Surgical and anesthesiological considerations of awake craniotomy: cerrahpasa experience

Abstract

AIm: Awake craniotomy (AC) with electrical cortical stimulation has become popular during the last ten years although the basic principles were introduced almost 50 years ago. The aim of this paper is to share with the readers our experience in 25 patients who underwent AC with electrical stimulation. mATERIAl and mEThods: Twenty-five patients who underwent AC between 2010 and 2013 are the subjects of this paper. All patients were diagnosed with intraaxial lesions involving the functional area itself or very close to it by preoperative imaging. During surgery, the functional area was demonstrated by cortical electrical stimulation and resection aimed to preserve it in order to avoid an irreversible functional deficit. REsulTs:Total resection was possible in 80% while in 20% subtotal resection had to be performed because of involvement of the functional area itself. The neurological complication rate was found to be 16% (4 patients) and all were transient. No complication regarding anesthesia was noted.CoNClusIoN: Awake craniotomy in selected patients is very effective, safe and practical for supratentorial lesions close to the eloquent area. Complications related to the surgery itself are uncommon and general anesthesia is avoided. The hospital stay including the intensive care unit is short which makes it very economical surgical procedure. soNuÇ: Seçilmiş hastalarda ve bölgelere yakın supratentoriyel lezyonlarda uyanık kraniyotomi etkili, güvenli ve pratiktir. Cerrahiye bağlı komplikasyon oranı düşüktür ve genel anesteziye bağlı komplikasyonlar ortadan kalkmaktadır. Yoğun bakım dahil hastanede kalış süresinin kısa olması nedeniyle uyanık kraniyotomi ekonomik olmaktadır.

Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis

“…Data of the study characteristics are shown in Table 1 . A total of fourteen case series [ 10 , 17 , 19 , 20 , 23 , 28 , 39 , 41 , 44 , 47 , 51 , 53 , 54 , 60 ] thirteen prospective studies [ 18 , 21 , 22 , 25 – 27 , 30 , 33 , 35 , 38 , 52 , 55 , 61 ], seventeen retrospective studies [ 24 , 29 , 31 , 34 , 37 , 40 , 42 , 43 , 45 , 46 , 48 – 50 , 57 – 59 , 62 ], two RCTs [ 32 , 56 ], and one pseudo-RCT [ 36 ] comprising 5945 AC procedures in 5931 patients were analysed ( Table 1 ). Of note, during the data extraction process it appeared that nine studies [ 20 , 22 , 27 , 31 , 42 – 46 ] partially repor...…”

“…We divided the identified records into three subtopics according to the used anaesthetic technique: Nineteen studies reported the asleep-awake-asleep (SAS) respectively sleep-awake (SA) technique [ 20 – 23 , 25 – 27 , 37 – 39 , 44 – 46 , 50 , 51 , 53 , 56 , 57 , 60 ], twenty-eight reported monitored anaesthesia care (MAC) [ 10 , 17 – 19 , 24 , 28 – 32 , 34 – 36 , 40 – 43 , 47 – 49 , 52 , 54 , 55 , 58 – 62 ] and one used the awake-awake-awake (AAA) technique [ 33 ]. Of note, Souter et al have used the SAS as well as the MAC technique in their patients [ 60 ].…”

“…The protocols of the nineteen identified articles [ 20 – 23 , 25 – 27 , 37 – 39 , 44 – 46 , 50 , 51 , 53 , 56 , 57 , 60 ], reporting the SA(S) technique, showed a huge variability in the anaesthesia conduction, but all kinds of this technique were feasible and safe for the patients. A total intravenous anaesthesia (TIVA) with propofol and remifentanil or fentanyl for the first asleep phase was used in fourteen trials [ 20 – 23 , 26 , 27 , 37 , 39 , 44 – 46 , 51 , 56 , 60 ].…”

“…It was successfully used for AC since 2001 [ 64 ]. Dexmedetomidine was applied in four studies, either combined with remifentanil [ 34 , 56 ], or propofol [ 50 ], or with remifentanil and propofol together [ 53 , 57 ]. The use of dexmedetomidine seems to show several advantages in AC.…”

“…The airway in the included studies was secured either with a laryngeal mask (LMA) [ 21 , 25 , 26 , 38 , 45 , 46 ], an endotracheal tube in all [ 56 ],respectively one patient [ 20 , 44 ] or an oesophageal naso-pharyngeal catheter [ 23 ]. One study, which used a TIVA, did not mention the utilized airway device, they only reported naso-pharyngeal airway [ 53 ] and another one reported only an "oral airway" for five patients [ 51 ]. Twelve studies [ 21 , 23 , 26 , 56 ] used controlled ventilation, the others maintained spontaneous breathing.…”