The Asleep-Awake-Asleep Anesthetic Technique for Intraoperative Language Mapping

Huncke, Kate; B, Van de Wiele; Fried, Itzhak; Rubinstein, Eduardo H.

doi:10.1097/00006123-199806000-00069

Cited by 120 publications

(58 citation statements)

References 11 publications

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“…Language function was also assessed in a detailed examination that included object naming, recalling, counting, fluency, comprehension, reading, and writing. In our series, the sleep-awake-sleep anesthetic technique was adopted, as described by Huncke et al [7]. …”

Section: Methodsmentioning

confidence: 99%

Impact of Preoperative Functional Magnetic Resonance Imaging during Awake Craniotomy Procedures for Intraoperative Guidance and Complication Avoidance

Trinh

Fahim

Maldaun

et al. 2014

Stereotact Funct Neurosurg

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Background: We wanted to study the role of functional MRI (fMRI) in preventing neurological injury in awake craniotomy patients as this has not been previously studied. Objectives: To examine the role of fMRI as an intraoperative adjunct during awake craniotomy procedures. Methods: Preoperative fMRI was carried out routinely in 214 patients undergoing awake craniotomy with direct cortical stimulation (DCS). Results: In 40% of our cases (n = 85) fMRI was utilized for the intraoperative localization of the eloquent cortex. In the other 129 cases significant noise distortion, poor task performance and nonspecific BOLD activation precluded the surgeon from using the fMRI data. Compared with DCS, fMRI had a sensitivity and specificity, respectively, of 91 and 64% in Broca's area, 93 and 18% in Wernicke's area and 100 and 100% in motor areas. A new intraoperative neurological deficit during subcortical dissection was predictive of a worsened deficit following surgery (p < 0.001). The use of fMRI for intraoperative localization was, however, not significant in preventing worsened neurological deficits, both in the immediate postoperative period (p = 1.00) and at the 3-month follow-up (p = 0.42). Conclusions: The routine use of fMRI was not useful in identifying language sites as performed and, more importantly, practiced tasks failed to prevent neurological deficits following awake craniotomy procedures.

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Section: Methodsmentioning

confidence: 99%

Impact of Preoperative Functional Magnetic Resonance Imaging during Awake Craniotomy Procedures for Intraoperative Guidance and Complication Avoidance

Trinh

Fahim

Maldaun

et al. 2014

Stereotact Funct Neurosurg

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“…In our series, the asleep-awake-asleep anesthetic technique was adopted as described by Huncke et al 6 After MRI-compatible patient monitors (Invivo) are applied, the patients routinely receive 4 mg of ondansetron, 20 mg of famotidine, and 10 mg of metoclopramide, all given intravenously. To induce anesthesia, we intravenously administer 50-100 mg of propofol plus 0.1-0.2 μg/kg/min of remifentanil with or without 50 mg of rocuronium.…”

Section: Anesthesia Techniquementioning

confidence: 99%

Awake craniotomy for gliomas in a high-field intraoperative magnetic resonance imaging suite: analysis of 42 cases

Maldaun¹,

Khawja²,

Levine³

et al. 2014

JNS

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Object. The object of this study was to describe the experience of combining awake craniotomy techniques with high-field (1.5 T) intraoperative MRI (iMRI) for tumors adjacent to eloquent cortex.Methods. From a prospective database the authors obtained and evaluated the records of all patients who had undergone awake craniotomy procedures with cortical and subcortical mapping in the iMRI suite. The integration of these two modalities was assessed with respect to safety, operative times, workflow, extent of resection (EOR), and neurological outcome.Results. Between February 2010 and December 2011, 42 awake craniotomy procedures using iMRI were performed in 41 patients for the removal of intraaxial tumors. There were 31 left-sided and 11 right-sided tumors. In half of the cases (21 [50%] of 42), the patient was kept awake for both motor and speech mapping. The mean duration of surgery overall was 7.3 hours (range 4.0-13.9 hours). The median EOR overall was 90%, and gross-total resection (EOR ≥ 95%) was achieved in 17 cases (40.5%). After viewing the first MR images after initial resection, further resection was performed in 17 cases (40.5%); the mean EOR in these cases increased from 56% to 67% after further resection. No deficits were observed preoperatively in 33 cases (78.5%), and worsening neurological deficits were noted immediately after surgery in 11 cases (26.2%). At 1 month after surgery, however, worsened neurological function was observed in only 1 case (2.3%).Conclusions. There was a learning curve with regard to patient positioning and setup times, although it did not adversely affect patient outcomes. Awake craniotomy can be safely performed in a high-field (1.5 T) iMRI suite to maximize tumor resection in eloquent brain areas with an acceptable morbidity profile at 1 month. (http://thejns.org/doi/abs/10.3171/2014.6.JNS132285) Key words • awake craniotomy • cortical mapping • glioma surgery • iMRI • EOR • oncologyAbbreviations used in this paper: DTI = diffusion tensor imaging; DWI = diffusion-weighted imaging; EOR = extent of resection; fMRI = functional MRI; GTR = gross-total resection; iMRI = intraoperative MRI; LMA = laryngeal mask airway; OR = operating room; PR = partial resection; STR = subtotal resection.

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“…Traditionally awake craniotomy has been performed for epilepsy surgery, which helps in better ECoG localization of the seizure focus without the influence of general anaesthetic agents.Varying anaesthetic techniques for awake craniotomy have been described in the literature [2][3][4][5][6][7]. One is using skull block along with conscious sedation.…”

Section: Discussionmentioning

confidence: 99%

“…Intraoperative neurological testing allows optimal tumour resection with minimal postoperative neurological dysfunction. Different anaesthetic techniques for awake craniotomy have been described in the literature [2][3][4][5][6][7]. Some have used conscious sedation, while others have used 'asleep-awake-asleep' technique.…”

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confidence: 99%

Awake Craniotomy for Tumour Excision

Prabhakaran

Mohan

Tripathy

et al. 2008

Medical Journal Armed Forces India

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A wake craniotomy literally means performing a craniotomy on an awake patient. It allows A A intraoperative assessment of the patient's neurological status. It is mainly used for mapping the resection margins during epilepsy surgery, accurate location of electrodes in surgery for movement disorders, and excision of tumours from eloquent areas of the cortex [1]. Eloquent areas are specialized areas of brain which control important functions, like movement, sensation, speech etc. Intraoperative neurological testing allows optimal tumour resection with minimal postoperative neurological dysfunction. Different anaesthetic techniques for awake craniotomy have been described in the literature [2][3][4][5][6][7]. Some have used conscious sedation, while others have used 'asleep-awake-asleep' technique. This is the first case series of awake craniotomies published from the Indian armed forces. Material and MethodsThis procedure was carried out in Command Hospital (SC), Pune during the ten month period. The inclusion criteria were supra tentorial, intra-axial tumours located close to eloquent areas of the brain and patients willing to co-operate. The exclusion criteria was posterior fossa tumours, non-willing patients, large tumours with midline shift and raised intracranial tension. Confused, demented or agitated patients are poor candidates. Patient was assessed for his fitness and psychological make up to undergo awake craniotomy. After history and physical examination the patient was subjected to detailed counselling. Patient was explained about the advantages of remaining awake during operation and the sequence of events in the operation theatre. Patient was educated about different tasks like moving the toes/ fingers on command, identification of picture cards, speaking etc. which he was supposed to perform during the surgery. It was re-emphasized that he will be conscious and he had to lie down still during the surgery. Option of general anaesthesia was also kept open and an informed consent was taken.In the operation theatre intravenous line was started and sedation in the form of injection midazolam 1-2 mg and injection fentanyl 50-75 mcg was given. The scalp was painted with 10% betadine lotion. The supraorbital,supratrochlear, auriculotemporal, zygomaticotemporal, greater occipital and lesser occipital nerves (Fig. 1) were blocked bilaterally with local anaesthetic (LA) solution.We used a mixture of 20 ml of 0.5% bupivacaine, 20 ml of 2% plain lignocaine, 0.4 ml (400 mcg) of adrenaline and 40 ml of saline adding upto a total of 80 ml of solution. This solution has a concentration of 0.125% bupivacaine, 0.5% of lignocaine and 5 mcg/ml of adrenaline. Adrenaline helps in hemostasis, reduces absorption of LA, thereby reducing its toxicity and prolongs the duration of action. About 25-30 ml of this solution was used for the nerve blocks. A band (Fig. 2) of subcutaneous and subfascial injection was given with 20-25 ml of this solution, around the head passing above the ears through forehead and occiput [8]. The rema...

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The Asleep-Awake-Asleep Anesthetic Technique for Intraoperative Language Mapping

Abstract: The combined technique that we describe abolished the potential discomfort of surgical stimulation on a sedated patient, reduced the duration of wakefulness, and provided a secure airway and the means to hyperventilate our patients before dural opening.

Cited by 120 publications

References 11 publications

Impact of Preoperative Functional Magnetic Resonance Imaging during Awake Craniotomy Procedures for Intraoperative Guidance and Complication Avoidance

Impact of Preoperative Functional Magnetic Resonance Imaging during Awake Craniotomy Procedures for Intraoperative Guidance and Complication Avoidance

Awake craniotomy for gliomas in a high-field intraoperative magnetic resonance imaging suite: analysis of 42 cases

Awake Craniotomy for Tumour Excision

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