title: Teaching and sustainably implementing awake craniotomy in resource-poor settings.
abstract: OBJECTIVE
  Awake craniotomy for brain tumor resection has the benefit of avoiding a general anesthetic and decreasing associated costs (e.g., intensive care unit beds and intravenous line insertion). In low- and middle-income countries, significant resource limitations for the system and individual make awake craniotomy an ideal tool, yet it is infrequently used. We sought to determine if awake craniotomy could be effectively taught and implemented safely and sustainably in low- and middle-income countries.
  
  
  METHODS
  A neurosurgeon experienced in the procedure taught awake craniotomy to colleagues in China, Indonesia, Ghana, and Nigeria during the period 2007-2012. Patients were selected on the basis of suspected intraaxial tumor, absence of major dysphasia or confusion, and ability to tolerate the positioning. Data were recorded by the local surgeons and included preoperative imaging, length of hospital admission, final pathology, postoperative morbidity, and mortality.
  
  
  RESULTS
  Awake craniotomy was performed for 38 cases of suspected brain tumor; most procedures were completed independently. All patients underwent preoperative computed tomography or magnetic resonance imaging. In 64% of cases, patients remained in the hospital <10 days. The most common pathology was high-grade glioma, followed by meningioma, low-grade glioma, and metastasis. No deaths occurred, and no case required urgent intubation. The most common perioperative and postoperative issue was seizure, with 1 case of permanent postoperative deficit.
  
  
  CONCLUSIONS
  Awake craniotomy was successfully taught and implemented in 6 neurosurgical centers in China, Indonesia, Ghana, and Nigeria. Awake craniotomy is safe, resource-sparing, and sustainable. The data suggest awake craniotomy has the potential to significantly improve access to neurosurgical care in resource-challenged settings.
authors.affiliation: Global Health Education Institute, University of Toronto, Toronto, Ontario, Canada. Electronic address: kathryn.howe@utoronto.ca.
authors.forename: Kathryn L
authors.initials: KL
authors.lastname: Howe
authors.forename: Guosheng
authors.initials: G
authors.lastname: Zhou
authors.forename: Julius
authors.initials: J
authors.lastname: July
authors.forename: Teddy
authors.initials: T
authors.lastname: Totimeh
authors.forename: Thomas
authors.initials: T
authors.lastname: Dakurah
authors.forename: Adefolarin O
authors.initials: AO
authors.lastname: Malomo
authors.forename: Muhammad R
authors.initials: MR
authors.lastname: Mahmud
authors.forename: Nasiru J
authors.initials: NJ
authors.lastname: Ismail
authors.forename: Mark A
authors.initials: MA
authors.lastname: Bernstein
mesh_terms: D000349:Africa; D000758:Anesthesia; D001208:Asia; D001932:Brain Neoplasms / Q000601:surgery; D002681:China / Q000453:epidemiology; D003399:Craniotomy / Q000379:methods* / Q000706:statistics & numerical data; D003906:Developing Countries; D005869:Ghana / Q000453:epidemiology; D006295:Health Resources; D006801:Humans; D007214:Indonesia / Q000453:epidemiology; D008279:Magnetic Resonance Imaging; D009493:Neurosurgery / Q000193:education* / Q000706:statistics & numerical data; D019635:Neurosurgical Procedures / Q000379:methods* / Q000706:statistics & numerical data; D009549:Nigeria / Q000453:epidemiology; D018579:Patient Selection; D019990:Perioperative Care; D011182:Postoperative Care; D013663:Teaching; D014057:Tomography, X-Ray Computed; D014851:Wakefulness
keywords: Brain tumor; Craniotomy; Education; LMIC; Low-income and middle-income countries; Neurosurgery; World health