Awake Craniotomy for Resection of Cerebral Arteriovenous Malformation: Initial Experience From a Low- and Middle-Income Country

Global health has shown progress over the years; however, neurosurgical care has not followed the same trajectory due to it being presumably resource intensive. Awake craniotomy (AC) is a neurosurgical technique that can improve neurological outcomes, can potentially reduce costs and hospital stay, and can be easily employed in low- and middle-income countries (LMICs). It has proven to be beneficial in surgical resection of tumors located in the critical areas of the brain, but there is limited literature to support AC for resection of arteriovenous malformations (AVM). We present four cases of AVM that were successfully treated surgically under awake settings in a developing country. Two of the AVMs were Spetzler-Martin grade (SMG) 3, one was SMG 4, and one was SMG 1. All the patients underwent successful excision of AVMs, and the postoperative digital subtraction angiography (DSA) was negative for any residual. They had a total hospital stay of three to five days with a mean postoperative stay of two days. Only one patient showed transient conductive dysphasia, which resolved on subsequent follow-ups, and none of the patients developed any long-term neurological deficit. There are limited data from LMICs regarding the benefits of using AC for AVMs. However, our cases show that this technique can be applied for AVM resection, particularly in eloquent areas of the brain (parts of the cerebral cortex that control vision, language, sensory, and motor functions), to minimize potential neurological deficits. Even though it requires careful selection of cases, and needs a higher level of microsurgical and neuro-anesthesia expertise, it can lead to better postoperative outcomes, lesser morbidity, and a shorter hospital stay, contributing to low resource utilization, making it feasible in a resource-limited setting.