosurgical anesthesiology, 23(1), 18-24.
• Ruis, C., Wajer, I., Robe, P., & van Zandvoort, M. (2014). Awake craniotomy and coaching. Open Journal of Medical Psychology, 3(5), 382-389.
• Ruis, C., Wajer, I. H., Robe, P., & van Zandvoort, M. (2017). Anxiety in the preoperative phase of awake brain tumor surgery. Clinical Neurology and Neurosurgery, 157, 7-10.
• Salazar Villanea, M., Ortega Araya, L. E., Ortiz Álvarez, J., Esquivel Miranda, M. A., Vindas Montoya, R., & Montero Vega, P. (2016). Calidad de vida en pacientes costarricenses con tumores cerebrales: aportes de la neuropsicología. Actualidades en Psicología, 30(121), 49-66.
• Santini, B., Talacchi, A., Casagrande, F., Casartelli, M., Savazzi, S., Procaccio, F., & Gerosa, M. (2012). Eligibility criteria and psychological profiles in patient candidates for awake craniotomy: a pilot study. Journal of neurosurgical anesthesiology, 24(3), 209-216.
• Vitón Martín, R. (2010). Drogadicción y anestesia. Revista Cubana de Anestesiología y Reanimación, 9(1), 39-47.
• Wrede, K. H., Stieglitz, L. H., Fiferna, A., Karst, M., Gerganov, V. M., Samii, M., … & Lüdemann, W. O. (2011). Patient acceptance of awake craniotomy. Clinical neurology and neurosurgery, 113(10), 880-884

If you enjoyed this article on clinical neuropsychology in the assessment and preparation of patients for awake neurosurgery, you may also be interested in these NeuronUP articles: