Anesthesia for awake craniotomy: a how-to guide for the occasional practitioner

Abstract

Awake craniotomy (AC), defined as the performance of at least part of an open cranial procedure with the patient awake, has been tied to beneficial outcomes compared with similar surgery under general anesthesia. Improved anesthetic techniques have made a major contribution to the increasing popularity of AC. However, the heterogeneity of practice among institutions doing large numbers of ACs raises questions (often among those who only occasionally perform AC - i.e., practitioners in low-volume AC institutions) as to the ideal anesthetic technique for AC. The procedure presents a variety of decision-making dilemmas, the origins of which are the varying institutional preferences, lack of quality evidence, and several practice controversies. Evidence-based data that support a single anesthetic algorithm for AC are sparse. In this narrative review, the technical nuances of 13 aspects of anesthetic care for AC are discussed based on institutional preferences and available evidence, and the various controversies and research priorities are discussed. The skills, experience, and commitment of both the surgeon and the anesthesiologist are large variables that are likely more important than what the literature suggests about "best" techniques for AC. Optimizing patient outcome is the fundamental goal of the anesthesiologist.

Awake craniotomy using dexmedetomidine and scalp blocks: a retrospective cohort study

“…4 Meng et al recently succinctly summarized AC as a pre-awake, awake, and post-awake phase, with and without airway intervention. 5 The goals include maintaining airway patency, optimizing cerebral perfusion, facilitating real-time brain mapping, minimizing postoperative pain, and allowing rapid recovery and assessment of neurologic function after surgery. 6 Various anesthesia drugs have been used to achieve these goals, including propofol, remifentanil, fentanyl, and dexmedetomidine.…”

Awake Throughout Craniotomy: Initial Experience and the Anaesthetic Challenges

“…The other relative contraindications are obstructive sleep apnea, cough. 1 There are two anaesthetic techniques 2 1. Awake throughout: The spontaneous ventilation is maintained without any airway device and sedation is titrated .…”

Dexmedetomidine as adjunct in awake craniotomy – improvement or not?

“…Besides techniques, also used medication differs between centers performing AC, and several different combinations have been reviewed [7][8][9][11][12][13].…”

“…dation (CS) [1,[6][7][8][9][10][11][12][13][14][15][16]. Not only applied techniques, but also used medication and airway devices, differ or have underlain changes and improvements over time [14,17,18].…”