Enhancing intra-axial brain surgery in resource-limited settings: a pilot study balancing safety and radicality

Abstract Background In Low-Middle-Income Countries (LMIC), the high cost of advanced surgical tools and limited access to specialized training restricts the ability to maximize the safety and thoroughness of intra-axial lesion surgeries especially for Diffuse Low-Grade Glioma (DLGG) Aim To enhance surgical safety and radicality on intra-axial brain lesions putatively diagnosed as DLGG. We evaluated four surgical techniques at our resource-limited institution: conventional asleep surgery, asleep surgery with intraoperative ultrasound (IOUS), awake craniotomy (AC) with intraoperative neuromonitoring (IONM), and AC with both IOUS and IONM. We also aim to report our single institution experience and lessons learned concerning the AC procedure from the perspective of LMIC. Results Forty-six patients aged fourteen years or older, harboring intra-axial brain lesions with the preoperative radiological diagnosis of DLGG were included. Outcomes were compared across the four surgical techniques, focusing on the extent of resection (EOR), complication rates, functional outcomes, blood loss, and length of hospital stay. Awake Craniotomy with both IOUS and IONM, compared to conventional surgery, achieved a significantly higher EOR (98.49% vs. 71.78%, p = 0.007) and a 100% gross total resection rate (vs. 41.18%, p = 0.012). However, this approach also led to a higher rate of immediate postoperative complications (88.89% vs. 47.06%, p = 0.02), a significant decline in Karnofsky Performance Status (KPS) (− 22.22 vs. − 2.35, p = 0.007), and longer hospital stays (15.00 vs. 7.29 days, p = 0.00002). No significant difference between the groups was observed in persistent neurological deficits (PNDs) ( p = 1.0). Conclusion Our pilot study demonstrated that the use of AC with IOUS and IONM significantly enhanced the resection of various diffuse intra-axial lesions. However, this approach also led to higher immediate postoperative complications and extended hospital stays. Thus, while advanced modalities offer substantial benefits, they can also present significant burdens without proper training, particularly in resource-constrained environments. As a LMIC, our institute has shown the potential to implement AC. Though it is still in its early stages facing numerous challenges that necessitate further training and potential multicenter collaboration for refinement. Thus for improved outcomes that balance between safety and radicality in LMIC institutes like ours, we would require a comprehensive knowledge transfer, dedicated personnel training, larger studies with longer follow-up periods, and a tailored approach to patient-by-patient resource allocation.