Thank you very much, Chairman. I'm very happy to be here to be able to present my opinion. My English is still so poor, please allow me to read the written sentence. This is my CY to be disclosed. These are requested question lists. I would like to answer these questions, but not all. First of all, I owe everything to Professor Berger's teachings. In 1994, Professor Berger published the concept of one centimeter rule. At that time, I had a great opportunity to receive instruction in an awake surgery, directly from Professor Berger. These are valuable photographs of Professor Berger's awake surgery in 1995. He always checked after discharge using electrocorticography named Berger cramp. Lungage mapping was done mainly by object naming using this good old slide changer. He told me that positive result is necessary. The patient is positioned with a large roll under his shoulder and with his head lying on a soft rest. I realized he was always thinking about the patient's comfort. All for the patient comfort and for the result. The result means maximize tumor resection and minimize surgical morbidity. After I came back to Japan, I did the first awake craniotomy of rheumatism in December 1996. So the awake surgery in Japan has a 20-year history. This is the patient's MRI and the record of anesthesia. I remember that we somehow accomplished this awake surgery. This is the first released video of awake surgery in Japan for the 35th annual meeting of Japan's Society of Clinical Oncology in 1997. I used the same good old slide changer and methods for cortical mapping include lungage mapping. 18 years have passed. There is no tumor recurrence. This patient has slight anartheria but otherwise look fine. He can work and manage to raise his two children successfully. During these years, awake surgery is changing and developing. Professor Berger summarized the techniques of awake surgery in Neurosurgery 2007. In this paper, he wrote the head is secured with a Mayfield pin fixation device in order to use surgical navigation. At that point, a wide exposure was still necessary to ensure that enough cortical sites are available for testing. Everybody knows this paper in New England Journal of Medicine 2008. Professor Berger made up a fascinating theory of negative lungage mapping. A tailored craniotomy in conjunction with negative lungage mapping can be relied on to maximize resection and minimize morbidity when gliomas within or near lungage pathways are removed. Very informative response from Professor Dufault to this concept can be seen in this paper as followed. Note that this procedure has been established by a team with vast experience in cortical mapping and thus should only be relied on if the cortical stimulation technique is well established within the mapping team. I would like to summarize the points so far. Paradigm shift had occurred in 2008. As for me, the need of pin fixation is unacceptable. The report cannot change this spot. In Japanese old saying, Mitsugo no tamashii hyaku made mo, this can be translated into that teachings given under the age of three influence his mind until the age of 100. So I do awake surgery in a manner of Professor Berger's teaching with some modifications. First of all, awake surgery is a teamwork, including the patient. We neuro-oncologists like the word mutually exclusive. Sometimes the key person may be an operator, but this condition must be avoided. Mandatory understanding is necessary. Most of all, operators must establish a relationship of mutual trust with the patient. In addition, the patient cannot be changed, no matter what. In order to awake surgery successfully, education for the patient is necessary. This is the first step, and visualization is mandatory using slides and videos. Understanding of the patient's situation. What happened in your brain? What is glioma? Why is this surgery necessary? Understanding of awake surgery. What is awake surgery? You are always fine during the surgery, no pain. Why is collaboration necessary? How you can collaborate during surgery? You are a leading actor. This is the largest point during description for the patient. Then I always run a simulation a day before the surgery. Head is lying on the soft rest. Care for back pain. Ask the patient, do you feel the cold easily? Are you sensitive to heat? What kind of music do you like to hear? A speech therapist, speech language therapist who had full communication with the patient is very important. During this simulation, final check for naming of object should be done. Objects are appropriate. Visual acuity and field is preserved. Contact lens or eyeglass is necessary. After phosphatidine, sodium hydrate, and leviciracetam had been commercially available, I think we can perform awake surgery more safely. After the introduction of asleep-awake-asleep method using learning air mask, we do not have to pay attention for pains during a setting of the skull recurrence, skin incision, and craniotomy. But nerve blocks still play a certain role for pain relief. Recently, electromagnetic tracking can be used as a neural navigation system without pin fixation. Circumferential local anesthesia by injection of mixture of a short and long acting regional anesthetics with epinephrine was used to obliterate pain at the incision inside. I do not want to be operated with pin fixation under wake condition. This is the reason why I still operate without pin fixation. In 2015, Professor Dufault suggested that electrocorticography is not mandatory. This sentence is almost same as the comment he wrote to the negative language mapping method in 2010. The method of awake surgery depends on the learning level. I think in order to define the most suitable amplitude of stimulation, electrocorticography recording is still necessary. This is our awake surgery. Language mapping without any discomfort. Drinking of small amount of water is important to maintain the patient's condition. We keep the patient fully awake and talking to each other freely until the final resection. Partial resection without awake craniotomy had been done twice at the previous hospital for this patient. We operated this patient under awake condition with interoperative neurophysiological monitoring. During the resection beneath the inferior frontal gyrus, preservation and disturbance of repetition were observed. So we had to stop resection. Upper row is preoperative T2-weighted images and lower row is postoperative. Residual tumor corresponding to the interoperative finding is observed. Seven years after the awake surgery, no recurrence of the tumor and how KPS is maintained at 100%. I apply awake surgery only for language mapping and monitoring, not for preserving motor function. A skull reference is used for neuro-navigation system without pin fixation. Under asleep condition using laryngal mask, we can keep the patient condition comfortable until the final resection. It must be not so unique, but we routinely use motor mapping and monitoring under general anesthesia with electromyogram monitoring. This is because I saw a lot of the same concept of surgery done by Professor Berger in 1998. These are pre- and postoperative imaging of a patient with gangliogram at left placental gyrus. Precise mapping could be done using bipolar stimulator under general anesthesia. Hand digit mode area for arm and upper arm and leg motor area could be detected. and stimulation to the posterior and lateral wall could elicit the leg movements. This mapping result could be confirmed by electromyogram monitoring, post-operative MR imaging, and Haar video. Slight weakness of right ankle dorsiflexion could be seen. Ten years after the surgery, there is no recurrence, no epilepsy, and no neurological deficit. She became an elementary school teacher. Several stimulation devices and parameters are applied for brain mapping. Precise localization can be obtained by bipolar stimulation. In contrast, monopolar stimulation can be used for continuous MEP monitoring and mapping. Even with monopolar stimulation, precise critical motor mapping can be obtained like this case. In addition, subcortical mapping can be obtained by monopolar stimulation. Continuous MEP monitoring using five trains of electrical pulses at 500 Hz delivered through subdural electrodes located at the M1 is useful for confirmation of motor function preservation. In order to distinguish arteries supplying the descending motor pathway, continuous MEP monitoring combined with temporal occlusion of suspected arteries is useful. This long insular artery was temporarily occluded, resulting in the obvious decreasing of the amplitude of MEP. So I preserved this artery. The patency of this artery was confirmed by ICG video angiography. This video was obtained six weeks after the surgery. No neurological deficit was observed. She told me that she was very sleepy during the operation. But if the next surgery is necessary, she promised me she will work together with me. In order to preserve the descending motor pathway itself, subcortical mapping using monopolar stimulation can be obtained by monopolar stimulation. Monopolar stimulation with continuous MEP monitoring is effective. Previously, Dr. Kamata reported that distance between the descending motor pathway can be estimated using monopolar stimulation trains of five. This is a patient with rapidly growing left thalamic glioblastoma. Stable MEP was obtained until the final resection of the tumor. Brain shift came about as a natural result. MEP was obtained by subcortical stimulation to the lateral wall of the resection cavity at a very low amplitude. She could come back to daily life. Advantages of this method are less damage to neural tissue, no seizure, no ECG monitoring, reproducible MEP, and distance between the descending motor pathway can be estimated. I briefly summarized our experiences. Two years ago, I chaired the annual meeting of Japan Society for Awake Surgery. At that time, Professor Berger gave us a wonderful educational lecture. I would like to thank Professor Berger again. Thank you very much for your attention.

awake surgery

Professor Berger

one centimeter rule

patient comfort

tumor resection