Anesthetic management with scalp nerve block and propofol/remifentanil infusion during awake craniotomy in an adolescent patient -A case report-

Abstract

Despite of various neurophysiologic monitoring methods under general anesthesia, functional mapping at awake state during brain surgery is helpful for conservation of speech and motor function. But, awake craniotomy in children or adolescents is worrisome considering their emotional friabilities. We present our experience on anesthetic management for awake craniotomy in an adolescent patient. The patient was 16 years old male who would undergo awake craniotomy for removal of brain tumor. Scalp nerve block was done with local anesthetics and we infused propofol and remifentanil with target controlled infusion. The patient endured well and was cooperative before scalp suture, but when surgeon sutured scalp, he complained of pain and was suddenly agitated. We decided change to general anesthesia. Neurosurgeon did full neurologic examinations and there was no neurologic deficit except facial palsy of right side. Facial palsy had improved with time.

Scalp Block for Burr Holle Evacuation of Subdural Hematoma: A Series of Seven Patients and Review of the Literature

“…In two reports of awake craniotomy in the literature that reported two children, aged 9 and 16 years, propofol was preferred to provide sedation [19,20]. However, scalp block was used in just one of these patients [20], and local anesthetic infiltration was preferred in the other patient [19]. The scalp block can be combined not only with awake craniotomy, but also with general anesthesia.…”

Pediatric Awake Craniotomy for Brain Lesions

“…However, combining these agents at high doses could lead to hypoventilation, apnea and airway obstruction. Therefore, the patient should be closely monitored by the anesthesia team [7]. In 2013, Sarıhasan et al [8] reported that they performed tumor resection in a 11-year-old patient with awake craniotomy without any problem using only local anesthetics and 1 mg midazolam, followed by 0.2 μg/kg/min remifentanil infusion.…”

“…Levetiracetam is continued in the postoperative period. Some authors recommend rinsing the brain tissue with cold saline during epileptic seizures and this procedure was reported to terminate epileptic seizures [7]. …”

The Use of “Scalp Block” in Pediatric Patients

“…The supraorbital and supratrochlear nerve have successfully been blocked in children undergoing frontal craniotomies, nevus scalp removal, and midline dermoid excision [8,9]. The "scalp block" technique in children has recently been extended with block of the supraorbital, supratrochlear, auriculotemporal, lesser occipital and greater occipital nerves in a pediatric patient undergoing craniotomy [17]. This block was used as an adjunct to propofol/remifentanil based anesthetic during awake craniotomy and tumor resection in an adolescent patient [17].…”

“…The "scalp block" technique in children has recently been extended with block of the supraorbital, supratrochlear, auriculotemporal, lesser occipital and greater occipital nerves in a pediatric patient undergoing craniotomy [17]. This block was used as an adjunct to propofol/remifentanil based anesthetic during awake craniotomy and tumor resection in an adolescent patient [17]. Infiltration of the supraorbital, supratrochlear, auriculotemporal, greater auricular, greater occipital, and lesser occipital in an 8-year-old girl undergoing a thalamic tumor resection with levobupivicaine 0.25%, was also recently shown to prevent the hemodynamic response to skull-pin placement and decrease the need for opioids [18].…”