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Freund BE, Feyissa AM, Khan A, Middlebrooks EH, Grewal SS, Sabsevitz D, Sherman WJ, Quiñones-Hinojosa A, Tatum WO. Early Postoperative Seizures Following Awake Craniotomy and Functional Brain Mapping for Lesionectomy. World Neurosurg 2024; 181:e732-e742. [PMID: 37898274 DOI: 10.1016/j.wneu.2023.10.119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVE Awake craniotomy with electrocorticography (ECoG) and direct electrical stimulation (DES) facilitates lesionectomy while avoiding adverse effects. Early postoperative seizures (EPS), occurring within 7 days following surgery, can lead to morbidity. However, risk factors for EPS after awake craniotomy including clinical and ECoG data are not well defined. METHODS We retrospectively studied the incidence and risk factors of EPS following awake craniotomy for lesionectomy, and report short-term outcomes between January 1, 2020, and December 31, 2022. RESULTS We included 138 patients (56 female) who underwent 142 awake craniotomies, average age was 50.78 ± 15.97 years. Eighty-eight (63.7%) patients had a preoperative history of tumor-related epilepsy treated with antiseizure medication (ASM), 12 (13.6%) with drug-resistance. All others (36.3%) received ASM prophylaxis with levetiracetam perioperatively and continued for 14 days. An equal number of cases (71) each utilized a novel circle grid or strip electrodes for ECoG. There were 31 (21.8%) cases of intraoperative seizures, 16 with EPS (11.3%). Acute abnormality on early postoperative neuroimaging (P = 0.01), subarachnoid hemorrhage (P = 0.01), young age (P = 0.01), and persistent postoperative neurologic deficits (P = 0.013) were associated with EPS. Acute abnormality on neuroimaging remained significant in multivariate analysis. Outcomes during hospitalization and early outpatient follow up were worse with EPS. CONCLUSIONS We report novel findings using ECoG and clinical features to predict EPS, including acute perioperative brain injury, persistent postoperative deficits and young age. Given worse outcomes with EPS, clinical indicators for EPS should alert clinicians of potential need for early postoperative EEG monitoring and perioperative ASM adjustment.
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Affiliation(s)
- Brin E Freund
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA.
| | | | - Aafreen Khan
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - Erik H Middlebrooks
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA; Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Sanjeet S Grewal
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - David Sabsevitz
- Department of Psychology and Psychiatry, Mayo Clinic, Jacksonville, Florida, USA
| | - Wendy J Sherman
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - William O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
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2
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Guidelines for Awake Surgery. Neurol Med Chir (Tokyo) 2024; 64:1-27. [PMID: 38220155 PMCID: PMC10835579 DOI: 10.2176/jns-nmc.2023-0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/07/2023] [Indexed: 01/16/2024] Open
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3
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Carotid and Intracranial Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00021-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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4
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Fang S, Zhou C, Wang L, Fan X, Wang Y, Zhang Z, Jiang T. Characteristic Alterations of Network in Patients With Intraoperative Stimulation-Induced Seizures During Awake Craniotomy. Front Neurol 2021; 12:602716. [PMID: 33815243 PMCID: PMC8012772 DOI: 10.3389/fneur.2021.602716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 02/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The use of electrocorticography (ECoG) to avoid intraoperative stimulation-induced seizure (ISS) during awake craniotomy is controversial. Although a standard direct cortical stimulating (DCS) protocol is used to identify the eloquent cortices and subcortical structures, ISS still occurs. Epilepsy is related to alterations in brain networks. In this study, we investigated specific alterations in brain networks in patients with ISS. Methods: Twenty-seven patients with glioma were enrolled and categorized into the ISS and non-ISS groups based on their history of ISS occurrence. A standard DCS protocol was used during awake craniotomy without ECoG supervision. Graph theoretical measurement was used to analyze resting-state functional magnetic resonance imaging data to quantitatively reveal alterations in the functional networks. Results: In the sensorimotor networks, the glioma significantly decreased the functional connectivity (FC) of four edges in the ISS group, which were conversely increased in the non-ISS group after multiple corrections (p < 0.001, threshold of p-value = 0.002). Regarding the topological properties, the sensorimotor network of all participants was classified as a small-world network. Glioma significantly increased global efficiency, nodal efficiency, and the sigma value, as well as decreased the shortest path length in the ISS group compared with the non-ISS group (p < 0.05). Conclusions: The specific alterations indicating patient susceptibility to ISS during DCS increased global and nodal efficiencies and decreased the shortest path length and FC induced by gliomas. If the patient has these specific alterations, ECoG is recommended to monitor after-discharge current during DCS to avoid ISS.
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Affiliation(s)
- Shengyu Fang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Chunyao Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lei Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xing Fan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yinyan Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tao Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Research Unit of Accurate Diagnosis, Treatment, and Translational Medicine of Brain Tumors Chinese (2019RU11), Chinese Academy of Medical Sciences, Beijing, China
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Idowu O, Adeleye A, Amanor-Boadu S. Awake craniotomy for intracranial lesions: An audit of the anaesthetists’ initial experience at the University College Hospital, Ibadan. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2016.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- O.K. Idowu
- Department of Anaesthesia, University College Hospital, UCH, Ibadan, Nigeria
| | - A.O. Adeleye
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan and University College Hospital, UCH, Ibadan, Nigeria
| | - S.D. Amanor-Boadu
- Department of Anaesthesia, College of Medicine, University of Ibadan and University College Hospital, UCH, Ibadan, Nigeria
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6
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Anesthesia for Awake Craniotomy: What Is New? CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0285-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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7
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Eseonu CI, Rincon-Torroella J, ReFaey K, Lee YM, Nangiana J, Vivas-Buitrago T, Quiñones-Hinojosa A. Awake Craniotomy vs Craniotomy Under General Anesthesia for Perirolandic Gliomas: Evaluating Perioperative Complications and Extent of Resection. Neurosurgery 2018; 81:481-489. [PMID: 28327900 DOI: 10.1093/neuros/nyx023] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/07/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND A craniotomy with direct cortical/subcortical stimulation either awake or under general anesthesia (GA) present 2 approaches for removing eloquent region tumors. With a reported higher prevalence of intraoperative seizures occurring during awake resections of perirolandic lesions, oftentimes, surgery under GA is chosen for these lesions. OBJECTIVE To evaluate a single-surgeon's experience with awake craniotomies (AC) vs surgery under GA for resecting perirolandic, eloquent, motor-region gliomas. METHODS Between 2005 and 2015, a retrospective analysis of 27 patients with perirolandic, eloquent, motor-area gliomas that underwent an AC were case-control matched with 31 patients who underwent surgery under GA for gliomas in the same location. All patients underwent direct brain stimulation with neuromonitoring and perioperative risk factors, extent of resection, complications, and discharge status were assessed. RESULTS The postoperative Karnofsky Performance Score (KPS) was significantly lower for the GA patients at 81.1 compared to the AC patients at 93.3 ( P = .040). The extent of resection for GA patients was 79.6% while the AC patients had an 86.3% resection ( P = .136). There were significantly more 100% total resections in the AC patients 25.9% compared to the GA group (6.5%; P = .041). Patients in the GA group had a longer mean length of hospitalization of 7.9 days compared to the AC group at 4.2 days ( P = .049). CONCLUSION We show that AC can be performed with more frequent total resections, better postoperative KPS, shorter hospitalizations, as well as similar perioperative complication rates compared to surgery under GA for perirolandic, eloquent motor-region glioma.
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Affiliation(s)
- Chikezie I Eseonu
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Jordina Rincon-Torroella
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Karim ReFaey
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Young M Lee
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Jasvinder Nangiana
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Tito Vivas-Buitrago
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Alfredo Quiñones-Hinojosa
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
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Anesthesia for awake craniotomy: a how-to guide for the occasional practitioner. Can J Anaesth 2017; 64:517-529. [DOI: 10.1007/s12630-017-0840-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 12/15/2016] [Accepted: 01/31/2017] [Indexed: 12/24/2022] Open
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9
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Hervey-Jumper SL, Li J, Lau D, Molinaro AM, Perry DW, Meng L, Berger MS. Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period. J Neurosurg 2015; 123:325-39. [DOI: 10.3171/2014.10.jns141520] [Citation(s) in RCA: 244] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Awake craniotomy is currently a useful surgical approach to help identify and preserve functional areas during cortical and subcortical tumor resections. Methodologies have evolved over time to maximize patient safety and minimize morbidity using this technique. The goal of this study is to analyze a single surgeon's experience and the evolving methodology of awake language and sensorimotor mapping for glioma surgery.
METHODS
The authors retrospectively studied patients undergoing awake brain tumor surgery between 1986 and 2014. Operations for the initial 248 patients (1986–1997) were completed at the University of Washington, and the subsequent surgeries in 611 patients (1997–2014) were completed at the University of California, San Francisco. Perioperative risk factors and complications were assessed using the latter 611 cases.
RESULTS
The median patient age was 42 years (range 13–84 years). Sixty percent of patients had Karnofsky Performance Status (KPS) scores of 90–100, and 40% had KPS scores less than 80. Fifty-five percent of patients underwent surgery for high-grade gliomas, 42% for low-grade gliomas, 1% for metastatic lesions, and 2% for other lesions (cortical dysplasia, encephalitis, necrosis, abscess, and hemangioma). The majority of patients were in American Society of Anesthesiologists (ASA) Class 1 or 2 (mild systemic disease); however, patients with severe systemic disease were not excluded from awake brain tumor surgery and represented 15% of study participants. Laryngeal mask airway was used in 8 patients (1%) and was most commonly used for large vascular tumors with more than 2 cm of mass effect. The most common sedation regimen was propofol plus remifentanil (54%); however, 42% of patients required an adjustment to the initial sedation regimen before skin incision due to patient intolerance. Mannitol was used in 54% of cases. Twelve percent of patients were active smokers at the time of surgery, which did not impact completion of the intraoperative mapping procedure. Stimulation-induced seizures occurred in 3% of patients and were rapidly terminated with ice-cold Ringer's solution. Preoperative seizure history and tumor location were associated with an increased incidence of stimulation-induced seizures. Mapping was aborted in 3 cases (0.5%) due to intraoperative seizures (2 cases) and patient emotional intolerance (1 case). The overall perioperative complication rate was 10%.
CONCLUSIONS
Based on the current best practice described here and developed from multiple regimens used over a 27-year period, it is concluded that awake brain tumor surgery can be safely performed with extremely low complication and failure rates regardless of ASA classification; body mass index; smoking status; psychiatric or emotional history; seizure frequency and duration; and tumor site, size, and pathology.
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Affiliation(s)
| | - Jing Li
- Departments of 1Neurological Surgery and
| | - Darryl Lau
- Departments of 1Neurological Surgery and
| | | | - David W. Perry
- 2Surgical Neurophysiology, University of California, San Francisco, California
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Shetty A, Pardeshi S, Shah VM, Kulkarni A. Anesthesia considerations in epilepsy surgery. Int J Surg 2015; 36:454-459. [PMID: 26188082 DOI: 10.1016/j.ijsu.2015.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/28/2015] [Accepted: 07/14/2015] [Indexed: 11/16/2022]
Abstract
Epilepsy surgeries can be done under general anesthesia or with local anesthesia and sedation. Epilepsy surgery done under general anesthesia have similar goals as any other neurosurgical procedure, except in patients with temporal lobe epilepsy requiring cortical mapping or electrocorticography (ECoG) where depth of anesthesia has to be reduced. Since seizure focus localization can be done preoperatively with modern diagnostic tools, general anesthesia is popular even for these patients. It is comfortable for both the surgeon and the patient. For intraoperative ECoG or cortical mapping awake craniotomy is the preferred technique.
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Affiliation(s)
- Anita Shetty
- Neuroanesthesia Fellowship Programme, Department of Anesthesia, Seth GS Medical College & KEM Hospital, Mumbai, India.
| | - Swarada Pardeshi
- Department of Anesthesia, Seth GS Medical College & KEM Hospital, Mumbai, India
| | - Viraj M Shah
- Department of Anesthesia, Seth GS Medical College & KEM Hospital, Mumbai, India
| | - Aarti Kulkarni
- Department of Anesthesia, Seth GS Medical College & KEM Hospital, Mumbai, India
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Sokhal N, Rath GP, Chaturvedi A, Dash HH, Bithal PK, Chandra PS. Anaesthesia for awake craniotomy: A retrospective study of 54 cases. Indian J Anaesth 2015; 59:300-5. [PMID: 26019355 PMCID: PMC4445152 DOI: 10.4103/0019-5049.156878] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background and Aims: The anaesthetic challenge of awake craniotomy is to maintain adequate sedation, analgesia, respiratory and haemodynamic stability in an awake patient who should be able to co-operate during intraoperative neurological assessment. The current literature, sharing the experience on awake craniotomy, in Indian context, is minimal. Hence, we carried out a retrospective study with the aim to review and analyse the anaesthetic management and perioperative complications in patients undergoing awake craniotomy, at our centre. Methods: Medical records of 54 patients who underwent awake craniotomy for intracranial lesions over a period of 10 years were reviewed, retrospectively. Data regarding anaesthetic management, intraoperative complications and post-operative course were recorded. Results: Propofol (81.5%) and dexmedetomidine (18.5%) were the main agents used for providing conscious sedation to facilitate awake craniotomy. Hypertension (16.7%) was the most commonly encountered complication during intraoperative period, followed by seizures (9.3%), desaturation (7.4%), tight brain (7.4%), and shivering (5.6%). The procedure had to be converted to general anaesthesia in one of patients owing to refractory brain bulge. The incidence of respiratory and haemodynamic complications were comparable in the both groups (P > 0.05). There was less incidence of intraoperative seizures in patients who received propofol (P = 0.03). In post-operative period, 20% of patients developed new motor deficit. Mean intensive care unit stay was 2.8 ± 1.9 day (1–14 days) and mean hospital stay was 7.0 ± 5.0 day (3–30 days). Conclusions: ‘Conscious sedation’ was the technique of choice for awake craniotomy, at our institute. Fentanyl, propofol, and dexmedetomidine were the main agents used for this purpose. Patients receiving propofol had less incidence of intraoperative seizure. Appropriate selection of patients, understanding the procedure of surgery, and judicious use of sedatives or anaesthetic agents are key to the success for awake craniotomy as a procedure.
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Affiliation(s)
- Navdeep Sokhal
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Girija Prasad Rath
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Chaturvedi
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Hari Hara Dash
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Parmod Kumar Bithal
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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12
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The evolution of brain surgery on awake patients. Acta Neurochir (Wien) 2015; 157:77-84. [PMID: 25352088 DOI: 10.1007/s00701-014-2249-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 10/01/2014] [Indexed: 12/19/2022]
Abstract
In the early days of modern neurological surgery, the inconveniences and potential dangers of general anesthesia by chloroform and ether using the so-called "open-drop technique" led to the quest for alternative methods of anesthesia. Besides preventing the feared side effects, the introduction of regional anesthesia revealed another decisive advantage over general anesthesia in neurosurgery: While intraoperative direct cortical stimulation under general anesthesia could only delineate the motor area (by evocation of contralateral muscular contraction), now, the awake patients were able to report sensations elicited by this method. These properties advanced regional anesthesia to the regimen of choice for cranial surgeries in the first half of the 20th century. While technical advances and new drugs led to a progressive return to general anesthesia for neurosurgical procedures, the use of regional anesthesia for epilepsy surgery has only decreased in recent decades. Meanwhile, awake craniotomies regained popularity in oncologically motivated surgeries, especially in craniotomies for diffuse low-grade gliomas. Intraoperative mapping of brain functions using electrical stimulation in awake patients enables not only for increased tumor removal while preserving the functional status of the patients but also opens a window to cognitive neuroscience. Observations during such interventions and their correlation with both pre - and postoperative neuropsychological examinations and functional neuroimaging is progressively leading to new insights into the complex functional anatomy of the human brain. Furthermore, it broadens our knowledge on cerebral network reorganization in the presence of disease-with implications for all disciplines of clinical neuroscience.
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Anestesia para craneotomía en el paciente despierto: una actualización. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rca.2014.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Ghazanwy M, Chakrabarti R, Tewari A, Sinha A. Awake craniotomy: A qualitative review and future challenges. Saudi J Anaesth 2014; 8:529-39. [PMID: 25422613 PMCID: PMC4236942 DOI: 10.4103/1658-354x.140890] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Neurosurgery in awake patients incorporates newer technologies that require the anesthesiologists to update their skills and evolve their methodologies. They need effective communication skills and knowledge of selecting the right anesthetic drugs to ensure adequate analgesia, akinesia, along with patient satisfaction with the anesthetic conduct throughout the procedure. The challenge of providing adequate anesthetic care to an awake patient for intracranial surgery requires more than routine vigilance about anesthetic management.
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Affiliation(s)
- Mahmood Ghazanwy
- Department of Anesthesiology, Cleveland Clinic Foundation, Ohio, USA
| | - Rajkalyan Chakrabarti
- Department of Neurosurgical Anesthesiology and Spine Surgery, Cleveland Clinic Foundation, Ohio, USA
| | - Anurag Tewari
- Department of Neurosurgical Anesthesiology and Spine Surgery, Cleveland Clinic Foundation, Ohio, USA
| | - Ashish Sinha
- Professor and Vice Chair (Research) Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, USA
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Talacchi A, Santini B, Casagrande F, Alessandrini F, Zoccatelli G, Squintani GM. Awake surgery between art and science. Part I: clinical and operative settings. FUNCTIONAL NEUROLOGY 2013; 28:205-21. [PMID: 24139657 DOI: 10.11138/fneur/2013.28.3.205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Awake surgery requires coordinated teamwork and communication between the surgeon and the anesthesiologist, as he monitors the patient, the neuroradiologist as he interprets the images for intraoperative confirmation, and the neuropsychologist and neurophysiologist as they evaluate in real-time the patient's responses to commands and questions. To improve comparison across published studies on clinical assessment and operative settings in awake surgery, we reviewed the literature, focusing on methodological differences and aims. In complex, interdisciplinary medical care, such differences can affect the outcome and the cost-benefit ratio of the treatment. Standardization of intraoperative mapping and related controversies will be discussed in Part II.
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Kayama T. The guidelines for awake craniotomy guidelines committee of the Japan awake surgery conference. Neurol Med Chir (Tokyo) 2013; 52:119-41. [PMID: 22450477 DOI: 10.2176/nmc.52.119] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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18
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Deras P, Moulinié G, Maldonado IL, Moritz-Gasser S, Duffau H, Bertram L. Intermittent general anesthesia with controlled ventilation for asleep-awake-asleep brain surgery: a prospective series of 140 gliomas in eloquent areas. Neurosurgery 2013; 71:764-71. [PMID: 22989957 DOI: 10.1227/neu.0b013e3182647ab8] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Awake brain tumor surgery is a unique opportunity for mapping sensorimotor and cognitive functions, allowing the operator to optimize the resection while preserving the patient's quality of life. During this type of procedure, active participation of the patient is necessary. OBJECTIVE To assess the efficacy and safety of a method of intermittent general anesthesia with controlled ventilation for performing invasive cerebral mapping. METHODS We report our prospective and observational single-center study with an asleep-awake-asleep protocol. Aspects of feasibility, airway management, timing of each phase, and occurrence of adverse events were detailed. RESULTS During a 35-month period, 140 patients underwent resection of a glioma in an eloquent area. During the asleep phases, controlled ventilation with a laryngeal mask was always efficient. Orotracheal intubation was performed for some patients for the second asleep period. The patients remained fully awake for a mean time of 98 minutes. Postural discomfort was reported in 17.8% of cases. There was 1 case of aspiration of gastric contents with a favorable outcome and no mortality. CONCLUSION Intermittent general anesthesia with controlled ventilation for this type of neurosurgical procedure remains an anesthesiological challenge. However, the results of this study suggest that it may be feasible, reproducible, and relatively safe in the context of a standardized protocol involving members of both anesthesiology and surgery teams. Such a technique has a great potential to improve the surgical results, from both oncological and functional perspectives.
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Affiliation(s)
- Pauline Deras
- Department of Anesthesiology C, Gui de Chauliac University Hospital, Montpellier, France
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Benatar-Haserfaty J, Tardáguila Sancho P. [Anesthesia for craniotomy in the conscious patient]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:264-74. [PMID: 23337779 DOI: 10.1016/j.redar.2012.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 11/14/2012] [Indexed: 11/27/2022]
Abstract
Craniotomy in the conscious patient (CPC) enables the neurological changes to be assessed during the mapping in epilepsy surgery, the location of the electrodes during deep brain stimulation surgery, and tumor resection in eloquent areas of the brain. CPC is a useful technique for radical surgery in order to minimize the damage to the functional areas of the brain. The anesthesiologist must ensure, adequate patient comfort, analgesia and ensure optimal collaboration. The appropriate selection of potential candidates for CPC should be made jointly with all professionals involved in the case. Knowledge of the different phases of CPC, coordination and communication among specialists, the right management of the pharmacology, and anesthetic techniques specific to CPC, along with the ability of psycho-emotional communication with the patient, determine the success of the procedure to be performed in the culture of patient safety. The aim of this review was to describe the anesthetic management, comprehensive considerations, and intraoperative neurophysiological tests for CPC.
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Affiliation(s)
- J Benatar-Haserfaty
- Servicio de Anestesiología, Hospital Universitario Ramón y Cajal, Madrid, España.
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Erickson KM, Cole DJ. Anesthetic considerations for awake craniotomy for epilepsy and functional neurosurgery. Anesthesiol Clin 2012; 30:241-268. [PMID: 22901609 DOI: 10.1016/j.anclin.2012.05.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The two most common neurosurgical procedures that call for an awake patient include epilepsy surgery and functional neurosurgery. Monitoring patients in the awake state allows more aggressive resection of epileptogenic foci in functionally important brain regions. Careful patient selection and preparation combined with attentive monitoring and anticipation of events are fundamental to a smooth awake procedure. Current pharmacologic agents and techniques at the neuroanesthesiologist's disposal facilitate an increasing number of procedures performed in awake patients.
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Affiliation(s)
- Kirstin M Erickson
- Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street SE, Rochester, MN 55901, USA.
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Analysis of Propofol/Remifentanil Infusion Protocol for Tumor Surgery With Intraoperative Brain Mapping. J Neurosurg Anesthesiol 2010; 22:119-27. [DOI: 10.1097/ana.0b013e3181c959f4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Abstract
Awake craniotomy has become an increasingly frequent procedure. In this paper, the principles of its anaesthetic management are reviewed. The means allowing achievement of anaesthetic objectives are described, with emphasis on points that determine success of the procedure. A careful and adequate selection and preparation of patients are mandatory, and the intervening team must be a skilled team. Choosing an awake technique or general anaesthesia depends on several factors, including the risk of obstructive apnoea, seizures, nausea and vomiting, patient's ability to cooperate, and localization of lesions. The main challenge of intraoperative anaesthetic management relies on the ability of rapidly adjusting the level of sedation and analgesia according to the sequence of surgical events, while ensuring haemodynamic stability, adequate ventilation, and minimal interference with eventual electrophysiological recordings. Throughout the procedure, complications must be anticipated and managed according to predefined guidelines. More prospective randomized clinical trials are still needed to improve safety and efficacy of awake craniotomies, as well as to validate this technique in comparison with more conventional anaesthetic management.
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Carvajal H, Carrasquilla R, Alcalá R, Jiménez JC, Benedetti JC. Anestesia para craneotomías con resecciones volumétricas en áreas elocuentes guiadas por estereotaxia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2008. [DOI: 10.1016/s0120-3347(08)63009-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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25
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Hwang JH, Kim YH, Lee JH, Jung YS, Go YK, Yoon MJ, Yoon SH. Comparison of Effects of Fentanyl, Alfentanil and Remifentanil on the Cardiovasuclar Response to Endotracheal Intubation during the Induction of General Anesthesia. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.54.1.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jae Ha Hwang
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Yoon Hee Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Jun Hwa Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Yu Soon Jung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Young-Kwon Go
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Mi Ja Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Suk Hwa Yoon
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
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26
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Abstract
A variety of anesthetic methods, with and without airway manipulation, are available to facilitate awake intraoperative examinations and cortical stimulation, which allow more aggressive resection of epileptogenic foci in functionally important brain regions. Careful patient selection and preparation combined with attentive cooperation of the medical team are the foundation for a smooth awake procedure. With improved pharmacologic agents and variety of techniques at the neuroanesthesiologist's disposal, awake craniotomy has become an elegant approach to epileptic focus resection in functional cortex.
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MESH Headings
- Anesthesia, General/adverse effects
- Anesthesia, General/methods
- Anesthesia, Intravenous/adverse effects
- Anesthesia, Intravenous/methods
- Anesthesia, Local
- Anesthetics, Intravenous/administration & dosage
- Anesthetics, Intravenous/adverse effects
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/adverse effects
- Brain/surgery
- Brain Mapping
- Craniotomy
- Epilepsy/surgery
- Humans
- Monitoring, Intraoperative
- Preoperative Care
- Wakefulness
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Affiliation(s)
- Kirstin M Erickson
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN 55901, USA.
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Souter MJ, Rozet I, Ojemann JG, Souter KJ, Holmes MD, Lee L, Lam AM. Dexmedetomidine sedation during awake craniotomy for seizure resection: effects on electrocorticography. J Neurosurg Anesthesiol 2007; 19:38-44. [PMID: 17198099 DOI: 10.1097/01.ana.0000211027.26550.24] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with refractory seizures may undergo awake craniotomy and cortical resection of the seizure area, using intraoperative functional mapping and electrocorticography (ECoG). We used dexmedetomidine in 6 patients, transitioning successively from the asleep-awake-asleep method, through a combined propofol/dexmedetomidine sedative infusion, to dexmedetomidine as the only sedation. Initial experience with the asleep-awake-asleep method in 2 patients was successful with the replacement of propofol/laryngeal mask anesthesia, 20 to 30 minutes before ECoG testing, by dexmedetomidine infusion, maintained at 0.2 mcg kg-1 h-1 throughout neurocognitive testing. Propofol anesthesia was reintroduced for resection. One patient received combined dexmedetomidine (0.2 mcg kg-1 h-1) and propofol (200 mcg kg-1 min-1) infusions for sedation. Both infusions were stopped 15 minutes before ECoG. Subsequently, they were restarted and the epileptic foci resected. Three patients received dexmedetomidine as the sole sedative agent, together with scalp block local anesthesia, and incremental boluses totaling 150 to 175 mcg of fentanyl per case. Dexmedetomidine was started with 0.3 mcg kg-1 boluses and maintained with 0.2 to 0.7 mcg kg-1 h-1for craniotomy, testing, and resection. The infusion was paused for 20 minutes in 1 patient to allow improvement in neurocognitive testing. This occurred within 10 minutes. All patients enjoyed good hemodynamic control, with blood pressure maintained within 20% of initial values, and made uneventful recoveries. The surgical conditions were all reported as favorable. Dexmedetomidine can be used singly for sedation in awake craniotomy requiring ECoG. Individual dose ranges vary, but a bolus of 0.3 mcg kg-1 with an infusion of 0.2 mcg kg-1 min-1 is a good starting point, allowing accurate mapping of epileptic foci and subsequent resection.
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Affiliation(s)
- Michael J Souter
- Department of Anesthesiology, University of Washington, Seattle 98104, USA.
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28
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Longatti P, Barzoi G, Fusco B, Corbanese U. Orbital Head Pain Elicited by Neuroendoscopy of the Third Ventricle Performed Under Local Anesthesia. J Neurosurg Anesthesiol 2006; 18:139-41. [PMID: 16628068 DOI: 10.1097/00008506-200604000-00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Endoscopic third ventriculostomy (ETVS) is considered a minimally invasive procedure for blocked hydrocephalus. In 24 cases, this procedure was carried out in awake patients under local anesthesia. All patients reported abrupt orbital pain when the third ventricle floor was manipulated. Although recent advancements in knowledge of some forms of migraine and cluster headache could be regarded as a good basis for interpreting the pain triggered by ETVS, other hypotheses should also be taken into consideration.
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Affiliation(s)
- Pierluigi Longatti
- Neurosurgical Department, Regional Hospital Cà Foncello, Piazza Ospedale, Treviso, Italy
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29
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Abstract
Awake craniotomies are often performed for resection of epileptogenic foci close to vital areas of the brain. For awake craniotomies at our institution, propofol is infused during local anesthetic injection and craniotomy, spontaneous ventilation is preserved, and no endotracheal tube or laryngeal mask airway is used. Propofol is discontinued for language, motor, and/or sensory mapping and for electrocorticography. Patients are re-sedated with propofol for resection and closure. We performed a retrospective chart review of 332 propofol-based "asleep-awake-asleep" (AAA) techniques with unsecured airways and 129 general anesthesia with endotracheal intubation craniotomies for epilepsy surgery. We compared the incidence of intraoperative respiratory and hemodynamic complications and incidence of seizures, nausea, brain swelling, patient movement, bleeding, aspiration, air embolism, and death. Airway compromise was uncommon in AAA cases and although incidences of hypertension, hypotension, and tachycardia were statistically increased in AAA versus general anesthesia craniotomy, these were treated appropriately. In only one patient the use of our AAA technique may have contributed to a poor clinical outcome.
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Affiliation(s)
- Andrius P Skucas
- Department of Anesthesiology, University of Washington, School of Medicine, Seattle, Washington 98195-6540, USA.
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30
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Keifer JC, Dentchev D, Little K, Warner DS, Friedman AH, Borel CO. A retrospective analysis of a remifentanil/propofol general anesthetic for craniotomy before awake functional brain mapping. Anesth Analg 2005; 101:502-508. [PMID: 16037168 DOI: 10.1213/01.ane.0000160533.51420.44] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED We performed this study to summarize drug dosing, physiologic responses, and anesthetic complications from an IV general anesthetic technique for patients undergoing craniotomy for awake functional brain mapping. Review of 98 procedures revealed "most rapid" IV infusion rates for remifentanil 0.05, 0.05-0.09 microg x kg(-1) x min(-1) and propofol 115, 100-150 microg x kg(-1) x min(-1). The infusions lasted for 78, 58-98 min. Intraoperative emergence from general anesthesia was 9 (6-13) min after discontinuing IV infusions to allow for brain mapping and was independent of infusion duration and duration of craniotomy before mapping. Spontaneous ventilation was generally satisfactory during drug infusion, as evidenced by Sao(2) = 95% (92%-98%) and Paco(2) = 50 (47-55) mm Hg. However, we recorded at least one 30-s epoch of apnea in 69 of 96 patients. Maximum systolic arterial blood pressure was 150 (139-175) mm Hg and minimal systolic arterial blood pressure was 100 (70-150) mm Hg during drug infusion. Three patients experienced intraoperative seizures. Two patients did not tolerate the awake state and required reinduction of general anesthesia. No patients required endotracheal intubation or discontinuation of surgery. This general anesthetic technique is effective for craniotomy with awake functional brain mapping and offers an alternative to continuous wakefulness or other IV sedation techniques. IMPLICATIONS An IV general anesthetic technique using remifentanil and propofol is an effective method allowing for reliable emergence for intraoperative awake functional brain mapping during craniotomy.
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Affiliation(s)
- John C Keifer
- Departments of Anesthesiology (Neuroanesthesia) and Surgery (Neurosurgery) Duke University Medical Center
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31
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Bulsara KR, Johnson J, Villavicencio AT. Improvements in brain tumor surgery: the modern history of awake craniotomies. Neurosurg Focus 2005; 18:e5. [PMID: 15844868 DOI: 10.3171/foc.2005.18.4.6] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ketan R Bulsara
- Division of Neurosurgery and Department of Anesthesiology, University of Missouri-Columbia, 65212, USA.
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32
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Lee JW, Jun JH, Kim YS, Cheong MA, Shim JC, Kim KS. Effect of Intraoperative Continuous I.V. Fentanyl on Tourniquet Induced Cardiovascular Changes and Postoperative Preemptive Analgesia in Total Knee Replacements. Korean J Pain 2005. [DOI: 10.3344/kjp.2005.18.2.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jong Won Lee
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jong Hun Jun
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Young Sun Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Mi Ae Cheong
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jae Chol Shim
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Kyo Sang Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
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33
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Abstract
This review article presents a detailed analysis of patients' management for awake craniotomy, at the light of the available data in the literature and the authors' experience. Indications of this type of surgery are discussed as well as anaesthetic management itself, from preoperative assessment of the patient to peroperative concerns. Anaesthetic strategy, choice of anaesthetic agents, anaesthetic technique, and management of the airway and possible complications are discussed. The authors emphasize the tricky aspect of the procedure, the necessity of rigorous patient selection and good preparation. They emphasize the need for controlled studies to validate the proposed techniques.
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Affiliation(s)
- V Bonhomme
- Service universitaire d'anesthésie-réanimation, CHR de la Citadelle, 4000 Liège, Belgique.
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34
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Abstract
We present our experience with the use of dexmedetomidine, an alpha2 agonist, in two children undergoing awake craniotomy. General anesthesia with the laryngeal mask airway was used for parts of the procedure not requiring patient cooperation to reduce the duration of wakefulness and abolish the discomfort of surgical stimulation. Dexmedetomidine was used as a primary anesthetic for brain mapping of the cortical speech area. The asleep-awake-sleep technique provided adequate sedation and analgesia throughout the surgery and allowed the patient to complete the necessary neuropsychological tests. To our knowledge, ours is the first description of the use of dexmedetomidine in pediatric neurosurgery.
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Affiliation(s)
- John Ard
- Department of Anesthesiology, New York University Medical Center, New York, New York 10016, USA
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35
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Yamamoto F, Kato R, Sato J, Nishino T. Anaesthesia for awake craniotomy with non-invasive positive pressure ventilation. Br J Anaesth 2003; 90:382-5. [PMID: 12594155 DOI: 10.1093/bja/aeg068] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Airway management during awake craniotomy is a crucial part of the anaesthetic technique, but it remains the subject of debate. We report two cases of anaesthesia for awake craniotomy using non-invasive positive pressure ventilation; biphasic positive airway pressure or proportional assist ventilation was employed. Both ventilatory techniques provided adequate lung ventilation, smooth transition between anaesthesia and arousal, and patient comfort.
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Affiliation(s)
- F Yamamoto
- Department of Anesthesiology, Graduate School of Medicine, Chiba University 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
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36
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Manninen PH, Tan TK. Postoperative nausea and vomiting after craniotomy for tumor surgery: a comparison between awake craniotomy and general anesthesia. J Clin Anesth 2002; 14:279-83. [PMID: 12088812 DOI: 10.1016/s0952-8180(02)00354-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To assess the frequency of postoperative nausea and vomiting (PONV) in patients following an awake craniotomy compared to general anesthesia for tumor surgery. DESIGN Prospective observational and chart review of all patients having a craniotomy for tumor during one year. SETTING Postanesthesia care unit (PACU) and intensive care unit (ICU) of a university hospital. PATIENTS 187 patients were reviewed. 107 patients who had a craniotomy for supratentorial tumor that was less than six hours in duration were analyzed and compared (50 awake craniotomy vs. 57 general anesthesia). INTERVENTIONS Medical records were reviewed for events after the first four hours until discharge. The occurrence and the time of any nausea, vomiting; the administration of antiemetics and analgesic drugs; and complications were documented. MEASUREMENTS Frequency of nausea, vomiting, administration of antiemetics and analgesia, and outcome between the two groups were compared using Chi-square and Student's t-test. MAIN RESULTS The frequency of nausea (4% vs. 23%; p = 0.012) and vomiting (0% vs. 11%; p = 0.052) were less in patients having an awake craniotomy compared to general anesthesia, but only during the first four hours. The administration of postoperative analgesia was not different between the two groups and did not influence the frequency of PONV. CONCLUSION The frequency of PONV during the initial recovery phase was less in patients having an awake craniotomy for tumor surgery than in patients having a similar procedure with general anesthesia.
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Affiliation(s)
- Pirjo H Manninen
- Department of Anesthesia, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8.
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37
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Tijero T, Ingelmo I, García-Trapero J, Puig A. Usefulness of monitoring brain tissue oxygen pressure during awake craniotomy for tumor resection: a case report. J Neurosurg Anesthesiol 2002; 14:149-52. [PMID: 11907397 DOI: 10.1097/00008506-200204000-00011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Awake craniotomy is indicated for surgical resection of tumors located near eloquent areas of the brain. The anesthetic technique is based on a combination of local anesthesia, sedation, and analgesia. Usually only clinical parameters are assessed and no other cerebral oxygenation monitoring techniques are applied. The authors report the use of brain tissue oxygen pressure monitoring during awake craniotomy. A 48-year-old right-handed man with a left temporoparietal mass was scheduled for awake craniotomy, cortical stimulation, and selective tumor removal. Monitoring included electrocardiography, pulse oximetry, end-tidal CO2, bladder temperature, invasive and noninvasive arterial pressure, and brain tissue oxygen pressure (PtiO2). The anesthetic technique consisted of continuous perfusions of 0.02 to 0.05 microg/kg/min remifentanil, propofol (target concentration, 0.5 to 1.2 microg/mL), and 25 to 50 microg/kg/min esmolol, and local anesthetic blockade of the head pin insertion sites and surgical incision area (a mixture of 0.2% ropivacaine, 1% lidocaine, and epinephrine, 1:200 000). Intraoperative cortical stimulation was performed to guide the resection according to the patient's verbal response. A change in PtiO2 was observed, gradually falling from 28 mm Hg at the beginning of the intervention down to 3 mm Hg. At this stage, surgical resection was concluded. On arrival at the intensive care unit, mixed dysphasia and slight weakness of the right arm were noted. Three weeks after surgery, the patient's speech is improving and the motor deficit has disappeared. This case suggests a possible role of PtiO2 in awake craniotomy as an aid in detecting intraoperative adverse events, but further experience with PtiO2 in this setting is needed.
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Affiliation(s)
- Teresa Tijero
- Servicio de Neuroanestesiología, Reanimación y Cuidados Críticos, Hospital Universitario Ramón y Cajal, Madrid, Spain
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38
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Abstract
We present our approach to management of awake craniotomy for epilepsy surgery for an adolescent. The importance of patient selection and preoperative preparation is stressed. Anaesthetic management included regional scalp block and preincisional surgical infiltration of local anaesthetic and light sedation with propofol, fentanyl and midazolam. The patient remained responsive to voice for all but a small part of the procedure.
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Affiliation(s)
- R J McDougall
- Department of Paediatric Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Victoria
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39
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Berkenstadt H, Perel A, Hadani M, Unofrievich I, Ram Z. Monitored anesthesia care using remifentanil and propofol for awake craniotomy. J Neurosurg Anesthesiol 2001; 13:246-9. [PMID: 11426102 DOI: 10.1097/00008506-200107000-00013] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Adequate analgesia and sedation with adequate respiratory and hemodynamic control are needed during brain surgery in awake patients. In this study, a protocol using clonidine premedication, intraoperative propofol, remifentanil, and labetalol was evaluated prospectively in 25 patients (aged 50 +/- 16). In all but one patient, no significant problems regarding cooperation, brain swelling, or loss of control were noticed, and it was not necessary to prematurely discontinue any of the procedures. One patient, who was uncooperative and hypertensive, became apneic with increasing sedation, and needed a laryngeal mask airway inserted. Patients were hemodynamically stable; elevated systolic blood pressure (>or= 150 mm Hg) was measured infrequently, and there were no events of significant hypotension, tachycardia, or bradycardia. Events of hypoxemia (SAO2 <or= 95%), severe hypoxemia (SaO2 <or= 90%), or hypoventilation (respiratory rate <or=8 minute), were frequent in the first ten patients, but the incidence decreased significantly in subsequent patients (P < .001). Three patients developed a focal neurologic deficit, and two patients experienced intraoperative seizures. Nausea and vomiting were not recorded in any of the patients. Although these findings attest to the safety of awake craniotomy, they demonstrate the difficulty of achieving adequate sedation without compromising ventilation and oxygenation. The learning curve of using a new protocol and a new potent anesthetic drug is emphasized.
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Affiliation(s)
- H Berkenstadt
- Department of Anesthesiology and Intensive Care, The Chaim Sheba Medical Center, Tel Hashomer, Israel
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40
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Affiliation(s)
- A Y Bekker
- Department of Anesthesiology, Neuroanesthesia Service, New York University Medical Center, 560 First Ave., New York, NY 10016, USA.
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41
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Mustaki JP, Villemure JG, Ravussin P. [Anesthesia for epilepsy surgery]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2001; 20:145-58. [PMID: 11270236 DOI: 10.1016/s0750-7658(00)00287-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Epilepsy is rather common, affecting 0.5 to 2% of the population. Numerous patients, particularly those resistant to the antiepileptic therapy, can be surgically treated after a thorough evaluation. Surgery for epilepsy can be carried out either under general or local anaesthesia with sedation. This second approach is reserved for the extirpation of foci localised in motor, sensory or language areas. During the preoperative anaesthetic evaluation, two specific points have to be taken into account: the psychological aspect and the antiepileptic medication. During the procedure, an electrocorticography with or without stimulation may be indicated, particularly when a perioperative stimulation is scheduled. Low doses of volatile agents are chosen, and no curare and large doses of benzodiazepines and barbiturates. Awakening takes place on the operation table for a rapid and reliable neurological evaluation. During procedures performed under local anaesthesia, the anaesthetist must be ready at any time to intubate the patient in order to secure the airway.
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Affiliation(s)
- J P Mustaki
- Service d'anesthésiologie, centre hospitalier universitaire vaudois (CHUV), 1011 Lausanne, Suisse
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42
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Balakrishnan G, Raudzens P, Samra SK, Song K, Boening JA, Bosek V, Jamerson BD, Warner DS. A comparison of remifentanil and fentanyl in patients undergoing surgery for intracranial mass lesions. Anesth Analg 2000; 91:163-9. [PMID: 10866905 DOI: 10.1097/00000539-200007000-00030] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED We compared the effects of remifentanil versus fentanyl during surgery for intracranial space-occupying lesions. Patients were randomly assigned to receive either remifentanil (0.5 microg. kg(-1). min(-1) IV during the induction of anesthesia reduced to 0.25 microg. kg(-1). min(-1) after endotracheal intubation; n = 49) or fentanyl (dose per usual practice of the anesthesiologist; n = 54). Anesthesia maintenance doses of isoflurane, nitrous oxide, and opioid were at the anesthesiologist's discretion for both groups. There were no differences between opioid groups for the frequency of responses (hemodynamic, movement, and tearing) to intubation, pinhead holder placement, skin incision, or closure of the surgical wound. Adverse event frequencies were similar between groups. Times to follow verbal commands (P < 0.001) and tracheal extubation (P = 0. 04) were more rapid for remifentanil. The percentage of patients with a normal recovery score (were alert or arousable to quiet voice, were oriented, were able to follow commands, had motor function unchanged from their preoperative evaluation, were not agitated, and had modified Aldrete Scores of 9-10) at 10 min after surgery was more for remifentanil (45% vs 18%; P = 0.005). By 20 min, no difference between groups existed (P = 0.27). Anesthesiologists used more isoflurane in the fentanyl group (4.22 vs 1.93 minimum alveolar anesthetic concentration hours). Neurosurgeons, blinded to treatment group, favored the use of remifentanil. Similar frequencies of light anesthesia responses and other adverse events suggest that intraoperative depths of anesthesia were similar in the two groups. Under these conditions, emergence was more rapid with remifentanil. This is consistent with the necessity for less isoflurane use in the remifentanil group and the intrinsic rapid clearance of this opioid. IMPLICATIONS Patients given remifentanil-based anesthesia for craniotomy had faster recovery times from anesthesia than did those given fentanyl-based anesthesia.
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43
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Balakrishnan G, Raudzens P, Samra SK, Song K, Boening JA, Bosek V, Jamerson BD, Warner DS. A Comparison of Remifentanil and Fentanyl in Patients Undergoing Surgery for Intracranial Mass Lesions. Anesth Analg 2000. [DOI: 10.1213/00000539-200007000-00030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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44
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Abstract
Anesthetic considerations for temporal lobectomy for refractory epilepsy include ensuring a safe and comfortable perioperative experience for the patient, providing suitable operating conditions for the surgeon, avoiding interference with intraoperative electrocorticographic (ECoG) recordings and facilitating intraoperative functional cortical mapping, if performed. Providing the conditions that simultaneously meet these requirements, using general anesthesia or local anesthesia with sedation, remains a significant challenge for the neuroanesthetist. We review issues pertinent to the choice of anesthetic technique for these procedures.
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Affiliation(s)
- I A Herrick
- Department of Anesthesia, University of Western Ontario, London Health Sciences Centre, Canada
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45
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Sahjpaul RL. Awake craniotomy: controversies, indications and techniques in the surgical treatment of temporal lobe epilepsy. Can J Neurol Sci 2000; 27 Suppl 1:S55-63; discussion S92-6. [PMID: 10830329 DOI: 10.1017/s0317167100000676] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In 1886, Victor Horsley excised an epileptogenic posttraumatic cortical scar in a 23-year-old man under general anaesthesia and discussed his choice of anaesthesia: "I have not employed ether in operations on man, fearing that it would tend to cause cerebral excitement; chloroform, of course, producing on the contrary, well-marked depression." His concerns regarding anaesthesia are reiterated 100 years later as evidenced by the ongoing controversy over the choice of anaesthetic in surgical procedures for epilepsy. The current controversies regarding the necessity for local anaesthesia in temporal lobe epilepsy operations concern the utility of electrocorticography in surgical decision making, its relationship to seizure outcome and the value of intraoperative language mapping in dominant temporal lobe resections. The increasing sophistication of pre-operative investigation and localization of both areas of epileptogenesis and normal brain function and the introduction of minimally invasive surgical techniques and smaller focal resections are changing the indications for local anaesthesia in temporal lobe epilepsy. Thus, indications which were previously absolute are now perhaps relative. This article reviews the current indications for craniotomy under local anaesthesia in the surgical treatment of temporal lobe epilepsy.
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Affiliation(s)
- R L Sahjpaul
- Department of Clinical Neurological Sciences, London Health Sciences Centre, ON, Canada
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Abstract
PURPOSE To review the current status and possible future of neuroleptanalgesia/anesthesia, techniques that may be nearly extinct. SOURCE Articles from 1966 to present were obtained from the Current Science and Medline databases. Search terms include neurolepananalgesia/anesthesia, conscious sedation, droperidol, benzodiazepines, propofol, ketamine, and opioids. Information and abstracts obtained from meetings on this topic helped complete the collection of information. PRINCIPAL FINDINGS Droperidol/fentanyl may still be clinically indicated in the management of surgical seizure therapy for electrocorticography. However, the high incidence of post-operative sedation and restlessness discourage its use for other surgical or diagnostic procedures. Many surgical interventions, once thought ideally suited for neuroleptic agents, now meet better success with newer medications. The use of midazolam and/or propofol, in association with newer opioids, provides ideal anesthetic combinations. CONCLUSION The advantages of newer anesthetic agents have redefined the clinical indications for neuroleptanesthesia. In routine modern anesthesia, anxiolysis, sedation, and/or analgesia is better provided, with quicker recovery, by the new pharmacokinetic and pharmacodynamic characteristics of recent medications than by the neuroleptic component of neuroleptanesthesia.
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Affiliation(s)
- B Bissonnette
- Department of Anaesthesia, Hospital for Sick Children, Toronto, Ontario, Canada.
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Huncke K, Van de Wiele B, Fried I, Rubinstein EH. The asleep-awake-asleep anesthetic technique for intraoperative language mapping. Neurosurgery 1998; 42:1312-6; discussion 1316-7. [PMID: 9632190 DOI: 10.1097/00006123-199806000-00069] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE We evaluated a combined technique designed for procedures requiring intraoperative language mapping. We planned to induce general anesthesia with endotracheal intubation and hyperventilation and then to awaken and extubate the patient for speech testing. After the latter, endotracheal reintubation and general anesthesia were planned. METHODS With the patient under intravenously induced sedation, we topically anesthetized the airway with lidocaine that was delivered through a spraying catheter. Fiberoptic endotracheal intubation was then performed on the awake patient, using a modified endotracheal tube. General anesthesia with intravenous propofol or sodium thiopental was induced, the patient's head was attached to a Mayfield holder, and the pin and operative sites were infiltrated with 0.5% bupivacaine with epinephrine. In anticipation of speech mapping, general anesthesia was discontinued and lidocaine was injected into the catheter that was spirally attached to the endotracheal tube. After speech mapping, the awake patients were endotracheally intubated, guided with the fiberoptic laryngoscope or tube changer, and general anesthesia was induced and maintained until termination of the surgery. RESULTS We did not observe any complications, such as coughing or head movements, during the preparation for general anesthesia, awakening and endotracheal extubation for speech mapping, and post-testing reintubation or induction of general anesthesia. CONCLUSION 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.
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Affiliation(s)
- K Huncke
- Department of Anesthesiology, University of California, Los Angeles 90095-1778, USA
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Craen RA, Herrick IA. SEIZURE SURGERY: GENERAL CONSIDERATIONS AND SPECIFIC PROBLEMS ASSOCIATED WITH AWAKE CRANIOTOMY. ACTA ACUST UNITED AC 1997. [DOI: 10.1016/s0889-8537(05)70356-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Herrick IA, Craen RA, Gelb AW, McLachlan RS, Girvin JP, Parrent AG, Eliasziw M, Kirkby J. Propofol sedation during awake craniotomy for seizures: electrocorticographic and epileptogenic effects. Anesth Analg 1997; 84:1280-4. [PMID: 9174307 DOI: 10.1097/00000539-199706000-00020] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This prospective study evaluated the effects of propofol sedation on the incidence of intraoperative seizures and the adequacy of electrocorticographic (ECoG) recordings during awake craniotomy performed for the management of refractory epilepsy. Thirty patients scheduled for temporal or frontal lobectomy for epilepsy under bupivacaine scalp block were randomized to receive patient-controlled propofol sedation (PCS) combined with a basal infusion of propofol (n = 15) or neurolept analgesia using an initial bolus dose of fentanyl (0.7 microg/kg) and droperidol (0.04 mg/kg) followed by a fentanyl infusion (n = 15). Propofol administration was suspended 15 min before ECoG recording in the PCS group. The occurrence of inappropriate intraoperative seizures was noted and, based on blind review, the adequacy of ECoG recordings was compared. A higher incidence of intraoperative seizures was noted among the neurolept patients (6 vs 0, P = 0.008). Intraoperatively, ECoG recordings were adequate to proceed with resection in both groups. Evidence of low spike activity on ECoG did not correlate with the type of sedation administered. Higher frequency background ECoG activity was noted among patients who received propofol, but this did not interfere with ECoG interpretation. The use of propofol sedation does not appear to interfere with ECoG during epilepsy surgery, provided administration is suspended at least 15 min before recording.
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Affiliation(s)
- I A Herrick
- Department of Anaesthesia, London Health Sciences Centre, University of Western Ontario, Canada
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Herrick IA, Craen RA, Gelb AW, Miller LA, Kubu CS, Girvin JP, Parrent AG, Eliasziw M, Kirkby J. Propofol sedation during awake craniotomy for seizures: patient-controlled administration versus neurolept analgesia. Anesth Analg 1997; 84:1285-91. [PMID: 9174308 DOI: 10.1097/00000539-199706000-00021] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This prospective study evaluated the safety and efficacy of patient-controlled sedation (PCS) using propofol during awake seizure surgery performed under bupivacaine scalp blocks. Thirty-seven patients were randomized to receive either propofol PCS combined with a basal infusion of propofol (n = 20) or neurolept analgesia using an initial bolus dose of fentanyl and droperidol followed by a fentanyl infusion (n = 17). Both groups received supplemental fentanyl and dimenhydrinate for intraoperative pain and nausea, respectively. Comparisons were made between groups for sedation, memory, and cognitive function, patient satisfaction, and incidence of complications. Levels of intraoperative sedation and patient satisfaction were similar between groups. Memory and cognitive function were well preserved in both groups. The incidence of transient episodes of ventilatory rate depression (<8 bpm) was more frequent among the propofol patients (5 vs 0, P = 0.04), particularly after supplemental doses of opioid. Intraoperative seizures were more common among the neurolept patients (7 vs 0, P = 0.002). PCS using propofol represents an effective alternative to neurolept analgesia during awake seizure surgery performed in a monitored care environment.
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Affiliation(s)
- I A Herrick
- Department of Anaesthesia, London Health Sciences Centre, University of Western Ontario, Canada
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