Pediatric awake craniotomy and intra-operative stimulation mapping

Feasibility of awake craniotomy in the pediatric population

“…With regard to the anesthetic management, asleep‐awake‐asleep was the approach of choice in our cohort. Both asleep‐awake‐asleep and conscious sedation are present in the literature, while none has demonstrated any superiority in children.…”

“…Complications considered serious were those that could lead to a fatal event or major sequelae without any intervention from the anesthesiologist. These were defined prior to data collection based on previous reports of awake craniotomy both from the pediatric and the adult population, and included seizures, increased intracranial pressure (presence of “tight brain” as indicated by the neurosurgeon), respiratory depression (oxygen saturation below 90% and/or respiratory rate below 8 rpm), airway obstruction (blockage in any part of the airway with or without oxygen saturation below 90%), bradycardia (heart rate below 60 lpm), vomiting, or severe agitation. Mild complications included moderate pain (numeric pain scale score ≥ 6) or and systolic hypertension above 20% of baseline.…”

“…Besides, ethical concerns regarding negative psychological experience and possible emotional distress have also been raised . Due to these limitations, only small series of awake craniotomy have been conducted in children, in contrast to the larger cohorts within the adult population . Similarly, data about the anesthetic technique are very scarce in the literature and frequently limited to case reports .…”

Epilepsy surgery near or in eloquent cortex in children—Practice patterns and recommendations for minimizing and reporting deficits

“…With regard to language cortex, although most respondents accept age of 5 years as the upper limit beyond which plasticity starts to decline, a minority believed that full plasticity extended to the end of the first decade; a presumption that prompts resection strategies carrying risk of incurring long‐term deficits. Irrespective of one's biases toward the handling of EC, wider usage of protective strategies such as awake surgery when feasible, tractography and intraoperative navigation tools, and intraoperative functional mapping is justified and strongly recommended . There is also increasing emphasis on ensuring the integrity of white matter tracts via subcortical mapping to maximize preservation of eloquent function and deployment of minimally invasive surgical strategies …”

“…Irrespective of one's biases toward the handling of EC, wider usage of protective strategies such as awake surgery when feasible, tractography and intraoperative navigation tools, and intraoperative functional mapping is justified and strongly recommended. 3,20,32,33,34,35 There is also increasing emphasis on ensuring the integrity of white matter tracts via subcortical mapping to maximize preservation of eloquent function 36 and deployment of minimally invasive surgical strategies. 37 The respondents varied considerably in their expectation of the chances of seizure freedom that were considered acceptable thresholds to "justify" a new deficit ranging from 50% to exceeding 90%.…”