Awake Craniotomy for Removal of Intracranial Tumor: Considerations for Early Discharge

Abstract

It may be feasible to perform awake craniotomies for removal of intracranial tumor as an ambulatory procedure; however, caution is advised. Patient selection must be stringent with respect to the patient's preoperative functional status, tumor depth, surrounding edema, patient support at home, and ease of access to hospital for readmission.

Awake Craniotomy for Tumour Excision

“…Dexmedetomidine is a highly specific In the United States, majority of these procedures are performed under local anaesthesia with sedation and it is considered as standard approach to certain supratentorial tumours [12]. A shorter hospital stay results in considerable cost reduction and some centres advocate day-case procedures [13]. The term conscious sedation has been used widely, however it is such an amorphous term that the term 'sedation and analgesia' is recommended [14].…”

Ethical Challenges with Awake Craniotomy for Tumor

“…Established exclusion criteria to awake craniotomy include patients unable to cooperate because of severe dysphasia, language barrier, cognitive impairment, emotional instability or delirium, as well as patients with low occipital tumors (requiring prone positioning) or tumors involving significant dural attachment (due to the probability of significant dural pain on resection). 4,7 It has further been recommended that patients under the age of 11 not be considered for awake craniotomy. 18 From the experience of the senior author, attention to these principles combined with experienced surgical and anesthesia teams who communicate well, results in smooth awake craniotomies in the overwhelming majority of cases with intraoperative problems significant enough to call into question whether awake craniotomy was the best choice for a particular patient occurring in approximately 1% of cases.…”

“…Outpatient awake craniotomy has been demonstrated to maximize resource utilization and increase patient satisfaction. 7 Furthermore, it likely reduces the potential for infection, thromboembolic events, and other hospital-based complications. 29,30 Patients have reported that having brain surgery done as outpatients made their disease seem less serious, which contributed to emotional well-being and aided in the recovery process.…”

“…2,3 It was followed by resection of tumors from eloquent brain regions, [1][2][3][4][5][6] and then to routine, nonselective tumor resection regardless of the involvement of eloquent cortex. 1,7 Faster resumption of normal activity by the patient and more efficient use of medical resources has led to its performance with less regard to tumor location, and even on an outpatient basis in some neurosurgeons' practices. [8][9][10] Awake brain surgery is also used for neuromodulation in the treatment of idiopathic Parkinsonism, essential tremor, dystonia and chronic pain, 11,12 and has been experimentally applied in a number of nonmovement disorders such as depression, obsessive compulsive disorder, Tourette's disorder, Alzheimer disease, chemical addiction and obesity.…”

“…1 In addition, it cuts operating times, and less frequently requires the use of a Foley catheter, endotracheal tube, and central venous or intra-arterial lines than does general anesthesia. 1,4,7,16 The most common intraoperative complications of awake craniotomy are seizure, respiratory depression, emotional stress and physical discomfort. 17 From the perspective of the senior author, who feels awake craniotomy is an excellent option for patients and the healthcare delivery system, the randomization of patients in the face of overwhelming circumstantial evidence of safety and efficacy is ethically questionable.…”