Patient Tolerance of Craniotomy Performed with the Patient under Local Anesthesia and Monitored Conscious Sedation

Danks, R. Andrew; Rogers, Malcolm P.; Aglio, Linda S.; Gugino, Laverne D.; Black, Peter McL.

doi:10.1097/00006123-199801000-00006

Cited by 163 publications

(89 citation statements)

References 8 publications

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“…[16] Complete resection, confirmed by postoperative imaging, was achieved in 23% of cases and substantial but incomplete resection (> 80%) was achieved in 57%. The principal reasons for incomplete resection were pathological involvement of cortex proven to be eloquent by cortical mapping or the development of an intraoperative deficit.…”

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confidence: 89%

“…We have performed craniotomies in more than 250 patients after induction of local anesthesia and monitored conscious sedation to secure maximum tumor excision with minimum postoperative deficits in tumors involving eloquent cortex. [16,57] Low-grade gliomas comprise the majority of tumors surgically treated after induction of local anesthesia. The infiltrating nature of these tumors as well as the fact that they occur in a relatively young population, with a better prognosis after complete excision, makes this histologically varied type of tumor a very good candidate for resection.…”

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confidence: 99%

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Neurosurgical considerations in supratentorial low-grade gliomas: experience with 175 patients

Nikas

Bello²,

Zamani³

et al. 1998

FOC

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The authors reviewed 175 low-grade hemispheric gliomas surgically treated by one surgeon (P.B.) between 1987 and 1996: 74 astrocytomas (42%), 35 oligodendrogliomas (20%), 52 mixed gliomas (30%), 12 gangliogliomas (7%), and two ependymomas (1%). Patient age ranged from 7.5 to 81.9 years (mean 39.2 years); 84 patients (48%) were males and 91 (52%) females. Postsurgical follow-up review ranged from 0.1 to 225.2 months (mean 36.2 months, median 24.9 months). Either T2-weighted or contrast-enhanced T1-weighted magnetic resonance (MR) images were used to evaluate the percentage of resection achieved and volume of residual disease postoperatively. The majority of patients (55%) had seizures as the presenting symptom, and 45% experienced preoperative symptoms for more than 12 months. Tumor enhancement was present in 21% of cases. In 66% of surgical procedures at least one of the following technical adjuncts was used: monitored local anesthesia, real-time MR imaging, stereotactic guidance with computerized tomography, three dimensional reconstruction, cortical mapping with cortical stimulation, somatosensory or visual evoked potential recording, corticography, or intraoperative ultrasound. Intraoperative MR imaging was used for 40 (22.9%) of the craniotomies and nine (5.14%) biopsies. There were no surgery-related deaths. Complications appeared in 6% of the patients. Progression to a higher-grade tumor occurred in 9.2% of patients within the 3-year follow-up period.

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confidence: 89%

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confidence: 99%

Neurosurgical considerations in supratentorial low-grade gliomas: experience with 175 patients

Nikas

Bello²,

Zamani³

et al. 1998

FOC

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“…The corticotomy was made in electrically silent regions and standard microneurosurgical resection of the tumor was undertaken. 3,4,15,[27][28][29] After 4 hours of observation in the Post Anesthetic Care Unit, a routine CT scan was performed and the patient returned to the Day Surgery Unit for further observation. Around 6:00 p.m. the neurosurgeon assessed the patient for discharge and provided appropriate prescriptions and information pamphlets.…”

Section: Outpatient Craniotomymentioning

confidence: 99%

“…The use of awake craniotomy shortens total operative time, does not require Foley catheter insertion, and minimizes the use of invasive central venous or intraarterial lines, while neurolept anesthesia obviates the risks associated with intubation and general anesthesia. 9,15,27,29 Because the hospital stay is shortened to just a few hours, the chances for nosocomial infection, thromboembolism, and medical error are reduced. 1,6 It may also diminish patients' fear and anxiety about undergoing brain tumor surgery.…”

Section: Fig 3 Axial Images Obtained In a 38mentioning

confidence: 99%

Outpatient brain tumor surgery: innovation in surgical neurooncology

Boulton¹,

Bernstein²

2008

JNS

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Object Recent studies of conventional craniotomies and image-guided biopsies have afforded a solid characterization of surgical morbidity and the timing of its occurrence. This report outlines a novel 11-year experience with outpatient image-guided biopsy and outpatient craniotomy for supratentorial intraaxial brain tumors. Methods During the period between August 1996 and May 2007, 117 awake image-guided biopsies and 145 elective craniotomies for tumor resection were prospectively selected to be performed as outpatient procedures. Data were recorded for each patient regarding tumor histological type, reasons for admission if planned early discharge failed, and surgical complications. Results Successful discharge from the Day Surgery Unit was possible in 109 (93%) of 117 biopsy cases and 136 (94%) of 145 craniotomy cases (only 2 of which [1.5%] required unplanned readmission after discharge). Neurological worsening occurred in 5.1% of the patients who underwent image-guided biopsies, and in 5.5% of those who underwent outpatient craniotomies (based on intent-to-treat group analysis). No patient suffered an adverse event with alteration in outcome because of planned outpatient discharge. Conclusions Outpatient image-guided brain biopsy and outpatient craniotomy for tumor resection are safe and effective procedures in selected patients.

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“…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.…”

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Ethical Challenges with Awake Craniotomy for Tumor

Kirsch

Bernstein

2012

Can. J. Neurol. Sci.

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78The frequency and indications for use of modern awake craniotomy are increasing. 1 The first "contemporary" application was for the treatment of epilepsy in the early 17th century. 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. 8-10 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. 12 We explore some of the factors that influence whether to recommend awake brain surgery to tumor ABSTRACT: Background: Awake brain surgery is useful for the treatment of a number of conditions such as epilepsy and brain tumor, as well as in functional neurosurgery. Several studies have been published regarding clinical results and outcomes of patients who have undergone awake craniotomy but few have dealt with related ethical issues. Objective: The authors undertake to explore broadly the ethical issues surrounding awake brain surgery for tumor resection to encourage further consideration and discussion. Methods: Based on a review of the literature related to awake craniotomy and in part from the personal experience of the senior author, we conducted an assessment of the ethical issues associated with awake brain tumor surgery. Results: The major ethical issues identified relate to: (1) lack of data; (2) utilization; (3) conflict of interest; (4) informed consent; (5) surgical innovation; and (6) surgical training. Conclusion: The authors respectfully suggest that the selection of patients for awake craniotomy needs to be monitored according to more consistent, objective standards in order to avoid conflicts of interest and potential harm to patients.RÉSUMÉ: Défis éthiques concernant la craniotomie en état vigile pour traiter une tumeur. Contexte : La chirurgie du cerveau en état de vigile est utile pour traiter certaines pathologies telles l'épilepsie et les tumeurs cérébrales ainsi qu'en neurochirurgie fonctionnelle. Plusieurs études ont été publiées sur les résultats cliniques et l'issue chez des patients qui ont subi une craniotomie en état vigile, mais peu d'études ont traité des aspects éthiques. Objectif : Les auteurs ont exploré d'une façon large les questions éthiques entourant la chirurgie en état vigile effectuée pour l'ablation de tumeurs dans le but de favoriser un examen plus approfondi du sujet et de susciter la discussion. Méthode : Nous avons procédé à une évaluation des questions éthiques associées à la chirurgie en état vigile pour l'ablation d'une tumeur c...

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Patient Tolerance of Craniotomy Performed with the Patient under Local Anesthesia and Monitored Conscious Sedation

Abstract: This series confirmed that this technique is a very useful and safe technique for resection of lesions involving eloquent cortex that might otherwise be considered inoperable. This procedure involves a level of stress that remains within the tolerance level of the average adult.

Cited by 163 publications

References 8 publications

Neurosurgical considerations in supratentorial low-grade gliomas: experience with 175 patients

Neurosurgical considerations in supratentorial low-grade gliomas: experience with 175 patients

Outpatient brain tumor surgery: innovation in surgical neurooncology

Ethical Challenges with Awake Craniotomy for Tumor

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