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Nourmohammadi A, Swift JR, de Pesters A, Guay CS, Adamo MA, Dalfino JC, Ritaccio AL, Schalk G, Brunner P. Passive functional mapping of receptive language cortex during general anesthesia using electrocorticography. Clin Neurophysiol 2023; 147:31-44. [PMID: 36634533 PMCID: PMC10267852 DOI: 10.1016/j.clinph.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 09/30/2022] [Accepted: 11/10/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate the feasibility of passive functional mapping in the receptive language cortex during general anesthesia using electrocorticographic (ECoG) signals. METHODS We used subdurally placed ECoG grids to record cortical responses to speech stimuli during awake and anesthesia conditions. We identified the cortical areas with significant responses to the stimuli using the spectro-temporal consistency of the brain signal in the broadband gamma (BBG) frequency band (70-170 Hz). RESULTS We found that ECoG BBG responses during general anesthesia effectively identify cortical regions associated with receptive language function. Our analyses demonstrated that the ability to identify receptive language cortex varies across different states and depths of anesthesia. We confirmed these results by comparing them to receptive language areas identified during the awake condition. Quantification of these results demonstrated an average sensitivity and specificity of passive language mapping during general anesthesia to be 49±7.7% and 100%, respectively. CONCLUSION Our results demonstrate that mapping receptive language cortex in patients during general anesthesia is feasible. SIGNIFICANCE Our proposed protocol could greatly expand the population of patients that can benefit from passive language mapping techniques, and could eliminate the risks associated with electrocortical stimulation during an awake craniotomy.
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Affiliation(s)
- Amin Nourmohammadi
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA.
| | - James R Swift
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA.
| | - Adriana de Pesters
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA.
| | - Christian S Guay
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Matthew A Adamo
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA.
| | - John C Dalfino
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA.
| | - Anthony L Ritaccio
- Department of Neurology, Albany Medical College, Albany, NY, USA; Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.
| | - Gerwin Schalk
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA; Chen Frontier Lab for Applied Neurotechnology, Tianqiao and Chrissy Chen Institute, Shanghai, P.R. China.
| | - Peter Brunner
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA; Department of Neurology, Albany Medical College, Albany, NY, USA.
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Awake Craniotomy without Invasive Blood Pressure Monitoring. World Neurosurg 2022; 168:e350-e353. [DOI: 10.1016/j.wneu.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 12/15/2022]
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Thakkar K, Mariappan R, Prabhu K, Yadav B, Singh G. Comparison of Monitored Anesthesia Care with Propofol Versus Dexmedetomidine for Awake Craniotomy: A Retrospective study. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1748195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
Abstract
Background Anesthetic agents used for awake craniotomy should be safe, short-acting, titratable, and provide an adequate level of sedation and analgesia, along with facilitating adequate neurological assessment during the functional testing. Our study aims to review the efficacy and safety profile, along with the potential for neurophysiological monitoring, of two commonly used anesthetic regimens, i.e., propofol and dexmedetomidine.
Methods After the Ethics Committee approval, a retrospective analysis of 51 patients who underwent awake craniotomy for brain tumor excision over a period of 7 years was done. Those who received monitored anesthesia care (MAC) were divided into two groups, namely, Group P for that received propofol, and Group D that received dexmedetomidine and their hemodynamic profile, perioperative complications, neuromonitoring techniques, and postoperative course was noted from the records.
Results A total of 31 patients were administered MAC with propofol and 20 with dexmedetomidine. The baseline demographic data, duration of surgery, intensive care unit (ICU), and hospital stay were comparable between the two. The hemodynamic profile as assessed by the heart rate and blood pressure was also comparable. The incidence of intraoperative seizures was found to be less in Group P, though. Episodes of transient desaturation were observed more in Group P (9.7%) than in Group D (5%), but none of the patients required conversion to general anesthesia. Direct cortical stimulation was satisfactorily elicited in 80% in Group P and 85% in Group D.
Conclusions MAC with propofol and dexmedetomidine are acceptable techniques with comparable hemodynamic profile, intraoperative and postoperative complications, and potential for neurophysiological monitoring.
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Affiliation(s)
- Keta Thakkar
- Department of Neuroanaesthesia, Christian Medical college, Vellore, Tamil Nadu, India
| | - Ramamani Mariappan
- Department of Neuroanaesthesia, Christian Medical college, Vellore, Tamil Nadu, India
| | - Krishna Prabhu
- Department of Neurosurgery, Christian Medical college, Vellore, Tamil Nadu, India
| | - Bijesh Yadav
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Georgene Singh
- Department of Neuroanaesthesia, Christian Medical college, Vellore, Tamil Nadu, India
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Zhou HY, Chen HY, Li Y. Anesthetic technique for awake artery malformation clipping with motor evoked potential and somatosensory evoked potential: A case report. World J Clin Cases 2021; 9:8207-8213. [PMID: 34621882 PMCID: PMC8462218 DOI: 10.12998/wjcc.v9.i27.8207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/09/2021] [Accepted: 08/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Awake craniotomy has been widely used for tumor resection, epilepsy surgery, deep brain stimulation, and carotid endarterectomy. The report on awake artery malformation clipping is rare, especially for anesthesia management.
CASE SUMMARY A 62-year-old female diagnosed with malformation of anterior cerebral artery at the right side. We clipped the artery malformation with intraoperative neuromonitoring (IONM) in awake craniotomy. Spontaneous respiration was maintained throughout the procedure by nasopharyngeal airway during the surgery successfully.
CONCLUSION The technique of monitoring anesthesia care can be performed successfully for the patient with IONM.
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Affiliation(s)
- Hong-Yu Zhou
- Department of Anesthesiology, West China Hospital, Chengdu 610041, Sichuan Province, China
| | - Hong-Yang Chen
- Department of Anesthesiology, West China Hospital, Chengdu 610041, Sichuan Province, China
| | - Yu Li
- Department of Anesthesiology, West China Hospital, Chengdu 610041, Sichuan Province, China
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Awake on Twitter. J Neurosurg Anesthesiol 2021; 34:339-340. [DOI: 10.1097/ana.0000000000000763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Deng M, Tu M, Liu Y, Hu X, Zhang T, Wu J, Wang Y. Comparing two airway management strategies for moderately sedated patients undergoing awake craniotomy: A single-blinded randomized controlled trial. Acta Anaesthesiol Scand 2020; 64:1414-1421. [PMID: 32659854 DOI: 10.1111/aas.13667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/03/2020] [Accepted: 07/05/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND In the monitored anesthesia care (MAC) setting for awake craniotomy (AC), maintaining airway patency in sedated patients remains challenging. This randomized controlled trial aimed to compare the validity of the below-epiglottis transnasal tube insertion (the tip of the tube placed between the epiglottis and vocal cords) and the nasopharyngeal airway (simulated by the above-epiglottis transnasal tube with the tip of the tube placed between the epiglottis and the free edge of the soft palate) with respect to maintaining upper airway patency for moderately sedated patients undergoing AC. METHODS Sixty patients scheduled for elective AC were randomized to receive below-epiglottis (n = 30) or above-epiglottis (n = 30) transnasal tube insertion before surgery. Moderate sedation was maintained in the pre- and post-awake phases. The primary outcome was the upper airway obstruction (UAO) remission rate (relieved obstructions after tube insertion/the total number of obstructions before tube insertion). RESULTS The UAO remission rate was higher in the below-epiglottis group [100% (12/12) vs 45% (5/11); P = .005]. The tidal volume values monitored through the tube were greater in the below-epiglottis group during the pre-awake phase (P < .001). End-tidal carbon dioxide (EtCO2 ) monitored through the tube was higher in the below-epiglottis group at bone flap removal (P < .001). During the awake phase, patients' ability to speak was not impeded. No patient had serious complications related to the tube. CONCLUSION The below-epiglottis tube insertion is a more effective method to maintain upper airway patency than the nasopharyngeal airway for moderately sedated patients undergoing AC.
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Affiliation(s)
- Meng Deng
- Department of Anesthesiology Huashan Hospital of Fudan University Shanghai China
| | - Meng‐Yun Tu
- Department of Anesthesiology Huashan Hospital of Fudan University Shanghai China
| | - Yi‐Heng Liu
- Department of Anesthesiology Huashan Hospital of Fudan University Shanghai China
| | - Xiao‐Bing Hu
- Department of Anesthesiology Huashan Hospital of Fudan University Shanghai China
| | - Tao Zhang
- Department of Epidemiology, School of Public Health Fudan University Shanghai China
| | - Jin‐Song Wu
- Department of Neurosurgery Huashan Hospital of Fudan University Shanghai China
| | - Ying‐Wei Wang
- Department of Anesthesiology Huashan Hospital of Fudan University Shanghai China
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Kim SH, Choi SH. Anesthetic considerations for awake craniotomy. Anesth Pain Med (Seoul) 2020; 15:269-274. [PMID: 33329824 PMCID: PMC7713838 DOI: 10.17085/apm.20050] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/17/2020] [Indexed: 11/17/2022] Open
Abstract
Awake craniotomy is a gold standard of care for resection of brain tumors located within or close to the eloquent areas. Both asleep-awake-asleep technique and monitored anesthesia care have been used effectively for awake craniotomy and the choice of optimal anesthetic approach is primarily based on the preferences of the anesthesiologist and surgical team. Propofol, remifentanil, dexmedetomidine, and scalp nerve block provide the reliable conditions for intraoperative brain mapping. Appropriate patient selection, adequate perioperative psychological support, and proper anesthetic management for individual patients in each stage of surgery are crucial for procedural safety, success, and patient satisfaction.
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Affiliation(s)
- Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Ho Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Anesthesia and brain tumor surgery: technical considerations based on current research evidence. Curr Opin Anaesthesiol 2020; 32:553-562. [PMID: 31145197 DOI: 10.1097/aco.0000000000000749] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Anesthetics may influence cancer recurrence and metastasis following surgery by modulating the neuroendocrine stress response or by directly affecting cancer cell biology. This review summarizes the current evidence on whether commonly used anesthetics potentially affect postoperative outcomes following solid organ cancer surgery with particular focus on neurological malignancies. RECENT FINDINGS Despite significant improvement in diagnostic and therapeutic technology over the past decades, mortality rates after cancer surgery (including brain tumor resection) remains high. With regards to brain tumors, interaction between microglia/macrophages and tumor cells by multiple biological factors play an important role in tumor progression and metastasis. Preclinical studies have demonstrated an association between anesthetics and brain tumor cell biology, and a potential effect on tumor progression and metastasis has been revealed. However, in the clinical setting, the current evidence is inadequate to draw firm conclusions on the optimal anesthetic technique for brain tumor surgery. SUMMARY Further work at both the basic science and clinical level is urgently needed to evaluate the association between perioperative factors, including anesthetics/technique, and postoperative brain tumor outcomes.
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Whiting BB, Lee BS, Mahadev V, Borghei-Razavi H, Ahuja S, Jia X, Mohammadi AM, Barnett GH, Angelov L, Rajan S, Avitsian R, Vogelbaum MA. Combined use of minimal access craniotomy, intraoperative magnetic resonance imaging, and awake functional mapping for the resection of gliomas in 61 patients. J Neurosurg 2020; 132:159-167. [PMID: 30684941 DOI: 10.3171/2018.9.jns181802] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/10/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Current management of gliomas involves a multidisciplinary approach, including a combination of maximal safe resection, radiotherapy, and chemotherapy. The use of intraoperative MRI (iMRI) helps to maximize extent of resection (EOR), and use of awake functional mapping supports preservation of eloquent areas of the brain. This study reports on the combined use of these surgical adjuncts. METHODS The authors performed a retrospective review of patients with gliomas who underwent minimal access craniotomy in their iMRI suite (IMRIS) with awake functional mapping between 2010 and 2017. Patient demographics, tumor characteristics, intraoperative and postoperative adverse events, and treatment details were obtained. Volumetric analysis of preoperative tumor volume as well as intraoperative and postoperative residual volumes was performed. RESULTS A total of 61 patients requiring 62 tumor resections met the inclusion criteria. Of the tumors resected, 45.9% were WHO grade I or II and 54.1% were WHO grade III or IV. Intraoperative neurophysiological monitoring modalities included speech alone in 23 cases (37.1%), motor alone in 24 (38.7%), and both speech and motor in 15 (24.2%). Intraoperative MRI demonstrated residual tumor in 48 cases (77.4%), 41 (85.4%) of whom underwent further resection. Median EOR on iMRI and postoperative MRI was 86.0% and 98.5%, respectively, with a mean difference of 10% and a median difference of 10.5% (p < 0.001). Seventeen of 62 cases achieved an increased EOR > 15% related to use of iMRI. Seventeen (60.7%) of 28 low-grade gliomas and 10 (30.3%) of 33 high-grade gliomas achieved complete resection. Significant intraoperative events included at least temporary new or worsened speech alteration in 7 of 38 cases who underwent speech mapping (18.4%), new or worsened weakness in 7 of 39 cases who underwent motor mapping (18.0%), numbness in 2 cases (3.2%), agitation in 2 (3.2%), and seizures in 2 (3.2%). Among the patients with new intraoperative deficits, 2 had residual speech difficulty, and 2 had weakness postoperatively, which improved to baseline strength by 6 months. CONCLUSIONS In this retrospective case series, the combined use of iMRI and awake functional mapping was demonstrated to be safe and feasible. This combined approach allows one to achieve the dual goals of maximal tumor removal and minimal functional consequences in patients undergoing glioma resection.
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Affiliation(s)
- Benjamin B Whiting
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
- 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland
| | - Bryan S Lee
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
- 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland
| | - Vaidehi Mahadev
- 3School of Medicine, Northeast Ohio Medical University, Rootstown
| | - Hamid Borghei-Razavi
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland
| | - Sanchit Ahuja
- 5Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland; and
| | - Xuefei Jia
- 6Quantitative Health Sciences, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
- 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland
| | - Gene H Barnett
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
- 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland
| | - Lilyana Angelov
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
- 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland
| | - Shobana Rajan
- 5Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland; and
| | - Rafi Avitsian
- 5Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland; and
| | - Michael A Vogelbaum
- 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland
- 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland
- 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland
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Shen E, Calandra C, Geralemou S, Page C, Davis R, Andraous W, Mikell C. The Stony Brook awake craniotomy protocol: A technical note. J Clin Neurosci 2019; 67:221-225. [PMID: 31279700 DOI: 10.1016/j.jocn.2019.06.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 05/21/2019] [Accepted: 06/21/2019] [Indexed: 12/16/2022]
Abstract
Most current awake craniotomy techniques utilize unnecessarily complicated airway management, and cause discomfort to the patients during the awake phase of the surgery. Our manuscript is written to discuss the neurosurgical and anesthetic techniques that we have developed to optimize awake craniotomy techniques at Stony Brook University Medical Center. We used the frameless Brainlab™ skull-mounted array for stereotactic navigation. Rigid fixation of the skull was avoided. General anesthesia with established airway was used during the "asleep" phase of the surgery. Following the removal of the bone flap and the opening of the dura, the patients were woken up, and the established airway was removed. Cortical mapping was performed to establish a safe entry zone for tumor removal. While the tumors were being removed, we continued motor examination and casual conversation with the patients to ensure safety. Patients were sedated during the remaining phase of the surgery until skin closure. No patient exhibited any neurological deficits or adverse anesthesia outcomes during the postoperative period. The protocol we developed avoids rigid skull fixation and emphasizes flexible intraoperative planning, thereby maximizing patient and physician comfort while allowing for successful tumor resection.
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Affiliation(s)
- Erica Shen
- Stony Brook University School of Medicine, United States
| | - Colleen Calandra
- Department of Neurosurgery, Stony Brook University Hospital, United States
| | - Sofia Geralemou
- Department of Anesthesiology, Stony Brook University Hospital, United States
| | - Christopher Page
- Department of Anesthesiology, Stony Brook University Hospital, United States
| | - Raphael Davis
- Department of Neurosurgery, Stony Brook University Hospital, United States
| | - Wesam Andraous
- Department of Anesthesiology, Stony Brook University Hospital, United States
| | - Charles Mikell
- Department of Neurosurgery, Stony Brook University Hospital, United States.
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Suero Molina E, Schipmann S, Mueller I, Wölfer J, Ewelt C, Maas M, Brokinkel B, Stummer W. Conscious sedation with dexmedetomidine compared with asleep-awake-asleep craniotomies in glioma surgery: an analysis of 180 patients. J Neurosurg 2018; 129:1223-1230. [PMID: 29328000 DOI: 10.3171/2017.7.jns171312] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/14/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVEAwake craniotomies have become a feasible tool over time to treat brain tumors located in eloquent regions. Different techniques have been applied in neurooncology centers. Both "asleep-awake-asleep" (asleep) and "conscious sedation" were used subsequently at the authors' neurosurgical department. Since 2013, the authors have only performed conscious sedation surgeries, predominantly using the α2-receptor agonist dexmedetomidine as the anesthetic drug. The aim of this study was to compare both mentioned techniques and evaluate the clinical use of dexmedetomidine in the setting of awake craniotomies for glioma surgery.METHODSThe authors retrospectively analyzed patients who underwent operations either under the asleep condition using propofol-remifentanil or under conscious sedation conditions using dexmedetomidine infusions. In the asleep group patients were intubated with a laryngeal mask and extubated for the assessment period. Adverse events, as well as applied drugs with doses and frequency of usage, were recorded.RESULTSFrom 224 awake surgeries between 2009 and 2015, 180 were performed for the resection of gliomas and included in the study. In the conscious sedation group (n = 75) significantly fewer opiates (p < 0.001) and vasoactive (p < 0.001) and antihypertensive (p < 0.001) drugs were used in comparison with the asleep group (n = 105). Furthermore, the postoperative length of stay (p < 0.001) and the surgical duration (p < 0.001) were significantly lower in the conscious sedation group.CONCLUSIONSUse of dexmedetomidine creates excellent conditions for awake surgeries. It sedates moderately and acts as an anxiolytic. Thus, after ceasing infusion it enables quick and reliable clinical neurological assessment of patients. This might lead to reducing the amount of administered antihypertensive and vasoactive drugs as well as the length of hospitalization, while likely ensuring more rapid surgery.
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Affiliation(s)
| | | | | | | | | | - Matthias Maas
- 2Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital of Münster, Germany
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Foster CH, Morone PJ, Cohen-Gadol A. Awake craniotomy in glioma surgery: is it necessary? J Neurosurg Sci 2018; 63:162-178. [PMID: 30259721 DOI: 10.23736/s0390-5616.18.04590-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The awake craniotomy has evolved from its humble beginnings in ancient cultures to become one of the most eloquent modern neurosurgical procedures. The development of intraoperative mapping techniques like direct electrostimulation of the cortex and subcortical white matter have further argued for its place in the neurosurgeon's armamentarium. Yet the suitability of the awake craniotomy with intraoperative functional mapping (ACWM) to optimize oncofunctional balance after peri-eloquent glioma resection continues to be a topic of active investigation as new methods of intraoperative monitoring and some unfavorable outcome data question its necessity. EVIDENCE ACQUISITION The neurosurgery and anesthesiology literatures were scoured for English-language studies that analyzed or reviewed the ACWM or its components as applied to glioma surgery via the PubMed, ClinicalKey, and OvidMEDLINE® databases or via direct online searches of journal archives. EVIDENCE SYNTHESIS Information on background, conceptualization, standard techniques, and outcomes of the ACWM were provided and compared. We parceled the procedure into its components and qualitatively described positive and negative outcome data for each. Findings were presented in the context of each study without attempt at quantitative analysis or reconciliation of heterogeneity between studies. Certain illustrative studies were highlighted throughout the review. Overarching conclusions were drawn based on level of evidence, expert opinion, and predominate concordance of data across studies in the literature. CONCLUSIONS Most investigators and studies agree that the ACWM is the best currently available approach to optimize oncofunctional balance in this difficult-to-treat patient population. This qualitative review synthesizes the most currently available data on the topic to provide contemporaneous insight into how and why the ACWM has become a favorite operation of neurosurgeons worldwide for the resection of gliomas from eloquent brain.
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Affiliation(s)
- Chase H Foster
- Department of Neurological Surgery, George Washington University Hospital, Washington D.C., USA -
| | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Aaron Cohen-Gadol
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, IN, USA
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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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Lu VM, Phan K, Rovin RA. Comparison of operative outcomes of eloquent glioma resection performed under awake versus general anesthesia: A systematic review and meta-analysis. Clin Neurol Neurosurg 2018; 169:121-127. [DOI: 10.1016/j.clineuro.2018.04.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 03/16/2018] [Accepted: 04/03/2018] [Indexed: 12/17/2022]
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Aoun RJN, Sattur MG, Krishna C, Gupta A, Welz ME, Nanney AD, Koht AH, Tate MC, Noe KH, Sirven JI, Anderies BJ, Bolton PB, Trentman TL, Zimmerman RS, Swanson KR, Bendok BR. Awake Surgery for Brain Vascular Malformations and Moyamoya Disease. World Neurosurg 2017; 105:659-671. [DOI: 10.1016/j.wneu.2017.03.121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/23/2017] [Accepted: 03/25/2017] [Indexed: 12/16/2022]
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D'Antico C, Hofer A, Fassl J, Tobler D, Zumofen D, Steiner LA, Goettel N. Case Report: Emergency awake craniotomy for cerebral abscess in a patient with unrepaired cyanotic congenital heart disease. F1000Res 2017; 5:2521. [PMID: 27928498 PMCID: PMC5115221 DOI: 10.12688/f1000research.9722.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2017] [Indexed: 12/04/2022] Open
Abstract
We report the case of a 39-year-old male with complex cyanotic congenital heart disease undergoing emergency craniotomy for a cerebral abscess. Maintenance of intraoperative hemodynamic stability and adequate tissue oxygenation during anesthesia may be challenging in patients with cyanotic congenital heart disease. In this case, we decided to perform the surgery as an awake craniotomy after interdisciplinary consensus. We discuss general aspects of anesthetic management during awake craniotomy and specific concerns in the perioperative care of patients with congenital heart disease.
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Affiliation(s)
- Corinne D'Antico
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - André Hofer
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jens Fassl
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel Tobler
- Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel Zumofen
- Department of Neurosurgery, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Radiology, Division of Diagnostic and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luzius A Steiner
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicolai Goettel
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
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Hill CS, Severgnini F, McKintosh E. How I do it: Awake craniotomy. Acta Neurochir (Wien) 2017; 159:173-176. [PMID: 27858231 DOI: 10.1007/s00701-016-3021-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 11/03/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Awake craniotomy allows continuous assessment of a patient's clinical and neurological status during open brain surgery. This facilitates early detection of interference with eloquent cortex, and hence can allow a surgeon to maximize resection margins without compromising neurological function. METHODS Awake craniotomy requires an effective scalp blockade, intraoperative assessment, and a carefully co-ordinated theatre team. A variety of clinical and electrophysiological techniques can be used to assess cortical function. CONCLUSIONS Effective scalp blockade and awake craniotomy provides the opportunity to intraoperatively assess cortical function in the awake patient, thus providing an important neurosurgical option for lesions near eloquent cortex.
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Dilmen OK, Akcil EF, Oguz A, Vehid H, Tunali Y. Comparison of Conscious Sedation and Asleep-Awake-Asleep Techniques for Awake Craniotomy. J Clin Neurosci 2017; 35:30-34. [DOI: 10.1016/j.jocn.2016.10.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 10/02/2016] [Indexed: 12/17/2022]
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The Effects of Dexmedetomidine and Remifentanil on Hemodynamic Stability and Analgesic Requirement After Craniotomy: A Randomized Controlled Trial. J Neurosurg Anesthesiol 2016; 28:282-90. [DOI: 10.1097/ana.0000000000000221] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Stevanovic A, Rossaint R, Veldeman M, Bilotta F, Coburn M. Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0156448. [PMID: 27228013 PMCID: PMC4882028 DOI: 10.1371/journal.pone.0156448] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 05/13/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Awake craniotomy (AC) renders an expanded role in functional neurosurgery. Yet, evidence for optimal anaesthesia management remains limited. We aimed to summarise the latest clinical evidence of AC anaesthesia management and explore the relationship of AC failures on the used anaesthesia techniques. METHODS Two authors performed independently a systematic search of English articles in PubMed and EMBASE database 1/2007-12/2015. Search included randomised controlled trials (RCTs), observational trials, and case reports (n>4 cases), which reported anaesthetic approach for AC and at least one of our pre-specified outcomes: intraoperative seizures, hypoxia, arterial hypertension, nausea and vomiting, neurological dysfunction, conversion into general anaesthesia and failure of AC. Random effects meta-analysis was used to estimate event rates for four outcomes. Relationship with anaesthesia technique was explored using logistic meta-regression, calculating the odds ratios (OR) and 95% confidence intervals [95%CI]. RESULTS We have included forty-seven studies. Eighteen reported asleep-awake-asleep technique (SAS), twenty-seven monitored anaesthesia care (MAC), one reported both and one used the awake-awake-awake technique (AAA). Proportions of AC failures, intraoperative seizures, new neurological dysfunction and conversion into general anaesthesia (GA) were 2% [95%CI:1-3], 8% [95%CI:6-11], 17% [95%CI:12-23] and 2% [95%CI:2-3], respectively. Meta-regression of SAS and MAC technique did not reveal any relevant differences between outcomes explained by the technique, except for conversion into GA. Estimated OR comparing SAS to MAC for AC failures was 0.98 [95%CI:0.36-2.69], 1.01 [95%CI:0.52-1.88] for seizures, 1.66 [95%CI:1.35-3.70] for new neurological dysfunction and 2.17 [95%CI:1.22-3.85] for conversion into GA. The latter result has to be interpreted cautiously. It is based on one retrospective high-risk of bias study and significance was abolished in a sensitivity analysis of only prospectively conducted studies. CONCLUSION SAS and MAC techniques were feasible and safe, whereas data for AAA technique are limited. Large RCTs are required to prove superiority of one anaesthetic regime for AC.
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Affiliation(s)
- Ana Stevanovic
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Veldeman
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Federico Bilotta
- Department of Anaesthesiology, Critical Care and Pain Medicine, University of Rome “La Sapienza”, Rome, Italy
| | - Mark Coburn
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- * E-mail:
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Awake brain tumor resection during pregnancy: Decision making and technical nuances. J Clin Neurosci 2016; 24:160-2. [DOI: 10.1016/j.jocn.2015.08.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 08/18/2015] [Accepted: 08/21/2015] [Indexed: 12/24/2022]
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Abstract
We review topics pertinent to the perioperative care of patients with neurological disorders. Our review addresses topics not only in the anesthesiology literature, but also in basic neurosciences, critical care medicine, neurology, neurosurgery, radiology, and internal medicine literature. We include literature published or available online up through December 8, 2013. As our review is not able to include all manuscripts, we focus on recurring themes and unique and pivotal investigations. We address the broad topics of general neuroanesthesia, stroke, traumatic brain injury, anesthetic neurotoxicity, neuroprotection, pharmacology, physiology, and nervous system monitoring.
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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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Sim EY, Tan TK. Awake Craniotomy with Intraoperative MRI: Description of a Sedation Technique Using Remifentanil and Dexmedetomidine. PROCEEDINGS OF SINGAPORE HEALTHCARE 2014. [DOI: 10.1177/201010581402300312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We describe the anaesthetic management of a patient requiring intra-operative MRI and awake neurological testing during neurosurgical resection of a frontal tumour. This tumour involved her motor and speech areas. The anaesthetic drugs administered during awake craniotomy should be safe and allow appropriate changes in the level of sedation, so that the patient is adequately sedated during periods of intense surgical stimulus, yet awake, comfortable and cooperative during functional testing and tumour resection. We report the novel and successful use of a sedative — dexmedetomidine in combination with a narcotic, remifentanil. There has not been much experience with this combination locally. Dexmedetomidine, a selective alpha-2 agonist with sedative, analgesic and anaesthetic-sparing effect does not suppress ventilation. Patients are sedated, but can be easily roused verbally. Remifentanil is a useful choice in this surgery as it can be rapidly titrated according to level of surgical intensity and has a reliable context sensitive half life. Potential problems associated with awake craniotomy such as impaired ventilation during sedation, nausea, vomiting and seizures are discussed. These anaesthetic challenges are compounded by the challenges posed by the iMRI environment. Emphasis is placed on patient selection and preparation peri-operatively. This is crucial to the success of the operation.
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Affiliation(s)
- Eileen Yilin Sim
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Tong Khee Tan
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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