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Huang PH, Pan YS, Chen SY, Lin SH. Anesthetic Effect on the Subthalamic Nucleus in Microelectrode Recording and Local Field Potential of Parkinson's Disease. Neuromodulation 2024:S1094-7159(24)00073-4. [PMID: 38852085 DOI: 10.1016/j.neurom.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 03/12/2024] [Accepted: 04/08/2024] [Indexed: 06/10/2024]
Abstract
OBJECTIVES Anesthetic agents used during deep brain stimulation (DBS) surgery might interfere with microelectrode recording (MER) and local field potential (LFP) and thus affect the accuracy of surgical target localization. This review aimed to identify the effects of different anesthetic agents on neuronal activity of the subthalamic nucleus (STN) during the MER procedure. MATERIALS AND METHODS We used Medical Subject Heading terms to search the PubMed, EMBASE, EBSCO, and ScienceDirect data bases. MER characteristics were sorted into quantitative and qualitative data types. Quantitative data included the burst index, pause index, firing rate (FR), and interspike interval. Qualitative data included background activity, burst discharge (BD), and anesthetic agent effect. We also categorized the reviewed manuscripts into those describing local anesthesia with sedation (LAWS) and those describing general anesthesia (GA) and compiled the effects of anesthetic agents on MER and LFP characteristics. RESULTS In total, 26 studies on MER were identified, of which 12 used LAWS and 14 used GA. Three studies on LFP also were identified. We found that the FR was preserved under LAWS but tended to be lower under GA, and BD was reduced in both groups. Individually, propofol enhanced BD but was better used for sedation, or the dosage should be minimized in GA. Similarly, low-dose dexmedetomidine sedation did not disturb MER. Opioids could be used as adjunctive anesthetic agents. Volatile anesthesia had the least adverse effect on MER under GA, with minimal alveolar concentration at 0.5. Dexmedetomidine anesthesia did not affect LFP, whereas propofol interfered with the power of LFP. CONCLUSIONS The effects of the tested anesthetics on the STN in MER and LFP of Parkinson's disease varied; however, identifying the STN and achieving a good clinical outcome are possible under controlled anesthetic conditions. For patient comfort, anesthesia should be considered in STN-DBS.
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Affiliation(s)
- Pin-Han Huang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Shen Pan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Shin-Yuan Chen
- Department of Neurosurgery, Hualien Tzu Chi Hospital/Tzu Chi University, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Sheng-Huang Lin
- Department of Neurology, Hualien Tzu Chi Hospital/Tzu Chi University, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.
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Cossu G, Vandenbulcke A, Zaccarini S, Gaudet JG, Hottinger AF, Rimorini N, Potie A, Beaud V, Guerra-Lopez U, Daniel RT, Berna C, Messerer M. Hypnosis-Assisted Awake Craniotomy for Eloquent Brain Tumors: Advantages and Pitfalls. Cancers (Basel) 2024; 16:1784. [PMID: 38730736 PMCID: PMC11083963 DOI: 10.3390/cancers16091784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Awake craniotomy (AC) is recommended for the resection of tumors in eloquent areas. It is traditionally performed under monitored anesthesia care (MAC), which relies on hypnotics and opioids. Hypnosis-assisted AC (HAAC) is an emerging technique that aims to provide psychological support while reducing the need for pharmacological sedation and analgesia. We aimed to compare the characteristics and outcomes of patients who underwent AC under HAAC or MAC. METHODS We retrospectively analyzed the clinical, anesthetic, surgical, and neuropsychological data of patients who underwent awake surgical resection of eloquent brain tumors under HAAC or MAC. We used Mann-Whitney U tests, Wilcoxon signed-rank tests, and repeated-measures analyses of variance to identify statistically significant differences at the 0.05 level. RESULTS A total of 22 patients were analyzed, 14 in the HAAC group and 8 in the MAC group. Demographic, radiological, and surgical characteristics as well as postoperative outcomes were similar. Patients in the HAAC group received less remifentanil (p = 0.047) and propofol (p = 0.002), but more dexmedetomidine (p = 0.025). None of them received ketamine as a rescue analgesic. Although patients in the HAAC group experienced higher levels of perioperative pain (p < 0.05), they reported decreasing stress levels (p = 0.04) and greater levels of satisfaction (p = 0.02). CONCLUSION HAAC is a safe alternative to MAC as it reduces perioperative stress and increases overall satisfaction. Further research is necessary to assess whether hypnosis is clinically beneficial.
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Affiliation(s)
- Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, 1011 Lausanne, Switzerland; (A.V.); (R.T.D.); (M.M.)
- L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, University Hospital of Lausanne, 1011 Lausanne, Switzerland;
| | - Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, 1011 Lausanne, Switzerland; (A.V.); (R.T.D.); (M.M.)
| | - Sonia Zaccarini
- Department of Anesthesiology, University Hospital of Lausanne, 1011 Lausanne, Switzerland; (S.Z.); (J.G.G.)
- Center for Integrative and Complementary Medicine, Department of Anesthesiology, University Hospital of Lausanne, The Sense and University of Lausanne, 1011 Lausanne, Switzerland; (N.R.); (C.B.)
| | - John G. Gaudet
- Department of Anesthesiology, University Hospital of Lausanne, 1011 Lausanne, Switzerland; (S.Z.); (J.G.G.)
| | - Andreas F. Hottinger
- L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, University Hospital of Lausanne, 1011 Lausanne, Switzerland;
- Division of Neuro-oncology, Department of Oncology, University Hospital of Lausanne and University of Lausanne, 1011 Lausanne, Switzerland
| | - Nina Rimorini
- Center for Integrative and Complementary Medicine, Department of Anesthesiology, University Hospital of Lausanne, The Sense and University of Lausanne, 1011 Lausanne, Switzerland; (N.R.); (C.B.)
| | - Arnaud Potie
- Department of Anesthesiology, University Hospital of Lausanne, 1011 Lausanne, Switzerland; (S.Z.); (J.G.G.)
| | - Valerie Beaud
- Service of Neuropsychology and Neurorehabilitation, University Hospital of Lausanne, 1011 Lausanne, Switzerland; (V.B.); (U.G.-L.)
| | - Ursula Guerra-Lopez
- Service of Neuropsychology and Neurorehabilitation, University Hospital of Lausanne, 1011 Lausanne, Switzerland; (V.B.); (U.G.-L.)
| | - Roy T. Daniel
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, 1011 Lausanne, Switzerland; (A.V.); (R.T.D.); (M.M.)
- L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, University Hospital of Lausanne, 1011 Lausanne, Switzerland;
| | - Chantal Berna
- Center for Integrative and Complementary Medicine, Department of Anesthesiology, University Hospital of Lausanne, The Sense and University of Lausanne, 1011 Lausanne, Switzerland; (N.R.); (C.B.)
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, 1011 Lausanne, Switzerland; (A.V.); (R.T.D.); (M.M.)
- L. Lundin and Family Brain Tumor Research Center, Departments of Oncology and Clinical Neurosciences, University Hospital of Lausanne, 1011 Lausanne, Switzerland;
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Bala A, Olejnik A, Dziedzic T, Piwowarska J, Podgórska A, Marchel A. What helps patients to prepare for and cope during awake craniotomy? A prospective qualitative study. J Neuropsychol 2024; 18:30-46. [PMID: 37036087 DOI: 10.1111/jnp.12311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 03/09/2023] [Indexed: 04/11/2023]
Abstract
There is growing interest in awake craniotomies, but some clinicians are concerned that such procedures are poorly tolerated by patients. Therefore, we conducted a study to assess this phenomenon. In this prospective qualitative study, 68 patients who qualified for awake craniotomy were asked to complete the Hospital Anxiety and Depression Scale (HADS)-two days before the surgery and visual analogue scales (VAS) for pain and stress, two days before the surgery and again about two days after. In addition, after their surgery, they took part in a structured interview about what helped them prepare for and cope with the surgery. Most patients tolerated the awake surgery well, scoring low on stress and pain scales. They reported a lower level of stress during the surgery (when questioned afterwards) than before it. Intensity of stress before the surgery correlated negatively with age, positively with HADS anxiety score and positively with stress subsequently experienced during surgery. The level of stress during surgery was associated with stress experienced before the surgery, pain and HADS anxiety and depression scores. Severity of pain during the surgery was positively correlated with stress during surgery and HADS depression and anxiety scores before the surgery. There was no correlation between stress, pain, anxiety and depression and the location of the lesion. Patients have a high tolerance for awake craniotomy. Various factors have an impact on how well patients cope with the operation. Extensive preoperative preparation should be considered a key part of the procedure.
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Affiliation(s)
| | | | - Tomasz Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Piwowarska
- Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Anna Podgórska
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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Tang L, Tan TK. Anaesthetic considerations and challenges during awake craniotomy. Singapore Med J 2024:00077293-990000000-00087. [PMID: 38305272 DOI: 10.4103/singaporemedj.smj-2022-053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/10/2023] [Indexed: 02/03/2024]
Abstract
ABSTRACT This article summarises the key anaesthetic considerations and challenges surrounding the perioperative management of a patient undergoing awake craniotomy. The main goals include patient comfort, facilitation of patient cooperation during the critical awake phase and maintenance of optimal operating conditions. These are achieved through appropriate patient selection and preparation, familiarity with the complexity of each surgical phase and potential complications that may arise, as well as maintenance of close communication among all team members. Challenges such as loss of patient cooperation, loss of airway, intraoperative nausea and vomiting, seizures, cerebral oedema, hypertension, blood loss and use of intraoperative magnetic resonance imaging are discussed. The importance of teamwork, competence, vigilance and clear management strategies for potential complications to maximise patient outcomes is also highlighted.
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Affiliation(s)
- Leonard Tang
- Department of Anaesthesia, Singapore General Hospital, Singapore
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Ramakrishnan PK, Saeed F, Thomson S, Corns R, Mathew RK, Sivakumar G. Awake craniotomy for high-grade gliomas - a prospective cohort study in a UK tertiary-centre. Surgeon 2024; 22:e3-e12. [PMID: 38008681 DOI: 10.1016/j.surge.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/07/2023] [Accepted: 11/02/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND Studies from the UK reporting on awake craniotomy (AC) include a heterogenous group of patients which limit the evaluation of the true impact of AC in high-grade glioma (HGG) patients. This study aims to report solely the experience and outcomes of AC for HGG surgery from our centre. METHODS A prospective review of all patients who underwent AC for HGG from 2013 to 2019 were performed. Data on patient characteristics including but not limited to demographics, pre- and post-operative Karnofsky performance status (KPS), tumour location and volume, type of surgery, extent of resection (EOR), tumour histopathology, intra- and post-operative complications, morbidity, mortality, disease recurrence, progression-free survival (PFS) and overall survival (OS) from the time of surgery were collected. RESULTS Fifteen patients (6 males; 9 females; 17 surgeries) underwent AC for HGG (median age = 55 years). Two patients underwent repeat surgeries due to disease recurrence. Median pre- and post-operative KPS score was 90 (range:80-100) and 90 (range:60-100), respectively. The EOR ranges from 60 to 100 % with a minimum of 80 % achieved in 81.3 % cases. Post-operative complications include focal seizures (17.6 %), transient aphasia/dysphasia (17.6 %), permanent motor deficit (11.8 %), transient motor deficit (5.9 %) and transient sensory disturbance (5.9 %). There were no surgery-related mortality or post-operative infection. The median PFS and OS were 13 (95%CI 5-78) and 30 (95%CI 21-78) months, respectively. CONCLUSION This is the first study in the UK to solely report outcomes of AC for HGG surgery. Our data demonstrates that AC for HGG in eloquent region is safe, feasible and provides comparable outcomes to those reported in the literature.
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Affiliation(s)
- Piravin Kumar Ramakrishnan
- Department of Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, United Kingdom
| | - Fozia Saeed
- Department of Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, United Kingdom
| | - Simon Thomson
- Department of Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, United Kingdom
| | - Robert Corns
- Department of Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, United Kingdom
| | - Ryan K Mathew
- Department of Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, United Kingdom; School of Medicine, University of Leeds, Woodhouse, Leeds LS2 9JT, United Kingdom.
| | - Gnanamurthy Sivakumar
- Department of Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, United Kingdom.
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Moniz-Garcia D, Bojaxhi E, Borah BJ, Dholakia R, Kim H, Sousa-Pinto B, Almeida JP, Mendhi M, Freeman WD, Sherman W, Christel L, Rosenfeld S, Grewal SS, Middlebrooks EH, Sabsevitz D, Gruenbaum BF, Chaichana KL, Quiñones-Hinojosa A. Awake Craniotomy Program Implementation. JAMA Netw Open 2024; 7:e2352917. [PMID: 38265799 PMCID: PMC10809012 DOI: 10.1001/jamanetworkopen.2023.52917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/30/2023] [Indexed: 01/25/2024] Open
Abstract
Importance Implementing multidisciplinary teams for treatment of complex brain tumors needing awake craniotomies is associated with significant costs. To date, there is a paucity of analysis on the cost utility of introducing advanced multidisciplinary standardized teams to enable awake craniotomies. Objective To assess the cost utility of introducing a standardized program of awake craniotomies. Design, Setting, and Participants A retrospective economic evaluation was conducted at Mayo Clinic Florida. All patients with single, unilateral lesions who underwent elective awake craniotomies between January 2016 and December 2021 were considered eligible for inclusion. The economic perspective of the health care institution and a time horizon of 1 year were considered. Data were analyzed from October 2022 to May 2023. Exposure Treatment with an awake craniotomy before standardization (2016-2018) compared with treatment with awake craniotomy after standardization (2018-2021). Main Outcomes and Measures Patient demographics, perioperative, and postoperative outcomes, including length of stay, intensive care (ICU) admission, extent of resection, readmission rates, and 1-year mortality were compared between patients undergoing surgery before and after standardization. Direct medical costs were estimated from Medicare reimbursement rates for all billed procedures. A cost-utility analysis was performed considering differences in direct medical costs and in 1-year mortality within the periods before and after standardization of procedures. Uncertainty was explored in probability sensitivity analysis. Results A total of 164 patients (mean [SD] age, 49.9 [15.7] years; 98 [60%] male patients) were included in the study. Of those, 56 underwent surgery before and 108 after implementation of procedure standardization. Procedure standardization was associated with reductions in length of stay from a mean (SD) of 3.34 (1.79) to 2.46 (1.61) days (difference, 0.88 days; 95% CI, 0.33-1.42 days; P = .002), length of stay in ICU from a mean (SD) of 1.32 (0.69) to 0.99 (0.90) nights (difference, 0.33 nights; 95% CI, 0.06-0.60 nights; P = .02), 30-day readmission rate from 14% (8 patients) in the prestandardization cohort to 5% (5 patients) (difference, 9%; 95% CI, 19.6%-0.3%; P = .03), while extent of resection and intraoperative complication rates were similar between both cohorts. The standardized protocol was associated with mean (SD) savings of $7088.80 ($12 389.50) and decreases in 1-year mortality (dominant intervention). This protocol was found to be cost saving in 75.5% of all simulations in probability sensitivity analysis. Conclusions and Relevance In this economic evaluation of standardization of awake craniotomy, there was a generalized reduction in length of stay, ICU admission time, and direct medical costs with implementation of an optimized protocol. This was achieved without compromising patient outcomes and with similar extent of resection, complication rates, and reduced readmission rates.
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Affiliation(s)
| | - Elird Bojaxhi
- Department of Anesthesiology, Mayo Clinic Florida, Jacksonville
| | - Bijan J Borah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Ruchita Dholakia
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Han Kim
- Department of Anesthesiology, Mayo Clinic Florida, Jacksonville
| | - Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | | | - Marvesh Mendhi
- Department of Anesthesiology, Mayo Clinic Florida, Jacksonville
| | | | - Wendy Sherman
- Department of Neurology, Mayo Clinic Florida, Jacksonville
| | - Lynda Christel
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville
| | | | | | | | - David Sabsevitz
- Department of Neuropsychology, Mayo Clinic Florida, Jacksonville
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Ladrero Paños I, Rivero Celada D, Jarén Cubillo P, Bueno Fernández C, Osorio Caicedo P, Gomez Gomez R. A Comparison of the Asleep-Awake Technique and Monitored Anesthesia Care During Awake Craniotomy: A 10-Year Analysis. Cureus 2023; 15:e50366. [PMID: 38213334 PMCID: PMC10782144 DOI: 10.7759/cureus.50366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/13/2024] Open
Abstract
Background Awake intracranial surgery with direct electrical stimulation (DES) is considered the gold standard for the resection of tumors affecting the eloquent areas of the brain. Awake craniotomy is a challenge for the anesthesiologist, as the patient's active cooperation is required throughout the operation. There are two frequent techniques, one is asleep-awake-asleep (AAA), and the other is called monitored anesthesia care (MAC). The AAA technique is the longer standing of the two and comprises general anesthesia followed by intraoperative awakening, which is necessary for neurological monitoring. In the present study, a comparison was made between the asleep-awake (AA) technique, a variation of the AAA anesthesia technique, and the MAC, which consists of a sedation that makes it possible to control pain and anxiety. Unlike the AA technique, the MAC does not involve the use of invasive airway devices. Objective The main objective was to contrast the two anesthetic management techniques for awake brain surgery used in our hospital. Methods A retrospective observational single-center study was performed consisting of a review of patient clinical records. The study sample comprised all patients above 18 years of age undergoing brain surgery through awake craniotomy between January 2013 and December 2022 at the Miguel Servet University Hospital (HUMS) in Zaragoza (Spain). Results Of the 79 patients included in the study, 39 were operated under AA anesthesia while the remaining 40 were operated under the MAC procedure. The main age of the participants was 52.8 years, the mean height was 169 cm, and the mean weight was 74.2 kg. No statistically significant differences were observed with respect to the patients' baseline characteristics, except for obesity which was more prevalent in the MAC group. In the MAC group, the airway was managed by means of nasal cannulas in all cases, with conversion to general anesthesia being required in only one instance. In the AA group, the laryngeal mask (LM) was used in 89.7% of the patients, and the endotracheal tube (ETT) in 10.3%. The surgical and anesthetic procedure duration was 15 and 20 minutes shorter in the MAC group, respectively. A reduction of almost 20 minutes in the anesthetic procedure and 15 minutes in the surgical one was observed. Tachycardia, desaturation, and airway complications were observed in four, five, and four patients respectively in the AA group but in none of the patients in the MAC group. The mean stay in the intensive care unit (ICU) and the mean postoperative hemoglobin levels between both groups were insignificant. Conclusions Both techniques analyzed in this study turned out to be equally safe and effective for brain tumor surgery in awake patients.
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Affiliation(s)
- Ignacio Ladrero Paños
- Department of Anesthesiology, Critical Care and Pain Medicine, Miguel Servet University Hospital, Zaragoza, ESP
| | - David Rivero Celada
- Department of Neurosurgery, Miguel Servet University Hospital, Zaragoza, ESP
| | - Paula Jarén Cubillo
- Department of Anesthesiology, Critical Care and Pain Medicine, Guadalajara University Hospital, Guadalajara, ESP
| | - Cristina Bueno Fernández
- Department of Anesthesiology, Critical Care and Pain Medicine, Miguel Servet University Hospital, Zaragoza, ESP
| | | | - Roberto Gomez Gomez
- Department of Anesthesiology, Critical Care and Pain Medicine, Miguel Servet University Hospital, Zaragoza, ESP
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Li M, Liu M, Cui Q, Zeng M, Li S, Zhang L, Peng Y. Effect of dexmedetomidine on postoperative delirium in patients undergoing awake craniotomies: study protocol of a randomized controlled trial. Trials 2023; 24:607. [PMID: 37743486 PMCID: PMC10519059 DOI: 10.1186/s13063-023-07632-2] [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: 11/23/2022] [Accepted: 09/08/2023] [Indexed: 09/26/2023] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a common complication, and it has a high incidence in neurosurgery patients. Awake craniotomy (AC) has been widely performed in patients with glioma in eloquent and motor areas. Most of the surgical procedure is frontotemporal craniotomy, and the operation duration has been getting longer. Patients undergoing AC are high-risk populations for POD. Dexmedetomidine (Dex) administration perioperatively might help to reduce the incidence of POD. The purpose of this study is to investigate the effect of Dex on POD in patients undergoing AC. METHODS The study is a prospective, single-center, double-blinded, paralleled-group, randomized controlled trial. Patients undergoing elective AC will be randomly assigned to the Dex group and the control group. Ten minutes before urethral catheterization, patients in the Dex group will be administered with a continuous infusion at a rate of 0.2 µg/kg/h until the end of dural closure. In the control group, patients will receive an identical volume of normal saline in the same setting. The primary outcome will be the cumulative incidence and severity of POD. It will be performed by using the confusion assessment method in the first 5 consecutive days after surgery. Secondary outcomes include quality of intraoperative awareness, stimulus intensity of neurological examination, pain severity, quality of recovery and sleep, and safety outcomes. DISCUSSION This study is to investigate whether the application of Dex could prevent POD in patients after undergoing AC and will provide strong evidence-based clinical practice on the impact of intraoperative interventions on preventing POD in AC patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT05195034. Registered on January 18, 2022.
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Affiliation(s)
- Muhan Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Minying Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qianyu Cui
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liyong Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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D’Onofrio G, Icolaro N, Fazzari E, Catapano D, Curcio A, Izzi A, Manuali A, Bisceglia G, Tancredi A, Marchello V, Recchia A, Tonti MP, Pazienza L, Carotenuto V, Bonis CD, Savarese L, Gaudio AD, Gorgoglione LP. Real-Time Neuropsychological Testing (RTNT) and Music Listening during Glioblastoma Excision in Awake Surgery: A Case Report. J Clin Med 2023; 12:6086. [PMID: 37763026 PMCID: PMC10531570 DOI: 10.3390/jcm12186086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/01/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
In this case report, real-time neuropsychological testing (RTNT) and music listening were applied for resections in the left temporal-parietal lobe during awake surgery (AS). The case is based on a 66-year-old with glioblastoma and alterations in expressive language and memory deficit. Neuropsychological assessment was run at baseline (2-3 days before surgery), discharge from hospital (2-3 days after surgery), and follow-up (1 month and 3 months). RTNT was started before beginning the anesthetic approach (T0) and during tumor excision (T1 and T2). At T0, T1, and T2 (before performing neuropsychological tests), music listening was applied. Before AS and after music listening, the patient reported a decrease in depression and anxiety. During AS, an improvement was shown in all cognitive parameters collected at T0, T1, and T2. After the excision and music listening, the patient reported a further decrease in depression and anxiety. Three days post surgery, and at follow-ups of one month and three months, the patient reported a further improvement in cognitive aspects, the absence of depression, and a reduction in anxiety symptoms. In conclusion, RTNT has been useful in detecting cognitive function levels during tumor excision. Music listening during AS decreased the patient's anxiety and depression symptoms.
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Affiliation(s)
- Grazia D’Onofrio
- Clinical Psychology Service, Health Department, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Nadia Icolaro
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (N.I.); (E.F.); (D.C.); (V.C.); (C.D.B.); (L.S.); (L.P.G.)
| | - Elena Fazzari
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (N.I.); (E.F.); (D.C.); (V.C.); (C.D.B.); (L.S.); (L.P.G.)
| | - Domenico Catapano
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (N.I.); (E.F.); (D.C.); (V.C.); (C.D.B.); (L.S.); (L.P.G.)
| | - Antonello Curcio
- Division of Neurosurgery, BIOMORF Department, University of Messina, 98122 Messina, Italy;
| | - Antonio Izzi
- Complex Unit of Anesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (A.M.); (G.B.); (A.T.); (V.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Aldo Manuali
- Complex Unit of Anesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (A.M.); (G.B.); (A.T.); (V.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Giuliano Bisceglia
- Complex Unit of Anesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (A.M.); (G.B.); (A.T.); (V.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Angelo Tancredi
- Complex Unit of Anesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (A.M.); (G.B.); (A.T.); (V.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Vincenzo Marchello
- Complex Unit of Anesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (A.M.); (G.B.); (A.T.); (V.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Andreaserena Recchia
- Complex Unit of Anesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (A.M.); (G.B.); (A.T.); (V.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Maria Pia Tonti
- Complex Unit of Anesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (A.M.); (G.B.); (A.T.); (V.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Luca Pazienza
- Complex Unit of Radiology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy;
| | - Vincenzo Carotenuto
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (N.I.); (E.F.); (D.C.); (V.C.); (C.D.B.); (L.S.); (L.P.G.)
| | - Costanzo De Bonis
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (N.I.); (E.F.); (D.C.); (V.C.); (C.D.B.); (L.S.); (L.P.G.)
| | - Luciano Savarese
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (N.I.); (E.F.); (D.C.); (V.C.); (C.D.B.); (L.S.); (L.P.G.)
| | - Alfredo Del Gaudio
- Complex Unit of Anesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (A.I.); (A.M.); (G.B.); (A.T.); (V.M.); (A.R.); (M.P.T.); (A.D.G.)
| | - Leonardo Pio Gorgoglione
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy; (N.I.); (E.F.); (D.C.); (V.C.); (C.D.B.); (L.S.); (L.P.G.)
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10
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Alanzi AK, Hakmi S, Adeel S, Ghazzal SY. Anesthesia for awake craniotomy: a case report. J Surg Case Rep 2023; 2023:rjad521. [PMID: 37724066 PMCID: PMC10505513 DOI: 10.1093/jscr/rjad521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 08/29/2023] [Indexed: 09/20/2023] Open
Abstract
Awake craniotomy (AC) is a neurosurgical technique that enables the precise localization of functional neural networks through intraoperative brain mapping and real-time monitoring. This operative method has been popularized in recent years due to decreased postoperative morbidities. We present a case of 31-year-old female who was presented with episodes of generalized tonic colonic seizures. She had a history of recurring seizures. Upon further investigations, she was diagnosed with brain space-occupying lesions initially suspected as low-grade glioma. Considering the lesion site, the patient was deemed a suitable candidate for an AC. To achieve conscious sedation, the patient received infusions of remifentanil and propofol at varying rates. During the procedure, the patient was under sedation and was regularly tested for response to predetermined commands. The tumor was successfully excised by using a combination of local anesthesia on the scalp and by the administration of propofol and boluses through a systemic infusion.
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Affiliation(s)
- Ahmed Khaled Alanzi
- Anesthesia Department, King Hamad University Hospital, Building 2435, Road 2835, Block 228, P.O Box 24343, Busaiteen, Kingdom of Bahrain
| | - Samah Hakmi
- Anesthesia Department, King Hamad University Hospital, Building 2435, Road 2835, Block 228, P.O Box 24343, Busaiteen, Kingdom of Bahrain
| | - Shahid Adeel
- Anesthesia Department, King Hamad University Hospital, Building 2435, Road 2835, Block 228, P.O Box 24343, Busaiteen, Kingdom of Bahrain
| | - Samar Yaser Ghazzal
- Anesthesia Department, King Hamad University Hospital, Building 2435, Road 2835, Block 228, P.O Box 24343, Busaiteen, Kingdom of Bahrain
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11
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D'Onofrio G, Izzi A, Manuali A, Bisceglia G, Tancredi A, Marchello V, Recchia A, Tonti MP, Icolaro N, Fazzari E, Carotenuto V, De Bonis C, Savarese L, Gorgoglione LP, Del Gaudio A. Anesthetic Management for Awake Craniotomy Applied to Neurosurgery. Brain Sci 2023; 13:1031. [PMID: 37508963 PMCID: PMC10377309 DOI: 10.3390/brainsci13071031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Our anesthetic technique proposed for awake craniotomy is the monitored anesthesia care (MAC) technique, with the patient in sedation throughout the intervention. Our protocol involves analgo-sedation through the administration of dexmedetomidine and remifentanil in a continuous intravenous infusion, allowing the patient to be sedated and in comfort, but contactable and spontaneously breathing. Pre-surgery, the patient is pre-medicated with intramuscular clonidine (2 µg/kg); it acts both as an anxiolytic and as an adjuvant in pain management and improves hemodynamic stability. In the operating setting, dexmedetomidine in infusion and remifentanil in target controlled infusion (TCI) for effect are started. The purpose of the association is to exploit the pharmacodynamics of dexmedetomidine which guarantees the control of respiratory drive, and the pharmacokinetics of remifentanil characterized by insensitivity to the drug. Post-operative management: at the end of the surgical procedure, the infusion of drugs was suspended. Wake-up craniotomy is associated with reduced hospital costs compared to craniotomy performed in general anesthesia, mainly due to reduced costs in the operating room and shorter hospital stays. Greater patient satisfaction and the benefits of avoiding hospital stay have led to the evolution of outpatient intracranial neurosurgery.
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Affiliation(s)
- Grazia D'Onofrio
- Clinical Psychology Service, Health Department, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Antonio Izzi
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Aldo Manuali
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Giuliano Bisceglia
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Angelo Tancredi
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Vincenzo Marchello
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Andreaserena Recchia
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Maria Pia Tonti
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Nadia Icolaro
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Elena Fazzari
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Vincenzo Carotenuto
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Costanzo De Bonis
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Luciano Savarese
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Leonardo Pio Gorgoglione
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Alfredo Del Gaudio
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
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12
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Jose GRB, Legaspi GD, Ibale MGD, Duñgo ABC. Awake craniotomy: nuts and bolts. Int Anesthesiol Clin 2023; 61:8-12. [PMID: 37243429 DOI: 10.1097/aia.0000000000000408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Geraldine Raphaela B Jose
- Department of Anesthesiology, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Gerardo D Legaspi
- Division of Neurosurgery, Department of Neurosciences, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Mark Gibson D Ibale
- Department of Anesthesiology, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Alec Brandon C Duñgo
- Department of Anesthesiology, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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13
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Al-Adli NN, Young JS, Sibih YE, Berger MS. Technical Aspects of Motor and Language Mapping in Glioma Patients. Cancers (Basel) 2023; 15:cancers15072173. [PMID: 37046834 PMCID: PMC10093517 DOI: 10.3390/cancers15072173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023] Open
Abstract
Gliomas are infiltrative primary brain tumors that often invade functional cortical and subcortical regions, and they mandate individualized brain mapping strategies to avoid postoperative neurological deficits. It is well known that maximal safe resection significantly improves survival, while postoperative deficits minimize the benefits associated with aggressive resections and diminish patients’ quality of life. Although non-invasive imaging tools serve as useful adjuncts, intraoperative stimulation mapping (ISM) is the gold standard for identifying functional cortical and subcortical regions and minimizing morbidity during these challenging resections. Current mapping methods rely on the use of low-frequency and high-frequency stimulation, delivered with monopolar or bipolar probes either directly to the cortical surface or to the subcortical white matter structures. Stimulation effects can be monitored through patient responses during awake mapping procedures and/or with motor-evoked and somatosensory-evoked potentials in patients who are asleep. Depending on the patient’s preoperative status and tumor location and size, neurosurgeons may choose to employ these mapping methods during awake or asleep craniotomies, both of which have their own benefits and challenges. Regardless of which method is used, the goal of intraoperative stimulation is to identify areas of non-functional tissue that can be safely removed to facilitate an approach trajectory to the equator, or center, of the tumor. Recent technological advances have improved ISM’s utility in identifying subcortical structures and minimized the seizure risk associated with cortical stimulation. In this review, we summarize the salient technical aspects of which neurosurgeons should be aware in order to implement intraoperative stimulation mapping effectively and safely during glioma surgery.
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Affiliation(s)
- Nadeem N. Al-Adli
- Department of Neurological Surgery, University of California, San Francisco, CA 94131, USA
- School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Jacob S. Young
- Department of Neurological Surgery, University of California, San Francisco, CA 94131, USA
| | - Youssef E. Sibih
- School of Medicine, University of California, San Francisco, CA 94131, USA
| | - Mitchel S. Berger
- Department of Neurological Surgery, University of California, San Francisco, CA 94131, USA
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14
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Viderman D, Nabidollayeva F, Bilotta F, Abdildin YG. Comparison of dexmedetomidine and propofol for sedation in awake craniotomy: A meta-analysis. Clin Neurol Neurosurg 2023; 226:107623. [PMID: 36791589 DOI: 10.1016/j.clineuro.2023.107623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Awake craniotomy (AC) is the preferred option for the resection of tumors adjacent to eloquent cortical areas and in cases of intractable epilepsy. It is mostly used to maintain the integrity of the brain during intracranial neurosurgical procedures. Awake craniotomy requires the use of ideal anesthetics, hypnotics, and analgesics to balance sedation, prompt the reversal of sedation, and prevent respiratory depression while maintaining communication between patient and medical team. Although a wide variety of anesthetics and hypnotics have been used for awake craniotomy over the past several decades, the optimal drug for the procedure has yet to be determined. The purpose of this meta-analysis was to compare dexmedetomidine and propofol in terms of intraoperative adverse events (i.e., hypertension, hypotension, nausea, vomiting, respiratory depression), patient and surgeon satisfaction, and procedure duration. METHODS We searched PubMed, Google Scholar, and the Cochrane Library for relevant articles published between the inception of these databases and April of 2022. The systematic search yielded 781 articles. After screening, we excluded 778 articles. The remaining three articles reporting 138 patients were selected for meta-analysis. RESULTS This meta-analysis showed no statistically significant difference between propofol and dexmedetomidine related to intraoperative adverse events, patient satisfaction, or procedure duration. The only statistically significant result was surgeon satisfaction, which appeared to be higher in the dexmedetomidine group. CONCLUSIONS Further high-quality randomized and controlled trials are needed to find a preferred agent for intraoperative sedation in awake craniotomy.
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Affiliation(s)
- Dmitriy Viderman
- Nazarbayev University School of Medicine (NUSOM), Kerei, Zhanibek Khans Str. 5/1, Astana, Kazakhstan; Department of Anesthesiology, Intensive Care, and Pain Medicine, National Research Oncology Center, Kerey and Zhanibek Khans Str. 3, Astana 020000, Kazakhstan.
| | - Fatima Nabidollayeva
- School of Engineering and Digital Sciences, Nazarbayev University, 53 Kabanbay Batyr Ave., Astana 010000, Kazakhstan.
| | - Federico Bilotta
- Department of Anesthesia and Intensive Care, University La Sapienza, Rome, Italy.
| | - Yerkin G Abdildin
- School of Engineering and Digital Sciences, Nazarbayev University, 53 Kabanbay Batyr Ave., Astana 010000, Kazakhstan.
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15
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Mofatteh M, Mashayekhi MS, Arfaie S, Chen Y, Hendi K, Kwan ATH, Honarvar F, Solgi A, Liao X, Ashkan K. Stress, Anxiety, and Depression Associated With Awake Craniotomy: A Systematic Review. Neurosurgery 2023; 92:225-240. [PMID: 36580643 DOI: 10.1227/neu.0000000000002224] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/09/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Awake craniotomy (AC) enables real-time monitoring of cortical and subcortical functions when lesions are in eloquent brain areas. AC patients are exposed to various preoperative, intraoperative, and postoperative stressors, which might affect their mental health. OBJECTIVE To conduct a systematic review to better understand stress, anxiety, and depression in AC patients. METHODS PubMed, Scopus, and Web of Science databases were searched from January 1, 2000, to April 20, 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. RESULTS Four hundred forty-seven records were identified that fit our inclusion and exclusion criteria for screening. Overall, 24 articles consisting of 1450 patients from 13 countries were included. Sixteen studies (66.7%) were prospective, whereas 8 articles (33.3%) were retrospective. Studies evaluated stress, anxiety, and depression during different phases of AC. Twenty-two studies (91.7%) were conducted on adults, and 2 studies were on pediatrics (8.3 %). Glioma was the most common AC treatment with 615 patients (42.4%). Awake-awake-awake and asleep-awake-asleep were the most common protocols, each used in 4 studies, respectively (16.7%). Anxiety was the most common psychological outcome evaluated in 19 studies (79.2%). The visual analog scale and self-developed questionnaire by the authors (each n = 5, 20.8%) were the most frequently tools used. Twenty-three studies (95.8%) concluded that AC does not increase stress, anxiety, and/or depression in AC patients. One study (4.2%) identified younger age associated with panic attack. CONCLUSION In experienced hands, AC does not cause an increase in stress, anxiety, and depression; however, the psychiatric impact of AC should not be underestimated.
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Affiliation(s)
- Mohammad Mofatteh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, UK
| | | | - Saman Arfaie
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.,Department of Molecular and Cell Biology, University of California Berkeley, California, USA
| | - Yimin Chen
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, China
| | - Kasra Hendi
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Faraz Honarvar
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Arad Solgi
- School of Kinesiology & Health Science, York University, Toronto, Ontario, Canada
| | - Xuxing Liao
- Department of Neurosurgery, Foshan Sanshui District People's Hospital, Foshan, China.,Department of Surgery of Cerebrovascular Diseases, Foshan First People's Hospital, Foshan, China
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK.,Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.,King's Health Partners Academic Health Sciences Centre, London, UK.,School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, UK
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16
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Monitored anesthesia care and asleep-awake-asleep techniques combined with multiple monitoring for resection of gliomas in eloquent brain areas: a retrospective analysis of 225 patients. Chin Neurosurg J 2022; 8:45. [PMID: 36582003 PMCID: PMC9801549 DOI: 10.1186/s41016-022-00311-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/22/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Awake craniotomy (AC) has become gold standard in surgical resection of gliomas located in eloquent areas. The conscious sedation techniques in AC include both monitored anesthesia care (MAC) and asleep-awake-asleep (AAA). The choice of optimal anesthetic method depends on the preferences of the surgical team (mainly anesthesiologist and neurosurgeon). The aim of this study was to compare the difference in physiological and blood gas data, dosage of different drugs, the probability of switching to endotracheal intubation, and extent of tumor resection and dysfunction after operation between AAA and MAC anesthetic management for resection of gliomas in eloquent brain areas. METHODS Two-hundred and twenty-five patients with super-tentorial tumor located in eloquent areas underwent AC from 2009 to 2021 in Xijing Hospital. Forty-one patients underwent AAA technique, and the rest one-hundred eighty-four patients underwent MAC technique. Anesthetic management, dosage of different drugs, intraoperative complications, postoperative outcomes, adverse events, extent of resection and motor, and sensory and language dysfunction after operation were compared between MAC and AAA. RESULT There was no significant difference in gender, KPS score, MMSE score, glioma grade, type, and growth site between the patients in the two groups, except the older age of patients in MAC group than that in AAA group. During the whole process of operation, there were greater pulse pressure difference (P = 0.046), shorter operation time (P = 0.039), less dosage of remifentanil (P = 0.000), more dosage of dexmedetomidine (P = 0.013), more use of antiemetics (81%, P = 0.0067), lower use of vasoactive agent (45.1%, P = 0.010), and lower probability of conversion to general anesthesia (GA, P = 0.027) in MAC group than that in AAA group. Blood gas analysis showed that PetCO2 (P = 0.000), Glu concentration (P = 0.000), and PaCO2 (P = 0.000) were higher, but SPO2 (P = 0.002) and PaO2 (P = 0.000) were lower in MAC group than that in AAA group. In the postoperative recovery stage, compared with that of AAA group, the probability of dysfunction in MAC group at 1, 3, 5, and 7 days after operation was lower, which were 27.8% vs 53.6% (P = 0.003), 31% vs 68.3% (P = 0.000), 28.8% vs 63.4% (P = 0.000), and 25.6% vs 58.5% (P = 0.000), respectively. CONCLUSION Compared with AAA, it seems that MAC has more advantages in the management for resection of gliomas in eloquent brain areas, and MAC combined with multiple monitoring such as cerebral cortical mapping, neuronavigation, and ultrasonic detection is worthy of popularization for the resection of gliomas in eloquent brain areas.
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17
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Khu KJO, Pascual JSG, Ignacio KHD. Patient-reported intraoperative experiences during awake craniotomy for brain tumors: a scoping review. Neurosurg Rev 2022; 45:3093-3107. [PMID: 35816270 DOI: 10.1007/s10143-022-01833-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/13/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
Awake craniotomy (AC) is a neurosurgical procedure that may be used to excise tumors located in eloquent areas of the brain. The techniques and outcomes of AC have been extensively described, but data on patient-reported experiences are not as well known. To determine these, we performed a scoping review of patient-reported intraoperative experiences during awake craniotomy for brain tumor resection. A total of 21 articles describing 534 patients were included in the review. Majority of the studies were performed on adult patients and utilized questionnaires and interviews. Some used additional qualitative methodology such as grounded theory and phenomenology. Most of the evaluation was performed within the first 2 weeks post-operatively. Recollection of the procedure ranged from 0 to 100%, and most memories dealt with the cranial fixation device application, cranial drilling, and intraoperative mapping. All patients reported some degree of pain and discomfort, mainly due to the cranial fixation device and uncomfortable operative position. Most patients were satisfied with their AC experience. They felt that participating in AC gave them a sense of control over their disease and thought that trust in the treatment team and adequate pre-operative preparation were very important. Patients who underwent AC for brain tumor resection had both positive and negative experiences intraoperatively, but overall, majority had a positive perception of and high levels of satisfaction with AC. Successful AC depends not only on a well-conducted intraoperative course, but also on adequate pre-operative information and patient preparation.
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Affiliation(s)
- Kathleen Joy O Khu
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Taft Avenue, 1000, Ermita, Manila, Philippines.
| | - Juan Silvestre G Pascual
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Taft Avenue, 1000, Ermita, Manila, Philippines
| | - Katrina Hannah D Ignacio
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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18
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Murcia D, D'Souza S, Abozeid M, Thompson JA, Djoyum TD, Ormond DR. Investigation of Asleep versus Awake Motor Mapping in Resective Brain Surgery. World Neurosurg 2021; 157:e129-e136. [PMID: 34619401 DOI: 10.1016/j.wneu.2021.09.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To develop an asleep motor mapping paradigm for accurate detection of the corticospinal tract during glioma surgery and compare outcomes with awake patients undergoing glioma resection. METHODS A consecutive cohort of adult patients undergoing craniotomy for suspected diffuse glioma with tumor in a perirolandic location who had awake or asleep cortical and subcortical motor mapping with positive areas of motor stimulation were assessed for postoperative extent of resection (EOR), permanent neurological deficit, and proximity of stimulation to diffusion tensor imaging-based corticospinal tract depiction on preoperative magnetic resonance imaging. Outcome data were compared between asleep and awake groups. RESULTS In the asleep group, all 16 patients had improved or no change in motor function at last follow-up (minimum 3 months of follow-up). In the awake group, all 23 patients had improved function or no change at last follow-up. EOR was greater in the asleep group (mean [SD] EOR 88.71% [17.56%]) versus the awake group (mean [SD] EOR 80.62% [24.44%]), although this difference was not statistically significant (P = 0.3802). Linear regression comparing distance from stimulation to corticospinal tract in asleep (n = 14) and awake (n = 4) patients was r = -0.3759, R2 = 0.1413, P = 0.1853, and 95% confidence interval = -0.4453 to 0.09611 and r = 0.7326, R2 = 0.5367, P = 0.2674, and 95% confidence interval = -7.042 to 14.75, respectively. CONCLUSION In this small patient series, asleep motor mapping using commonly available motor evoked potential hardware appears to be safe and efficacious in regard to EOR and functional outcomes.
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Affiliation(s)
- Derrick Murcia
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Shawn D'Souza
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mohab Abozeid
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - John A Thompson
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Teguo Daniel Djoyum
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - D Ryan Ormond
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
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19
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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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20
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Kamata K, Maruyama T, Komatsu R, Ozaki M. Intraoperative panic attack in patients undergoing awake craniotomy: a retrospective analysis of risk factors. J Anesth 2021; 35:854-861. [PMID: 34402974 DOI: 10.1007/s00540-021-02990-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/14/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Intraoperative anxiety is the most common psychological response of the patient during awake craniotomy. Psychological stress can trigger patient decline, resulting in failed awake craniotomy and significantly poor outcomes. This study aimed to identify the risk factors for panic attack (PA) during awake craniotomies. METHODS With the local ethics committee approval, we conducted a manual chart review of the medical record of patients who underwent consecutive awake craniotomies between November 1999 and October 2016 at Tokyo Women's Medical University. A total of 405 patients were identified and assigned to 2 groups based on the Diagnostic and Statistical Manual of Mental Disorders-V criteria: those that met the PA criteria (Group PA) and those that did not (Group non-PA). Patient characteristics and the incidence of the PA specifier were collected. The features of the two groups were statistically compared, and risk factors for PA occurrence were determined by regression analysis. RESULTS Sixteen of 405 patients met the diagnostic criteria of PA. Patients' characteristics were not statistically different between the groups. Multivariate logistic regression showed that intraoperative anxiety (p = 0.0002) and age younger than 39 years (as opposed to age > = 39 years; p = 0.0328) were significantly associated with the occurrence of PA during awake craniotomy. CONCLUSIONS For patients undergoing awake craniotomy, intraoperative anxiety and age younger than 39 years were considered risk factors of PA. As PA often necessitates conversion to general anesthesia, intensive perioperative psychological support and pain management are required to achieve patient satisfaction and the surgical goal of awake craniotomy.
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Affiliation(s)
- Kotoe Kamata
- Department of Anesthesiology and Perioperative Medicine, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai-shi, Miyagi, 980-8575, Japan. .,Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan.
| | - Takashi Maruyama
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Ryu Komatsu
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Makoto Ozaki
- Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Primary Care Medicine, Nishiarai Hospital, Tokyo, Japan
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21
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Domingo RA, Vivas-Buitrago T, De Biase G, Middlebrooks EH, Bechtle PS, Sabsevitz DS, Quiñones-Hinojosa A, Tatum WO. Intraoperative Seizure Detection During Active Resection of Glioblastoma Through a Novel Hollow Circular Electrocorticography Array. Oper Neurosurg (Hagerstown) 2021; 21:E147-E152. [PMID: 33885817 DOI: 10.1093/ons/opab110] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Data supporting the use of electrocorticography (ECoG) monitoring during electrical stimulation in awake craniotomies for resection of supratentorial neoplasms is robust, but its applicability during active resection is often limited by the inability to keep the array in place. Given the known survival benefit of gross total resection in glioma surgery, novel approaches to surgical monitoring are warranted to maximize safe resection and optimize surgical outcomes in patients with glioblastoma. CLINICAL PRESENTATION A 68-yr-old right-handed woman presented to the emergency department with confusion. Imaging studies revealed a bifrontal intra-axial brain lesion. She underwent a left-sided awake craniotomy procedure with cortical and subcortical mapping. During surgical resection, multiple electrographic seizures were detected on continuous ECoG monitoring with a customized 22-channel high-density hollow circular array. She remained without clinical evidence of seizures at 3 mo after surgery. CONCLUSION We report a unique case of serial electrographic seizures detected during continuous intraoperative ECoG monitoring during active surgical resection of a glioblastoma using a novel circular hollow array during an awake craniotomy. The use of continuous ECoG monitoring during active resection may provide additional data, with potential influence in outcomes for patients undergoing resection of high-grade glial neoplasms.
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Affiliation(s)
- Ricardo A Domingo
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Gaetano De Biase
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Erik H Middlebrooks
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.,Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Perry S Bechtle
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - David S Sabsevitz
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.,Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - William O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
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Chen YJ, Nie C, Lu H, Zhang L, Chen HL, Wang SY, Li W, Shen S, Wang H. Monitored Anesthetic Care Combined with Scalp Nerve Block in Awake Craniotomy: An Effective Attempt at Enhanced Recovery After Neurosurgery. World Neurosurg 2021; 154:e509-e519. [PMID: 34303853 DOI: 10.1016/j.wneu.2021.07.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Enhanced recovery after surgery has been attempted in neurosurgery at a greater rate. However, concern exists regarding the feasibility of using enhanced recovery after neurosurgery (ERANS). How to manage available resources to safely perform ERANS and improve clinical outcomes has been the subject of much debate and discussion. METHODS Owing to the paucity of data available on the use of ERANS protocols, we performed the present feasibility study. We studied the outcomes of the protocols used within a tertiary referral neurosurgery center. Data from patients who had undergone awake craniotomy within an ERANS protocol were prospectively recorded in our institution from September 2017 to December 2018. We also evaluated the safety and effectiveness of the novel ERANS protocol. RESULTS A total of 20 patients (mean age, 49.5 ± 17.8 years) were included in the present study. Intraoperative hypertension, hypotension, and bradycardia were present in 4 (20%), 1 (5%), and 1 (5%) patient, respectively. The postoperative morbidities included epilepsy in 1 (5%), pain in 3 (15%), and nausea or vomiting in 2 (10%). No significant changes had occurred in the mean arterial pressure, heart rate, blood glucose, or lactic acid level throughout the procedure. The median length of intensive care unit stay and postoperative hospital stay were 1 and 9.5 days, respectively. No 30-day readmissions or reoperations occurred during the present study. CONCLUSIONS Applying an ERANS protocol was feasible, associated with a low incidence of complications, and acceptable intensive care unit and postoperative hospital lengths of stay. The findings from the present study might provide a new approach for the further research of ERANS.
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Affiliation(s)
- Yan-Jun Chen
- Department of Anesthesiology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Cai Nie
- Department of Anesthesiology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Hao Lu
- Department of Anesthesiology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Liu Zhang
- Department of Neurosurgery, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Hong-Lin Chen
- Medical Imaging Center, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Shi-Yong Wang
- Department of Neurosurgery, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Wei Li
- Department of Neurosurgery, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Si Shen
- Medical Imaging Center, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Hao Wang
- Department of Anesthesiology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China.
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23
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Ibrahim O, Hafez MA, Haleem HA, El Maghraby H. Recent Advances in the Treatment of Gliomas: The Multimodal Care Therapy. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Glioblastoma (GBM) is the most devastating primary malignancy of the central nervous system in adults. At present, standard treatment consists of maximal safe surgical resection followed by radiotherapy (60 Gray) with concomitant daily temozolomide chemotherapy. Low-grade gliomas constitute approximately 15% of the nearly primary brain tumors diagnosed in adults each year. Extent of tumor resection has become a strong predictor of patient outcomes, alongside patient age, performance status, tumor histology, and molecular genetics (isocitrate dehydrogenase-1 and 1p/19q codeletion status). Over the past two decades, surgeons have emphasized the importance of maximizing extent of resection and its impact on overall survival, progression-free survival, and time to malignant transformation.
AIM: We aimed to present recent advances in the treatment of gliomas.
METHODS: This is a prospective analysis of 50 patients diagnosed with gliomas which are enrolled in a joint supervision between Kasr Al Aini Hospital, Cairo University, Egypt, and Coventry University Hospitals, England.
RESULTS: The study included 50 patients, 31 males and 19 females, ages ranged from 21 to 75 years (mean age 47.5 years). Gross total resection was achieved in 28 patients (56%). The most common surgical complication in our series was post-operative transient weakness in 4 patients (8%). Mean true survival of low-grade glioma patients was 40.5 months while the mean true survival for anaplastic astrocytoma (Grade 3) patients was 38 months and that of GBM (Grade 4) patients was 18.8 months.
CONCLUSION: Despite persistent limitations in the quality of data, mounting evidence suggests that more extensive surgical resection is associated with longer life expectancy for both low- and high-grade gliomas.
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24
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Kwinta BM, Myszka AM, Bigaj MM, Krzyżewski RM, Starowicz-Filip A. Intra- and postoperative adverse events in awake craniotomy for intrinsic supratentorial brain tumors. Neurol Sci 2021; 42:1437-1441. [PMID: 32808173 PMCID: PMC7955997 DOI: 10.1007/s10072-020-04683-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/12/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine the frequency and consequences of intra- and postoperative adverse events in awake craniotomy for intrinsic supratentorial brain tumors. Despite the growing prevalence of awake craniotomy intra- and postoperative, adverse events related to this surgery are poorly discussed. METHODS We studied 25 patients undergoing awake craniotomy with maximum safe resection of intrinsic supratentorial brain tumors in the awake-asleep-awake protocol. RESULTS Surgery-related inconveniences occurred in 23 patients (92%), while postoperative adverse events were observed in 17 cases (68%). Seven patients suffered from more than one postoperative complication. The most common surgery-related inconvenience was intraoperative hypertension (8 cases, 32%), followed by discomfort (7 cases, 28%), pain during surgery (5 cases, 20%), and tachycardia (3 cases, 12%). The most common postoperative adverse event was a new language deficit that occurred in 10 cases (40%) and remained permanent in one case (4%). Motor deficits occurred in 36% of cases and were permanent in one case (1%). Seizures were observed in 4 cases (16%) intra- and in 2 cases (8%) postoperatively. Seizures appeared more frequently in patients with multilobar insular-involving gliomas and in patients without prophylactic antiepileptic drug therapy. CONCLUSIONS Surgery-related inconveniences and postoperative adverse events occur in most awake craniotomies. The most common intraoperative adverse event is hypertension, pain, and tachycardia. The most frequent postoperative adverse events are new language deficits and new motor deficits.
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Affiliation(s)
- Borys M Kwinta
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland.
| | | | - Monika M Bigaj
- Department of Anesthesiology, 5th Military Hospital in Krakow, Krakow, Poland
| | - Roger M Krzyżewski
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Anna Starowicz-Filip
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
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25
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Xu Y, Vagnerova K. Anesthetic Management of Asleep and Awake Craniotomy for Supratentorial Tumor Resection. Anesthesiol Clin 2021; 39:71-92. [PMID: 33563387 DOI: 10.1016/j.anclin.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Understanding how anesthetics impact cerebral physiology, cerebral blood flow, brain metabolism, brain relaxation, and neurologic recovery is crucial for optimizing anesthesia during supratentorial craniotomies. Intraoperative goals for supratentorial tumor resection include maintaining cerebral perfusion pressure and cerebral autoregulation, optimizing surgical access and neuromonitoring, and facilitating rapid, cooperative emergence. Evidence-based studies increasingly expand the impact of anesthetic care beyond immediate perioperative care into both preoperative optimization and minimizing postoperative consequences. New evidence is needed for neuroanesthesia's role in neurooncology, in preventing conversion from acute to chronic pain, and in decreasing risk of intraoperative ischemia and postoperative delirium.
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Affiliation(s)
- Yifan Xu
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code UH2, Portland, OR 97239, USA.
| | - Kamila Vagnerova
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code UH2, Portland, OR 97239, USA
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26
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Experience with awake throughout craniotomy in tumour surgery: technique and outcomes of a prospective, consecutive case series with patient perception data. Acta Neurochir (Wien) 2020; 162:3055-3065. [PMID: 33006649 DOI: 10.1007/s00701-020-04561-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Awake craniotomy is the standard of care in surgery of tumours located in eloquent parts of the brain. However, high variability is recorded in multiple parameters, including anaesthetic techniques, mapping paradigms and technology adjuncts. The current study is focused primarily on patients' level of consciousness, surgical technique, and experience based on a cohort of 50 consecutive cases undergoing awake throughout craniotomy (ATC). METHODS Data was collected prospectively for 46 patients undergoing 50 operations over 14-month period, by the senior author, including demographics, extent of resection (EOR), adverse intraoperative events, surgical morbidity, surgery duration, levels of O2 saturation and brain oedema. A prospective, patient experience questionnaire was delivered to 38 patients. RESULTS The ATC technique was well tolerated in all patients. Once TCI stopped, all patients were immediately assessable for mapping. Despite > 75% of cases being considered inoperable/high risk, gross total resection (GTR) was achieved in 68% patients and subtotal resection in 20%. The average duration of surgery was 220 min with no episodes of hypoxia. Early and late severe deficits recorded in 12% and 2%, respectively. No stimulation-induced seizures or failed ATCs were recorded. Patient-recorded data showed absent/minimal pain during (1) clamp placement in 95.6% of patients; (2) drilling in 94.7% of patients; (3) surgery in 78.9% of patients. Post-operatively, 92.3% of patients reported willingness to repeat the ATC, if necessary. CONCLUSIONS The current ATC paradigm allows immediate brain mapping, maximising patient comfort during self-positioning. Despite the cohort of challenging tumour location, satisfactory EOR was achieved with acceptable morbidity and no adverse intraoperative events.
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27
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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: 14] [Impact Index Per Article: 3.5] [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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28
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Wang AT, Pillai P, Guran E, Carter H, Minasian T, Lenart J, Vandse R. Anesthetic Management of Awake Craniotomy for Resection of the Language and Motor Cortex Vascular Malformations. World Neurosurg 2020; 143:e136-e148. [PMID: 32736129 DOI: 10.1016/j.wneu.2020.07.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/09/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although the safety and feasibility of awake craniotomy are well established for epilepsy and brain tumor surgery, its application for resection of vascular lesions, including arteriovenous malformations (AVMs) and cavernomas, is still limited. Apart from the usual challenges of awake craniotomy, vascular lesions pose several additional problems. Our goal is to determine the safety and practicality of awake craniotomy in patients with cerebral vascular malformations located near the eloquent areas, using a refined anesthetic protocol. METHODS A retrospective case series was performed on 7 patients who underwent awake craniotomy for resection of AVMs or cavernomas located in the eloquent language and motor areas. Our protocol consisted of achieving deep sedation, without a definitive airway, using a combination of propofol, dexmedetomidine, and remifentanil/fentanyl during scalp block placement and surgical exposure, then transitioning to a wakeful state during the resection. RESULTS Six patients had intracranial AVMs, and 1 patient had a cavernoma. Six patients had complete resection; however, 1 patient underwent repeat awake craniotomy for residual AVM nidus. The patients tolerated the resection under continuous awake neurologic and neurophysiologic testing without significant perioperative complications or the need to convert to general anesthesia with a definitive airway. CONCLUSIONS Awake craniotomy for excision of intracranial vascular malformations located near the eloquent areas, in carefully selected patients, can facilitate resection by allowing close neuromonitoring and direct functional assessment. A balanced combination of sedative and analgesic medications can provide both adequate sedation and rapid wakeup, facilitating the necessary patient interaction and tolerance of the procedure.
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Affiliation(s)
- Annie Ting Wang
- Departments of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Promod Pillai
- Departments of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Elyse Guran
- Departments of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Harmony Carter
- Departments of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Tanya Minasian
- Departments of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - John Lenart
- Departments of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Rashmi Vandse
- Departments of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA.
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29
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Arzoine J, Levé C, Pérez-Hick A, Goodden J, Almairac F, Aubrun S, Gayat E, Freyschlag CF, Vallée F, Mandonnet E, Madadaki C. Anesthesia management for low-grade glioma awake surgery: a European Low-Grade Glioma Network survey. Acta Neurochir (Wien) 2020; 162:1701-1707. [PMID: 32128618 DOI: 10.1007/s00701-020-04274-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Awake surgery has become a key treatment of diffuse low-grade gliomas (DLGG) and is divided in three main phases: opening, tumor resection - during which the patient needs to be fully awake - and closure. The anesthetic management of awake neurosurgery is a challenge, and there are currently no guidelines. OBJECTIVE The objective of the survey was to explore differences and commonalities regarding the anesthetic management of awake DLGG surgery within the European Low-Grade Glioma Network (ELGGN) centers. METHODS A form that contained 14 questions about the anesthetic management was sent to 28 centers in May 2015. RESULTS Twenty centers responded. During the opening and closing non-awake periods, 56% of teams chose general anesthesia with mechanical ventilation for at least one period (asleep-awake-asleep, SAS protocol), and 44% monitored anesthesia care including sedation without mechanical ventilation (MAC protocol). In case of SAS, all the teams chose intravenous anesthesia, 82% used laryngeal mask instead of endotracheal intubation during the opening sequence, and 71% during closure. Local and regional anesthesia was practiced by all the teams. The most frequently reported cause of pain was dural and cerebral vessels manipulation (77%). Pain management was mostly based on paracetamol (70%) and remifentanil (55%). CONCLUSION Our survey showed that there was an equivalent proportion of centers using SAS or MAC protocols in the anesthetic management of awake surgery in ELGGN centers. The advantages and disadvantages of each anesthesia protocol were reviewed.
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Affiliation(s)
- Jeremy Arzoine
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
| | - Charlotte Levé
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
- INSERM UMR-942, Paris, France
| | | | - John Goodden
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Fabien Almairac
- Department of Neurosurgery, Hôpital Pasteur II, University Hospital of Nice, Nice, France
| | - Sylvie Aubrun
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
| | - Etienne Gayat
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
- University Paris 7, Paris, France
| | | | - Fabrice Vallée
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
- INSERM UMR-942, Paris, France
| | - Emmanuel Mandonnet
- University Paris 7, Paris, France.
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France.
- Frontlab, Institut du Cerveau et de la Moelle épinière, Inserm U 1127, CNRS UMR 7225, Paris, France.
| | - Catherine Madadaki
- Department of Anesthesiology and Critical Care, St-Louis-Lariboisière-Fernand Widal University Hospitals, APHP, Paris, France
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30
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ReFaey K, Tripathi S, Bhargav AG, Grewal SS, Middlebrooks EH, Sabsevitz DS, Jentoft M, Brunner P, Wu A, Tatum WO, Ritaccio A, Chaichana KL, Quinones-Hinojosa A. Potential differences between monolingual and bilingual patients in approach and outcome after awake brain surgery. J Neurooncol 2020; 148:587-598. [PMID: 32524393 DOI: 10.1007/s11060-020-03554-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/01/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION 20.8% of the United States population and 67% of the European population speak two or more languages. Intraoperative different languages, mapping, and localization are crucial. This investigation aims to address three questions between BL and ML patients: (1) Are there differences in complications (i.e. seizures) and DECS techniques during intra-operative brain mapping? (2) Is EOR different? and (3) Are there differences in the recovery pattern post-surgery? METHODS Data from 56 patients that underwent left-sided awake craniotomy for tumors infiltrating possible dominant hemisphere language areas from September 2016 to June 2019 were identified and analyzed in this study; 14 BL and 42 ML control patients. Patient demographics, education level, and the age of language acquisition were documented and evaluated. fMRI was performed on all participants. RESULTS 0 (0%) BL and 3 (7%) ML experienced intraoperative seizures (P = 0.73). BL patients received a higher direct DECS current in comparison to the ML patients (average = 4.7, 3.8, respectively, P = 0.03). The extent of resection was higher in ML patients in comparison to the BL patients (80.9 vs. 64.8, respectively, P = 0.04). The post-operative KPS scores were higher in BL patients in comparison to ML patients (84.3, 77.4, respectively, P = 0.03). BL showed lower drop in post-operative KPS in comparison to ML patients (- 4.3, - 8.7, respectively, P = 0.03). CONCLUSION We show that BL patients have a lower incidence of intra-operative seizures, lower EOR, higher post-operative KPS and tolerate higher DECS current, in comparison to ML patients.
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Affiliation(s)
- Karim ReFaey
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Shashwat Tripathi
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.,Department of Mathematics, University of Texas at Austin, Austin, TX, USA
| | - Adip G Bhargav
- Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA
| | - Sanjeet S Grewal
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Erik H Middlebrooks
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.,Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - David S Sabsevitz
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.,Department of Psychology, Mayo Clinic, Jacksonville, FL, USA
| | - Mark Jentoft
- Department of Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - Peter Brunner
- Albany Medical College, Albany, NY, USA.,National Center for Adaptive Neurotechnologies, Albany, NY, USA
| | - Adela Wu
- Department of Neurologic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | | | | | - Alfredo Quinones-Hinojosa
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA. .,Brain Tumor Stem Cell Laboratory, Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Rd. S, FloridaJacksonville, FL, 32224, USA.
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31
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Cathey K, Gunyon N, Chung N, Conway N, Ames D, Singh M, Kassam AB, Rovin RA. A Feasibility Study of Lavender Aromatherapy in an Awake Craniotomy Environment. J Patient Cent Res Rev 2020; 7:19-30. [PMID: 32002444 PMCID: PMC6988712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
PURPOSE Integrative medicine interventions are needed for awake craniotomies, as many patients experience anxiety. Lavender aromatherapy significantly reduces anxiety or pain in a variety of surgical procedures. This feasibility study used lavender aromatherapy during awake craniotomies to determine the number of patients who would consent and complete the study, the technicality of lavender aromatherapy use, and acceptance by operating room (OR) staff. METHODS We approached 40 consecutive patients (≥18 years old). Exclusion criteria were pulmonary issues or sensitivity to lavender. Outcome measures in consented patients were enrollment and completion rates, anxiety and pain as measured by the Visual Analog Scale for Anxiety (VAS-A) and Visual Analog Scale for Pain (VAS-P), and satisfaction with pain control using the Patient Opinion of Pain Management (POPM) survey. RESULTS Of the 40 patients approached, 4 declined participation or had their surgery cancelled. Of the remaining 36, 4 required increased sedation during surgery and 1 was unable to detect lavender. Thus, 31 patients (77.5%) completed the study. VAS-A and VAS-P scores trended lower after lavender inhalation, but the difference did not reach statistical significance. There was a slight increase in VAS-P score at the OR1 time point. Expectancy for reduction in both anxiety and pain were not significantly different. Improvement in anxiety also was not different, while improvement in pain trended lower (P=0.025). POPM results indicated the majority of patients were either "satisfied" or "very satisfied" with pain management. CONCLUSIONS This study demonstrated 77.5% completion and the ability to integrate lavender aromatherapy into the OR. Thus, we plan to conduct a randomized clinical trial to assess efficacy of lavender aromatherapy.
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Affiliation(s)
| | - Nichole Gunyon
- Aurora Neuroscience Innovation Institute, Aurora Health Care, Milwaukee, WI
| | - Nancy Chung
- Aurora Neuroscience Innovation Institute, Aurora Health Care, Milwaukee, WI
| | - Nancy Conway
- Integrative Medicine, Aurora Health Care, Milwaukee, WI
| | - Diane Ames
- Integrative Medicine, Aurora Health Care, Milwaukee, WI
| | - Maharaj Singh
- Aurora Research Institute, Aurora Health Care, Milwaukee, WI
| | - Amin B. Kassam
- Aurora Neuroscience Innovation Institute, Aurora Health Care, Milwaukee, WI
| | - Richard A. Rovin
- Aurora Neuroscience Innovation Institute, Aurora Health Care, Milwaukee, WI
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Comparison of the Asleep-Awake-Asleep Technique and Monitored Anesthesia Care During Awake Craniotomy. J Neurosurg Anesthesiol 2020; 34:e1-e13. [DOI: 10.1097/ana.0000000000000675] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 12/07/2019] [Indexed: 11/26/2022]
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Grabert J, Klaschik S, Güresir Á, Jakobs P, Soehle M, Vatter H, Hilbert T, Güresir E, Velten M. Supraglottic devices for airway management in awake craniotomy. Medicine (Baltimore) 2019; 98:e17473. [PMID: 31577780 PMCID: PMC6783250 DOI: 10.1097/md.0000000000017473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Awake craniotomy is a unique technique utilized for mapping neuro and motor function during neurosurgical procedures close to eloquent brain tissue. Since active communication is required only during surgical manipulation of eloquent brain tissue and the patient is "sedated" during other parts of the procedure, different methods for anesthesia management have been explored. Furthermore, airway management ranges from spontaneous breathing to oro or nasotracheal intubation. Case reports have described the use of laryngeal masks (LMs) previously; however, its safety compared to tracheal intubation has not been assessed.We conducted a retrospective analysis of 30 patients that underwent awake craniotomy for tumor surgery to compare the feasibility and safety of different airway management strategies. Nasal fiberoptic intubation (FOI) was performed in 21 patients while 9 patients received LM for airway management. Ventilation, critical events, and perioperative complications were evaluated.Cannot intubate situation occurred in 4 cases reinserting the tube after awake phase, while no difficulties were described reinserting the LM (P < .0001). Furthermore, duration of mechanical ventilation after tumor removal was significantly lower in the LM group compared to FOI group (62 ± 24 vs. 339 ± 82 [min] mean ± sem, P < .0001). Postoperatively, 2 patients in each group were diagnosed with and treated for respiratory complications including pneumonia, without statistical significance between groups.In summary, LM is a feasible airway management method for patients undergoing awake craniotomy, resulting in reduced ventilation duration compared to FOI procedure.
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Affiliation(s)
| | - Sven Klaschik
- Department of Anesthesiology and Intensive Care Medicine
| | - Ági Güresir
- Department of Neurosurgery, University Medical Center, Rheinische Friedrich-Wilhelms University, Bonn, Germany
| | - Patrick Jakobs
- Department of Anesthesiology and Intensive Care Medicine
| | - Martin Soehle
- Department of Anesthesiology and Intensive Care Medicine
| | - Hartmut Vatter
- Department of Neurosurgery, University Medical Center, Rheinische Friedrich-Wilhelms University, Bonn, Germany
| | - Tobias Hilbert
- Department of Anesthesiology and Intensive Care Medicine
| | - Erdem Güresir
- Department of Neurosurgery, University Medical Center, Rheinische Friedrich-Wilhelms University, Bonn, Germany
| | - Markus Velten
- Department of Anesthesiology and Intensive Care Medicine
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Tachibana S, Omote M, Yamakage M. Successful awake craniotomy in an aged patient with a severe hearing impairment using a bone conduction voice amplifier: a case report. JA Clin Rep 2019; 5:37. [PMID: 32026961 PMCID: PMC6966765 DOI: 10.1186/s40981-019-0258-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 05/31/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The main purposes of awake craniotomy are to minimize postoperative brain dysfunction caused by the surgical procedure and to maximize the tumor resection range. In awake craniotomy, it is important to have a good quality of awakening and to obtain patient's obedience in the awake phase. CASE PRESENTATION The patient was a 75-year-old woman with an advanced hearing impairment who was scheduled for awake craniotomy. We used a bone conduction voice amplifier before and during the awake phase and communicated with the patient smoothly. CONCLUSIONS We were able to complete awake craniotomy fully, and overcoming the deafness problem might have contributed to the patient's good outcome. This case report indicates that awake craniotomy can be performed in a patient with an advanced hearing impairment under the condition of careful anesthetic management.
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Affiliation(s)
- Shunsuke Tachibana
- Department of Anesthesiology, School of Medicine, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Masahito Omote
- Department of Anesthesiology, School of Medicine, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, School of Medicine, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
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Abstract
PURPOSE OF REVIEW The current review reports on current trends in the anesthetic management of awake craniotomy, including preoperative preparation, sedation schemes, pain management, and prevention of intraoperative complications. RECENT FINDINGS Both approaches for anesthesia for awake craniotomy, asleep-awake-asleep and monitored anesthesia care (MAC), have shown equal efficacy for performing intraoperative brain mapping. Choice of the appropriate scheme is currently based mainly on the preferences of the particular anesthesiologist. Dexmedetomidine has demonstrated high efficacy and safety in MAC for awake craniotomy and has become a rational alternative to propofol. Despite the high efficacy of scalp block and opioids, pain remains a common compliant in awake craniotomy. Appropriate surgical tactics can reduce pain and even prevent postoperative neurological complications. Although the efficacy of prophylaxis of intraoperative seizures with anticonvulsants remains doubtful, levetiracetam can be superior to other drugs for this purpose. SUMMARY Following a great deal of progress in anesthetic management, awake craniotomy, which had been a relatively rare approach, is now a commonly performed procedure for neurosurgical intervention. Modern anesthesia techniques can provide for successful brain mapping in almost any patient. Management of awake craniotomy in high-risk patients is a central task for future research.
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Piazza O, De Benedictis G. Xenon as a quick reversal anesthetic agent for asleep awake asleep approach. Minerva Anestesiol 2018; 85:112-114. [PMID: 30394072 DOI: 10.23736/s0375-9393.18.13233-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Ornella Piazza
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy -
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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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Özlü O. Anaesthesiologist's Approach to Awake Craniotomy. Turk J Anaesthesiol Reanim 2018; 46:250-256. [PMID: 30140530 DOI: 10.5152/tjar.2018.56255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/13/2018] [Indexed: 12/29/2022] Open
Abstract
Awake craniotomy, which was initially used for the surgical treatment of epilepsy, is performed for the resection of tumours in the vicinity of some eloquent areas of the cerebral cortex which is essential for language and motor functions. It is also performed for stereotactic brain biopsy, ventriculostomy, and supratentorial tumour resections. In some institutions, avoiding risks of general anaesthesia, shortened hospitalization and reduced use of hospital resources may be the other indications for awake craniotomy. Anaesthesiologists aim to provide safe and effective surgical status, maintaining a comfortable and pain-free condition for the patient during surgical procedure and prolonged stationary position and maintaining patient cooperation during intradural interventions. Providing anaesthesia for awake craniotomy require scalp blockage, specific sedation protocols and airway management. Long-acting local anaesthetic agents like bupivacaine or levobupivacaine are preferred. More commonly, propofol, dexmedetomidine and remifentanyl are used as sedative agents. A successful anaesthesia for awake craniotomy depends on the personal experience and detailed planning of the anaesthetic procedure. The aim of this review was to present an anaesthetic technique for awake craniotomy under the light of the literature.
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Affiliation(s)
- Onur Özlü
- Department of Anaesthesiology and Reanimation, TOBB University of Economics and Technology, Ankara, Turkey
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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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Pellerino A, Franchino F, Soffietti R, Rudà R. Overview on current treatment standards in high-grade gliomas. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2018; 62:225-238. [PMID: 29696949 DOI: 10.23736/s1824-4785.18.03096-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
High-grade gliomas (HGGs) are the most common primary tumors of the central nervous system, which include anaplastic gliomas (grade III) and glioblastomas (GBM, grade IV). Surgery is the mainstay of treatment in HGGs in order to achieve a histological and molecular characterization, as well as relieve neurological symptoms and improve seizure control. Combinations of some molecular factors, such as IDH 1-2 mutations, 1p/19q codeletion and MGMT methylation status, allow to classify different subtypes of gliomas and identify patients with different outcome. The SOC in HGGs consists in a combination of radiotherapy and chemotherapy with alkylating agents. Despite this therapeutic approach, tumor recurrence occurs in HGGs, and new surgical debulking, reirradiation or second-line chemotherapy are needed. Considering the poor results in terms of survival, several clinical trials have explored the efficacy and tolerability of antiangiogenic agents, targeted therapies against epidermal growth factor receptor (EGFR) and different immunotherapeutic approaches in recurrent and newly-diagnosed GBM, including immune checkpoint inhibitors (ICIs), and cell- or peptide-based vaccination with unsatisfactory results in term of disease control. In this review we describe the major updates in molecular biology of HGGs according to 2016 WHO Classification, the current management in newly-diagnosed and recurrent GBM and grade III gliomas, and the results of the most relevant clinical trials on targeted agents and immunotherapy.
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Affiliation(s)
- Alessia Pellerino
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy -
| | - Federica Franchino
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
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Feyissa AM, Worrell GA, Tatum WO, Mahato D, Brinkmann BH, Rosenfeld SS, ReFaey K, Bechtle PS, Quinones-Hinojosa A. High-frequency oscillations in awake patients undergoing brain tumor-related epilepsy surgery. Neurology 2018; 90:e1119-e1125. [PMID: 29490917 DOI: 10.1212/wnl.0000000000005216] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 12/22/2017] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To examine the relationship between high-frequency oscillations (HFOs) and the presence of preoperative seizures, World Health Organization tumor grade, and isocitrate dehydrogenase 1 (IDH1) mutational status in gliomas. METHODS We retrospectively studied intraoperative electrocorticography recorded in 16 patients with brain tumor (12 presenting with seizures) who underwent awake craniotomy and surgical resection between September 2016 and June 2017. The number and distribution of HFOs were determined and quantified visually and with an automated HFO detector. RESULTS Five patients had low-grade (1 with grade I and 4 with grade II) and 11 had high-grade (6 with grade III and 5 with grade IV) brain tumors. An IDH1 mutation was found in 6 patients. Patients with a history of preoperative seizures were more likely to have HFOs than those without preoperative seizures (9 of 12 vs 0 of 4, p = 0.02). The rate of HFOs was higher in patients with IDH1 mutant (mean 7.2 per minute) than IDH wild-type (mean 2.3 per minute) genotype (p = 0.03). CONCLUSIONS HFOs are common in brain tumor-related epilepsy, and HFO rate may be a useful measure of epileptogenicity in gliomas. Our findings further support the notion that IDH1 mutant genotype is more epileptogenic than IDH1 wild-type genotype gliomas.
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Affiliation(s)
- Anteneh M Feyissa
- From the Departments of Neurology (A.M.F., W.O.T.), Neurological Surgery (D.M., K.R., A.Q.-H.), Hematology/Oncology (S.S.R.), and Anesthesiology (P.S.B.), Mayo Clinic, Jacksonville, FL; and Departments of Neurology (G.A.W., B.H.B.) and Physiology and Biomedical Engineering (G.A.W., B.H.B.), Mayo Clinic, Rochester, MN.
| | - Gregory A Worrell
- From the Departments of Neurology (A.M.F., W.O.T.), Neurological Surgery (D.M., K.R., A.Q.-H.), Hematology/Oncology (S.S.R.), and Anesthesiology (P.S.B.), Mayo Clinic, Jacksonville, FL; and Departments of Neurology (G.A.W., B.H.B.) and Physiology and Biomedical Engineering (G.A.W., B.H.B.), Mayo Clinic, Rochester, MN
| | - William O Tatum
- From the Departments of Neurology (A.M.F., W.O.T.), Neurological Surgery (D.M., K.R., A.Q.-H.), Hematology/Oncology (S.S.R.), and Anesthesiology (P.S.B.), Mayo Clinic, Jacksonville, FL; and Departments of Neurology (G.A.W., B.H.B.) and Physiology and Biomedical Engineering (G.A.W., B.H.B.), Mayo Clinic, Rochester, MN
| | - Deependra Mahato
- From the Departments of Neurology (A.M.F., W.O.T.), Neurological Surgery (D.M., K.R., A.Q.-H.), Hematology/Oncology (S.S.R.), and Anesthesiology (P.S.B.), Mayo Clinic, Jacksonville, FL; and Departments of Neurology (G.A.W., B.H.B.) and Physiology and Biomedical Engineering (G.A.W., B.H.B.), Mayo Clinic, Rochester, MN
| | - Benjamin H Brinkmann
- From the Departments of Neurology (A.M.F., W.O.T.), Neurological Surgery (D.M., K.R., A.Q.-H.), Hematology/Oncology (S.S.R.), and Anesthesiology (P.S.B.), Mayo Clinic, Jacksonville, FL; and Departments of Neurology (G.A.W., B.H.B.) and Physiology and Biomedical Engineering (G.A.W., B.H.B.), Mayo Clinic, Rochester, MN
| | - Steven S Rosenfeld
- From the Departments of Neurology (A.M.F., W.O.T.), Neurological Surgery (D.M., K.R., A.Q.-H.), Hematology/Oncology (S.S.R.), and Anesthesiology (P.S.B.), Mayo Clinic, Jacksonville, FL; and Departments of Neurology (G.A.W., B.H.B.) and Physiology and Biomedical Engineering (G.A.W., B.H.B.), Mayo Clinic, Rochester, MN
| | - Karim ReFaey
- From the Departments of Neurology (A.M.F., W.O.T.), Neurological Surgery (D.M., K.R., A.Q.-H.), Hematology/Oncology (S.S.R.), and Anesthesiology (P.S.B.), Mayo Clinic, Jacksonville, FL; and Departments of Neurology (G.A.W., B.H.B.) and Physiology and Biomedical Engineering (G.A.W., B.H.B.), Mayo Clinic, Rochester, MN
| | - Perry S Bechtle
- From the Departments of Neurology (A.M.F., W.O.T.), Neurological Surgery (D.M., K.R., A.Q.-H.), Hematology/Oncology (S.S.R.), and Anesthesiology (P.S.B.), Mayo Clinic, Jacksonville, FL; and Departments of Neurology (G.A.W., B.H.B.) and Physiology and Biomedical Engineering (G.A.W., B.H.B.), Mayo Clinic, Rochester, MN
| | - Alfredo Quinones-Hinojosa
- From the Departments of Neurology (A.M.F., W.O.T.), Neurological Surgery (D.M., K.R., A.Q.-H.), Hematology/Oncology (S.S.R.), and Anesthesiology (P.S.B.), Mayo Clinic, Jacksonville, FL; and Departments of Neurology (G.A.W., B.H.B.) and Physiology and Biomedical Engineering (G.A.W., B.H.B.), Mayo Clinic, Rochester, MN
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Advances in Brain Tumor Surgery for Glioblastoma in Adults. Brain Sci 2017; 7:brainsci7120166. [PMID: 29261148 PMCID: PMC5742769 DOI: 10.3390/brainsci7120166] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 11/24/2017] [Accepted: 12/13/2017] [Indexed: 01/18/2023] Open
Abstract
Glioblastoma (GBM) is the most common primary intracranial neoplasia, and is characterized by its extremely poor prognosis. Despite maximum surgery, chemotherapy, and radiation, the histological heterogeneity of GBM makes total eradication impossible, due to residual cancer cells invading the parenchyma, which is not otherwise seen in radiographic images. Even with gross total resection, the heterogeneity and the dormant nature of brain tumor initiating cells allow for therapeutic evasion, contributing to its recurrence and malignant progression, and severely impacting survival. Visual delimitation of the tumor’s margins with common surgical techniques is a challenge faced by many surgeons. In an attempt to achieve optimal safe resection, advances in approaches allowing intraoperative analysis of cancer and non-cancer tissue have been developed and applied in humans resulting in improved outcomes. In addition, functional paradigms based on stimulation techniques to map the brain’s electrical activity have optimized glioma resection in eloquent areas such as the Broca’s, Wernike’s and perirolandic areas. In this review, we will elaborate on the current standard therapy for newly diagnosed and recurrent glioblastoma with a focus on surgical approaches. We will describe current technologies used for glioma resection, such as awake craniotomy, fluorescence guided surgery, laser interstitial thermal therapy and intraoperative mass spectrometry. Additionally, we will describe a newly developed tool that has shown promising results in preclinical experiments for brain cancer: optical coherence tomography.
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