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Fareed A, Iftikhar Z, Haider R, Shah SI, Ennabe M, Alan A, Weinand M. Awake neurosurgery: Advancements in microvascular decompression for trigeminal neuralgia. Surg Neurol Int 2024; 15:215. [PMID: 38974545 PMCID: PMC11225509 DOI: 10.25259/sni_286_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/24/2024] [Indexed: 07/09/2024] Open
Abstract
Background The treatment landscape for trigeminal neuralgia (TN) involves various surgical interventions, among which microvascular decompression (MVD) stands out as highly effective. While MVD offers significant benefits, its success relies on precise surgical techniques and patient selection. In addition, the emergence of awake surgery techniques presents new opportunities to improve outcomes and minimize complications associated with MVD for TN. Methods A thorough review of the literature was conducted to explore the effectiveness and challenges of MVD for TN, as well as the impact of awake surgery on its outcomes. PubMed and Medline databases were searched from inception to March 2024 using specific keywords "Awake Neurosurgery," "Microvascular Decompression," AND "Trigeminal Neuralgia." Studies reporting original research on human subjects or preclinical investigations were included in the study. Results This review highlighted that MVD emerges as a highly effective treatment for TN, offering long-term pain relief with relatively low rates of recurrence and complications. Awake surgery techniques, including awake craniotomy, have revolutionized the approach to MVD, providing benefits such as reduced postoperative monitoring, shorter hospital stays, and improved neurological outcomes. Furthermore, awake MVD procedures offer opportunities for precise mapping and preservation of critical brain functions, enhancing surgical precision and patient outcomes. Conclusion The integration of awake surgery techniques, particularly awake MVD, represents a significant advancement in the treatment of TN. Future research should focus on refining awake surgery techniques and exploring new approaches to optimize outcomes in MVD for TN.
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Affiliation(s)
- Areeba Fareed
- Global Neurosurgical Alliance, Tucson, Arizona, USA
- Karachi Medical and Dental College, Karachi, Pakistan
| | - Zoha Iftikhar
- Global Neurosurgical Alliance, Tucson, Arizona, USA
- Karachi Medical and Dental College, Karachi, Pakistan
| | - Ramsha Haider
- Global Neurosurgical Alliance, Tucson, Arizona, USA
- Karachi Medical and Dental College, Karachi, Pakistan
| | - Safa Irfan Shah
- Global Neurosurgical Alliance, Tucson, Arizona, USA
- Karachi Medical and Dental College, Karachi, Pakistan
| | - Michelle Ennabe
- Global Neurosurgical Alliance, Tucson, Arizona, USA
- College of Medicine, The University of Arizona College of Medicine-Phoenix, USA
| | - Albert Alan
- Global Neurosurgical Alliance, Tucson, Arizona, USA
- College of Medicine, The University of Arizona College of Medicine-Tucson, USA
- Department of Neurosurgery, University of Arizona, Tucson, Arizona, USA
| | - Martin Weinand
- College of Medicine, The University of Arizona College of Medicine-Tucson, USA
- Department of Neurosurgery, University of Arizona, Tucson, Arizona, USA
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Sattari SA, Rincon-Torroella J, Sattari AR, Feghali J, Yang W, Kim JE, Xu R, Jackson CM, Mukherjee D, Lin SC, Gallia GL, Comair YG, Weingart J, Huang J, Bettegowda C. Awake Versus Asleep Craniotomy for Patients With Eloquent Glioma: A Systematic Review and Meta-Analysis. Neurosurgery 2024; 94:38-52. [PMID: 37489887 DOI: 10.1227/neu.0000000000002612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/22/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Awake vs asleep craniotomy for patients with eloquent glioma is debatable. This systematic review and meta-analysis sought to compare awake vs asleep craniotomy for the resection of gliomas in the eloquent regions. METHODS MEDLINE and PubMed were searched from inception to December 13, 2022. Primary outcomes were the extent of resection (EOR), overall survival (month), progression-free survival (month), and rates of neurological deficit, Karnofsky performance score, and seizure freedom at the 3-month follow-up. Secondary outcomes were duration of operation (minute) and length of hospital stay (LOS) (day). RESULTS Fifteen studies yielded 2032 patients, from which 800 (39.4%) and 1232 (60.6%) underwent awake and asleep craniotomy, respectively. The meta-analysis concluded that the awake group had greater EOR (mean difference [MD] = MD = 8.52 [4.28, 12.76], P < .00001), overall survival (MD = 2.86 months [1.35, 4.37], P = .0002), progression-free survival (MD = 5.69 months [0.75, 10.64], P = .02), 3-month postoperative Karnofsky performance score (MD = 13.59 [11.08, 16.09], P < .00001), and 3-month postoperative seizure freedom (odds ratio = 8.72 [3.39, 22.39], P < .00001). Furthermore, the awake group had lower 3-month postoperative neurological deficit (odds ratio = 0.47 [0.28, 0.78], P = .004) and shorter LOS (MD = -2.99 days [-5.09, -0.88], P = .005). In addition, the duration of operation was similar between the groups (MD = 37.88 minutes [-34.09, 109.86], P = .30). CONCLUSION Awake craniotomy for gliomas in the eloquent regions benefits EOR, survival, postoperative neurofunctional outcomes, and LOS. When feasible, the authors recommend awake craniotomy for surgical resection of gliomas in the eloquent regions.
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Affiliation(s)
- Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jordina Rincon-Torroella
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Ali Reza Sattari
- Department of Surgery, Saint Agnes Hospital, Baltimore , Maryland , USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jennifer E Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Shih-Chun Lin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Youssef G Comair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jon Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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Shakir M, Khowaja AH, Altaf A, Tameezuddin A, Bukhari SS, Enam SA. Risk factors and predictors of intraoperative seizures during awake craniotomy: A systematic review and meta-analysis. Surg Neurol Int 2023; 14:195. [PMID: 37404511 PMCID: PMC10316139 DOI: 10.25259/sni_135_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/04/2023] [Indexed: 07/06/2023] Open
Abstract
Background Awake craniotomy (AC) aims to minimize postoperative neurological complications while allowing maximum safe resection. Intraoperative seizures (IOSs) have been a reported complication during AC; however, literature delving into the predictors of IOS remains limited. Therefore, we planned a systematic review and meta-analysis of existing literature to explore predictors of IOS during AC. Methods From the inception until June 1, 2022, systematic searches of PubMed, Scopus, the Cochrane Library, CINAHL, and Cochrane's Central Register of Controlled Trials were conducted to look for published studies reporting IOS predictors during AC. Results We found 83 different studies in total; included were six studies with a total of 1815 patients, and 8.4% of them experienced IOSs. The mean age of included patients was 45.3 years, and 38% of the sample was female. Glioma was the most common diagnosis among the patients. A pooled random effect odds ratio (OR) of frontal lobe lesions was 2.42 (95% confidence intervals [CI]: 1.10-5.33, P = 0.03). Those with a pre-existing history of seizures had an OR of 1.80 (95% CI: 1.13-2.87, P = 0.01), and patients on antiepileptic drugs (AEDs) had a pooled OR of 2.47 (95% CI: 1.59-3.85, P < 0.001). Conclusion Patients with lesions of the frontal lobe, a prior history of seizures, and patients on AEDs are at higher risk of IOSs. These factors should be taken into consideration during the patient's preparation for an AC to avoid an intractable seizure and consequently a failed AC.
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Affiliation(s)
- Muhammad Shakir
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Aly Hamza Khowaja
- Medical student, Aga Khan University Medical College, Aga Khan University, Karachi, Pakistan
| | - Ahmed Altaf
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Syed Sarmad Bukhari
- Department of Neurosurgery, Northwest School of Medicine, Peshawar, Pakistan
| | - Syed Ather Enam
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
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Dziedzic TA, Bala A, Piwowarska J, Podgórska A, Olejnik A, Koczyk K, Marchel A. Monitored Anesthesia Care Protocol for Awake Craniotomy and Patient's Perspective on the Procedure. World Neurosurg 2023; 170:e151-e158. [PMID: 36309335 DOI: 10.1016/j.wneu.2022.10.080] [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: 07/11/2022] [Revised: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE There is ongoing discussion on pros and cons in terms of different anesthesia protocols for awake craniotomy (AC) with direct brain stimulation. The aim of this study is to share our anesthesia protocol and present our patients' perspectives. METHODS We conducted an analysis of prospectively collected data from 53 (54 procedures) consecutive patients. Most of the patients (50) underwent surgery due to primary brain lesions. Eight procedures were performed in patients with lesions in the nondominant hemisphere for language. Four of all procedures were reoperations, and one patient was operated on in awake conditions twice. The psychological evaluation of patients was performed 2 times: 2 days before and after surgery. A visual analog scale for pain and stress levels as well as structured interviews was used. RESULTS Most patients tolerated ACwell. Patients reported that discomfort was mostly related to urinary catheter insertion, head holder placement, and temporal muscle detachment in cases of frontotemporal craniotomies. The intensity of stress measured with the visual analog scale before surgery was negatively associated with age and positively correlated with stress experienced in the operating room. In all patients, we were able to finish the procedure according to the monitored anesthesia care protocol without the need for conversion to general anesthesia. We observed 3 (5.6%) intraoperative seizures that required deepening of sedation. CONCLUSION AC using the monitored anesthesia care protocol was a safe and well-tolerated procedure with satisfactory patient experience. Extensive preoperative preparation should be considered a key part of the procedure.
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Affiliation(s)
- Tomasz A Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland.
| | - Aleksandra Bala
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland; Faculty of Psychology, University of Warsaw, Warsaw, Poland
| | - Jolanta Piwowarska
- II Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Anna Podgórska
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Agnieszka Olejnik
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland; Faculty of Psychology, University of Warsaw, Warsaw, Poland
| | - Kacper Koczyk
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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Schaldemose M, Lehnus K. Peripheral nerve block of the dorsal cranium in two dogs undergoing craniotomy. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Yu R, Wang S, Xu J, Wang Q, He X, Li J, Shang X, Chen H, Liu Y. Machine Learning Approaches-Driven for Mortality Prediction for Patients Undergoing Craniotomy in ICU. Brain Inj 2022; 35:1658-1664. [PMID: 35080996 DOI: 10.1080/02699052.2021.2008491] [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: 10/19/2022]
Abstract
OBJECTIVES We aimed to predict the mortality of patients with craniotomy in ICU by using predictive models to extract the high-risk factors leading to the death of patients from a retrospective a study. METHODS Five machine-learning (ML) algorithms were applied for training on mortality predictive models with the data from a surgical intensive care unit (ICU) database of the Fujian Provincial Hospital in China. The accuracy, precision, recall, f1 score and the area under the receiver operator characteristic curve (AUC) were used to evaluate the performance of different models, and the calibration of the model was evaluated by brier score. RESULTS We demonstrated that eXtreme Gradient Boosting (XGBoost) was more suitable for the task, demonstrating a AUC of 0.84. We analyzed the feature importance with the Local Interpretable Model-agnostic Explanations (LIME) analysis and further identified the high-risk factors of mortality in ICU through this study. CONCLUSIONS This study established the mortality predictive model of patients who had undergone craniotomy in ICU. Identification of the factors that had great influence on mortality has the potential to provide auxiliary decision support for clinical medical staff on their practices.
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Affiliation(s)
- Ronguo Yu
- Surgical Intensive Care Unit, Fujian Provincial Hospital, Fujian, China
| | - Shaobo Wang
- College of Life Science and Bioengineering, Beijing University of Technology, Beijing, China.,Yidu Cloud (Beijing) Technology Co. Ltd, Beijing, China
| | - Jingqing Xu
- Surgical Intensive Care Unit, Fujian Provincial Hospital, Fujian, China
| | - Qiqi Wang
- Yidu Cloud (Beijing) Technology Co. Ltd, Beijing, China
| | - Xinjun He
- Yidu Cloud (Beijing) Technology Co. Ltd, Beijing, China
| | - Jun Li
- Surgical Intensive Care Unit, Fujian Provincial Hospital, Fujian, China
| | - Xiuling Shang
- Surgical Intensive Care Unit, Fujian Provincial Hospital, Fujian, China
| | - Han Chen
- Surgical Intensive Care Unit, Fujian Provincial Hospital, Fujian, China
| | - Youjun Liu
- College of Life Science and Bioengineering, Beijing University of Technology, Beijing, China
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Lee CZ, Poon CCM. An Update of Neuroanesthesia for Intraoperative Brain Mapping Craniotomy. Neurosurgery 2022; 90:1-6. [PMID: 33647962 DOI: 10.1093/neuros/nyab022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 12/13/2020] [Indexed: 01/06/2023] Open
Abstract
The perioperative multidisciplinary team approach has probably been best exemplified by the care of awake craniotomy patients. Advancement in anesthesia and meticulous perioperative care has supported the safety and complexity of the surgical and mapping efforts in glioma resection. The discussions in this review will emphasize on anesthetic and perioperative management strategies to prevent complications and minimize their effects if they occur, including current practice guidelines in anesthesia, updates on the applications of anesthetic medications, and emerging devices. Planning the anesthetic and perioperative management is based on understanding the pharmacology of the medications, the goals of different stages of the surgery and mapping, and anticipating potential problems.
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Affiliation(s)
- Chanhung Z Lee
- Department of Anesthesia and Perioperative Care, University of California , San Francisco, San Francisco, California, USA
| | - Clara C M Poon
- Department of Anaesthesiology, Queen Mary Hospital, University of Hong Kong , Hong Kong
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8
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Bakhshi SK, Jawed N, Shafiq F, Enam SA. Awake Craniotomy for Resection of Intracranial Meningioma: First Case Series From a Low- and Middle-Income Country. Cureus 2021; 13:e18716. [PMID: 34790471 PMCID: PMC8583986 DOI: 10.7759/cureus.18716] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Awake craniotomy (AC) has emerged as a better modality for resection of intra-axial brain tumors. The advantages are not just related to the preservation of neurological function, but also include early recovery, short hospital stay and possibly lower costs. However, data on AC for meningioma resection is deficient, likely because of concerns related to intra-operative pain and blood loss. Methods All patients who underwent AC, using awake through-out technique for resection of meningioma, during the last five years, were included in the study. Non-probability consecutive sampling technique was employed. Variables for demographics, and details of diagnosis and surgical procedure were recorded. The outcomes measured were length of hospital stay, worsening of neurological function during surgery and significant intra-operative or post-operative pain. Results Seventeen patients underwent AC for resection of meningioma during the study period. Eleven of these were grade I meningioma, and six were grade II meningioma. The mean age was 45.8 ± 10.5 years. Presenting complaints were variable, with seizures being the most common (n = 7; 41.2%). The mean duration of surgery was 180.8 ± 36.2 minutes and median estimated blood loss was 450 ml (IQR: 225 ml - 737.5 ml). The mean length of stay in the hospital was 3.1 ± 1.3 days. Only one patient had a prolonged hospital stay of seven days, because of post-operative seizures. Eleven patients (58.3%) had convexity meningioma, 4 (33.3%) had parasagittal meningioma and 1 each had a parafalcine and anterior skull-base meningioma. Simpson grade I resection was performed in 6 (41.7%) patients, grade II resection in 10 (50%) patients, and grade III resection in 1 (5.9%) patient. None of our patients had deterioration in their neurological deficits after surgery and no one required emergency intubation, conversion of surgery to general anesthesia, or redo exploration. Conclusion AC may be considered a safe modality for surgical resection of convexity and parasagittal meningioma, with no significant risk of intra-operative or post-operative pain, although it requires more evidence. It can be offered to patients who are at higher risk, or are not willing to undergo general anesthesia. Ultimately, it might also be beneficial in terms of reducing overall costs.
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Affiliation(s)
| | - Noyan Jawed
- Surgery, Aga Khan University Hospital, Karachi, PAK
| | - Faraz Shafiq
- Anaesthesiology, Aga Khan University Hospital, Karachi, PAK
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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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Uribe AA, Stoicea N, Echeverria-Villalobos M, Todeschini AB, Esparza Gutierrez A, Folea AR, Bergese SD. Postoperative Nausea and Vomiting After Craniotomy: An Evidence-based Review of General Considerations, Risk Factors, and Management. J Neurosurg Anesthesiol 2021; 33:212-220. [PMID: 31834247 PMCID: PMC8195733 DOI: 10.1097/ana.0000000000000667] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 11/05/2019] [Indexed: 11/25/2022]
Abstract
One of the most common and distressing symptoms after craniotomy is postoperative nausea and vomiting (PONV). PONV could generate delayed postanesthesia care and hospitalization discharge, lower patient satisfaction, and an increase in overall hospitalization costs. The incidence of reported PONV after craniotomy is 22% to 70% without prophylaxis, and a multimodal regimen of medication has been recommended. We conducted a comprehensive literature review of the clinical evidence related to PONV prevention and management after craniotomy. All clinical trials in adult populations relevant to PONV after craniotomy available in English language and indexed in PubMed, Google Scholar and Cochrane Library databases from January 1997 up to September 2018 were retrieved using a combination of free-text words related to PONV in craniotomy. After screening manuscripts identified in the initial search, 23 clinical trials investigating systemic pharmacological intervention versus placebo or active control in patients undergoing craniotomy under general anesthesia met the criteria for inclusion in this comprehensive narrative review. The pathophysiology and mechanisms of PONV after craniotomy could be multifactorial in etiology. Therefore, based on current evidence, PONV management after craniotomy should focus on perioperative patient assessment, surgical, and anesthesia-related risk factors and the selection of systemic pharmacological considerations to reduce its incidence and complications. A multimodal regimen of medication targeting different chemoreceptors in the vomiting center is recommended. Ondansetron and dexamethasone, or their combination, are the most frequently used and effective agents. Further randomized clinical trials comparing different regimens that significantly reduce the incidence of PONV in craniotomy would provide relevant evidence-based data for PONV management in this patient population.
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Affiliation(s)
| | | | | | | | | | | | - Sergio D. Bergese
- Departments of Anesthesiology
- Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
- Department of Anesthesiology, School of Medicine, Stony Brook University, Stony Brook, NY
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11
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Awake brain surgery in children-a single-center experience. Childs Nerv Syst 2020; 36:967-974. [PMID: 32055975 DOI: 10.1007/s00381-020-04522-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 01/25/2020] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Awake brain surgery (ABS) represents a rare surgical procedure in children as age and psychological aspects, which are considered to interfere with its feasibility and psychological outcome and limit its application. Only few pediatric case series have been reported so far, indicating a more complex translation of this surgical approach to children. However, the advances in neuropsychological testing and monitoring may have a substantial impact on ameliorating the eligibility of children undergoing awake procedures. This study addresses the condition of ABS in a pediatric cohort, focusing on its practicability and diversified outcome aspects. METHODS We performed a retrospective review and prospective outcome analysis of pediatric patients with CNS lesions undergoing ABS between 2005 and 2018, completed at the University of Lyon, France. RESULTS Eighteen children were considered for ABS with respect to the eloquent location of their CNS lesions documented in their pre-operative MRI. Seventeen of them underwent asleep-awake-asleep brain surgery. The cohort included 5 males and 12 females. The median age at surgery was 14.8 years, (range 9.4 to 17.6 years). Intraoperative testing included electrocortical stimulation while pursuing speech or motor activity. Most of the lesions were intrinsic tumors of glial origin. A complete tumor removal was achieved in 11 patients (65%). Post-operative neurological deficits were transiently observed in 2 patients, whereas severe psychological reactions occurred in 1 child. Persistent attention deficits were found in 2 patients. One patient experienced an infectious complication requiring antibiotic treatment. Two patients died during follow-up due to tumor progression. The mean duration of follow up was 22.2 months (range 3.4 to 46.8 months). CONCLUSIONS ABS was shown to be beneficial in terms of efficient tumor resection besides simultaneous preservation of neurological functions. Psychological preparation of the families and the children is essential to increase the number and age range of patients, who can benefit from this technique. Neuropsychological testing before and after surgery is essential to determine cognitive outcome, which can be altered in a minority of patients.
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12
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Pendharkar AV, Rezaii PG, Ho AL, Sussman ES, Li G, Desai AM. Functional Mapping for Glioma Surgery: A Propensity-Matched Analysis of Outcomes and Cost. World Neurosurg 2020; 137:e328-e335. [PMID: 32028000 DOI: 10.1016/j.wneu.2020.01.197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/24/2020] [Accepted: 01/25/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare clinical outcomes and payments between glioma resections with and without functional mapping. METHODS The Thomas Reuters MarketScan national longitudinal database was used to identify patients undergoing resection of supratentorial primary malignant glioma with or without functional mapping between 2007 and 2016. Patients were stratified into mapped and unmapped (conventional) groups and subsequently propensity-matched based on demographics, clinical comorbidities, and surgical characteristics (i.e., use of stereotactic navigation, microscope, and intratumoral chemotherapy). Outcomes and charges were compared between matched groups using bivariate analyses. RESULTS A total of 14,037 patients were identified, of whom 796 (6.0%) received functional mapping. Propensity matching (1:1) resulted in 796 mapped patients and 796 propensity-matched controls. Thirty-day postoperative rates of new-onset seizures, cerebral edema, hemorrhage, and neurologic deficits were significantly lower for the functional mapping group (all P < 0.05). Functional mapping was also associated with shorter hospital length of stay (P = 0.0144), lower 30-day rates of emergency department visits (P = 0.0001), and fewer reoperations (P = 0.0068). Total costs of initial admission were not significantly different between groups. CONCLUSIONS Intraoperative functional mapping during glioma resection was associated with decreased complications, reoperations, emergency department visits, and shorter lengths of stay. Furthermore, total charges of mapped resections were not significantly different from those of conventional resections. These findings support the usefulness of functional mapping for resection of supratentorial primary malignant gliomas.
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Affiliation(s)
- Arjun V Pendharkar
- Department of Neurosurgery, Stanford University, Stanford, California, USA.
| | - Paymon G Rezaii
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Allen L Ho
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Eric S Sussman
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Atman M Desai
- Department of Neurosurgery, Stanford University, Stanford, California, USA
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13
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Awake craniotomies for epileptic gliomas: intraoperative and postoperative seizure control and prognostic factors. J Neurooncol 2019; 142:577-586. [DOI: 10.1007/s11060-019-03131-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
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14
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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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15
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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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16
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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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17
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Sargın M, Samancıoğlu H, Uluer MS. Transient Facial Nerve Palsy After the Scalp Block for Burr Hole Evacuation of Subdural Hematoma. Turk J Anaesthesiol Reanim 2017; 46:238-240. [PMID: 30140522 DOI: 10.5152/tjar.2018.58219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 02/06/2018] [Indexed: 11/22/2022] Open
Abstract
Scalp block has become a frequently used technique with an increasing number of indications today. Despite the many advantages of the scalp block, certain rare complications have been identified. It should be remembered that although it is a relatively safe procedure, it may lead to the development of facial nerve palsy. In this article, we present a case of transient facial nerve palsy developed after the scalp block that was used to drain the subdural hematoma with a burr hole.
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Affiliation(s)
- Mehmet Sargın
- Department of Anaesthesiology and Reanimation, Isparta City Hospital, Isparta, Turkey
| | | | - Mehmet Selçuk Uluer
- Department of Anaesthesiology and Reanimation, Health Sciences University Konya Training and Research Hospital, Konya, Turkey
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18
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Patients' perspective on awake craniotomy for brain tumors-single center experience in Brazil. Acta Neurochir (Wien) 2017; 159:725-731. [PMID: 28247161 DOI: 10.1007/s00701-017-3125-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 02/16/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Awake craniotomy with brain mapping is the gold standard for eloquent tissue localization. Patients' tolerability and satisfaction have been shown to be high; however, it is a matter of debate whether these findings could be generalized, since patients across the globe have their own cultural backgrounds and may perceive and accept this procedure differently. METHODS We conducted a prospective qualitative study about the perception and tolerability of awake craniotomy in a population of consecutive brain tumor patients in Brazil between January 2013 and April 2015. Seventeen patients were interviewed using a semi-structured model with open-ended questions. RESULTS Patients' thoughts were grouped into five categories: (1) overall perception: no patient considered awake craniotomy a bad experience, and most understood the rationale behind it. They were positively surprised with the surgery; (2) memory: varied from nothing to the entire surgery; (3) negative sensations: in general, it was painless and comfortable. Remarks concerning discomfort on the operating table were made; (4) postoperative recovery: perception of the postoperative period was positive; (5) previous surgical experiences versus awake craniotomy: patients often preferred awake surgery over other surgery under general anesthesia, including craniotomies. CONCLUSIONS Awake craniotomy for brain tumors was well tolerated and yielded high levels of satisfaction in a population of patients in Brazil. This technique should not be avoided under the pretext of compromising patients' well-being.
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Au K, Bharadwaj S, Venkatraghavan L, Bernstein M. Outpatient brain tumor craniotomy under general anesthesia. J Neurosurg 2016; 125:1130-1135. [PMID: 26943840 DOI: 10.3171/2015.11.jns152151] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Outpatient craniotomy has many advantages to the psychological and physical well-being of patients, as well as benefits to the health care system. Its efficacy and safety have been well demonstrated, but barriers to its widespread adoption remain. Among the challenges is a perception that its application is limited to cases performed under conscious sedation, which is not always feasible given certain patient or surgeon factors. The object of this study was to characterize the rate of patient discharge from the day surgery unit (DSU) following craniotomy for tumor resection in a patient under general anesthesia. The authors identify postoperative complications and discuss appropriate patient selection for day surgery craniotomy. METHODS Patients undergoing elective craniotomy for supratentorial tumors between January 2010 and June 2014 were prospectively considered for outpatient management. Authors of the present study performed a retrospective chart review of these patients, analyzing cases by intention to treat. RESULTS Of 318 craniotomies undertaken in the study period, 141 were performed with the patient under general anesthesia. The day surgery protocol was initiated in 44 cases and completed in 38 (86%). Five patients required admission from the DSU, and 1 was discharged but admitted within the 1st postoperative day. In-hospital medical complications were fewer in the outpatient group, and no patients experienced an adverse outcome due to early discharge. CONCLUSIONS Close clinical and imaging surveillance in the early postoperative period allows for safe discharge of patients following craniotomy for tumor resection performed under general anesthesia. Therefore, general anesthesia does not preclude the application of outpatient craniotomy.
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Affiliation(s)
| | - Suparna Bharadwaj
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Lashmi Venkatraghavan
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
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20
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Paldor I, Drummond KJ, Awad M, Sufaro YZ, Kaye AH. Is a wake-up call in order? Review of the evidence for awake craniotomy. J Clin Neurosci 2016; 23:1-7. [DOI: 10.1016/j.jocn.2015.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 11/21/2015] [Indexed: 10/22/2022]
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22
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Hervey-Jumper SL, Li J, Lau D, Molinaro AM, Perry DW, Meng L, Berger MS. Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period. J Neurosurg 2015; 123:325-39. [DOI: 10.3171/2014.10.jns141520] [Citation(s) in RCA: 244] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Awake craniotomy is currently a useful surgical approach to help identify and preserve functional areas during cortical and subcortical tumor resections. Methodologies have evolved over time to maximize patient safety and minimize morbidity using this technique. The goal of this study is to analyze a single surgeon's experience and the evolving methodology of awake language and sensorimotor mapping for glioma surgery.
METHODS
The authors retrospectively studied patients undergoing awake brain tumor surgery between 1986 and 2014. Operations for the initial 248 patients (1986–1997) were completed at the University of Washington, and the subsequent surgeries in 611 patients (1997–2014) were completed at the University of California, San Francisco. Perioperative risk factors and complications were assessed using the latter 611 cases.
RESULTS
The median patient age was 42 years (range 13–84 years). Sixty percent of patients had Karnofsky Performance Status (KPS) scores of 90–100, and 40% had KPS scores less than 80. Fifty-five percent of patients underwent surgery for high-grade gliomas, 42% for low-grade gliomas, 1% for metastatic lesions, and 2% for other lesions (cortical dysplasia, encephalitis, necrosis, abscess, and hemangioma). The majority of patients were in American Society of Anesthesiologists (ASA) Class 1 or 2 (mild systemic disease); however, patients with severe systemic disease were not excluded from awake brain tumor surgery and represented 15% of study participants. Laryngeal mask airway was used in 8 patients (1%) and was most commonly used for large vascular tumors with more than 2 cm of mass effect. The most common sedation regimen was propofol plus remifentanil (54%); however, 42% of patients required an adjustment to the initial sedation regimen before skin incision due to patient intolerance. Mannitol was used in 54% of cases. Twelve percent of patients were active smokers at the time of surgery, which did not impact completion of the intraoperative mapping procedure. Stimulation-induced seizures occurred in 3% of patients and were rapidly terminated with ice-cold Ringer's solution. Preoperative seizure history and tumor location were associated with an increased incidence of stimulation-induced seizures. Mapping was aborted in 3 cases (0.5%) due to intraoperative seizures (2 cases) and patient emotional intolerance (1 case). The overall perioperative complication rate was 10%.
CONCLUSIONS
Based on the current best practice described here and developed from multiple regimens used over a 27-year period, it is concluded that awake brain tumor surgery can be safely performed with extremely low complication and failure rates regardless of ASA classification; body mass index; smoking status; psychiatric or emotional history; seizure frequency and duration; and tumor site, size, and pathology.
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Affiliation(s)
| | - Jing Li
- Departments of 1Neurological Surgery and
| | - Darryl Lau
- Departments of 1Neurological Surgery and
| | | | - David W. Perry
- 2Surgical Neurophysiology, University of California, San Francisco, California
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23
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Ibrahim GM, Bernstein M. Awake craniotomy for supratentorial gliomas: why, when and how? CNS Oncol 2015; 1:71-83. [PMID: 25054301 DOI: 10.2217/cns.12.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Awake craniotomy has become an increasingly utilized procedure in the treatment of supratentorial intra-axial tumors. The popularity of this procedure is partially attributable to improvements in intraoperative technology and anesthetic techniques. The application of awake craniotomy to the field of neuro-oncology has decreased iatrogenic postoperative neurological deficits, allowed for safe maximal tumor resection and improved healthcare resource stewardship by permitting early patient discharge. In this article, we review recent evidence for the utility of awake craniotomy in the resection of gliomas and describe the senior author's experience in performing this procedure. Furthermore, we explore innovative applications of awake craniotomy to outpatient tumor resections and the conduct of neurosurgery in resource-poor settings. We conclude that awake craniotomy is an effective and versatile neurosurgical procedure with expanding applications in neuro-oncology.
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Affiliation(s)
- George M Ibrahim
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, 4th Floor West Wing Rm 4WW448, 399 Bathurst St., Toronto, Ontario, M5T 2S8, Canada
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Ghazanwy M, Chakrabarti R, Tewari A, Sinha A. Awake craniotomy: A qualitative review and future challenges. Saudi J Anaesth 2014; 8:529-39. [PMID: 25422613 PMCID: PMC4236942 DOI: 10.4103/1658-354x.140890] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Neurosurgery in awake patients incorporates newer technologies that require the anesthesiologists to update their skills and evolve their methodologies. They need effective communication skills and knowledge of selecting the right anesthetic drugs to ensure adequate analgesia, akinesia, along with patient satisfaction with the anesthetic conduct throughout the procedure. The challenge of providing adequate anesthetic care to an awake patient for intracranial surgery requires more than routine vigilance about anesthetic management.
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Affiliation(s)
- Mahmood Ghazanwy
- Department of Anesthesiology, Cleveland Clinic Foundation, Ohio, USA
| | - Rajkalyan Chakrabarti
- Department of Neurosurgical Anesthesiology and Spine Surgery, Cleveland Clinic Foundation, Ohio, USA
| | - Anurag Tewari
- Department of Neurosurgical Anesthesiology and Spine Surgery, Cleveland Clinic Foundation, Ohio, USA
| | - Ashish Sinha
- Professor and Vice Chair (Research) Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, USA
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Ouyang MW, McDonagh DL, Phillips-Bute B, James ML, Friedman AH, Gan TJ. Does midline shift predict postoperative nausea in brain tumor patients undergoing awake craniotomy? A retrospective analysis. Curr Med Res Opin 2013; 29:1033-8. [PMID: 23731200 DOI: 10.1185/03007995.2013.811071] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The presence of midline shift on neuroradiologic studies in brain tumor patients represents mass effect from the tumor and surrounding edema. We hypothesized that baseline cerebral edema as measured by midline shift would increase postoperative nausea (PON). We studied the incidence of PON in brain tumor patients, with and without midline shift on preoperative magnetic resonance (MRI) or computed tomographic (CT) imaging, undergoing awake craniotomy. METHODS After IRB approval, we retrospectively extracted data from perioperative records between January 2005 and December 2010. Post-craniotomy nausea and pain scores were collected. Intraoperative anti-emetic, anesthetic, and analgesic regimens were assessed. Both the rescue anti-emetic and cumulative postoperative analgesic requirements were collected up to 12 hours postoperatively. The amount of midline shift on preoperative neuroimaging was gathered from radiology reports. Univariate comparisons between groups (no midline shift vs. midline shift) were made with t-tests for continuous variables, and chi-square tests for categorical variables. A multivariable analysis was performed to identify predictors of postoperative nausea. Limitations of this study include the retrospective design and the inability to gather accurate data regarding vomiting from the medical record. RESULTS Data from 386 patients were available for analysis. Patients were divided into two groups: no midline shift (n = 283) and midline shift (n = 103). The mean midline shift distance was 5.96 mm (95% CI [5.32, 6.59]). There was no difference in the incidence of nausea or pain scores between the two groups. More malignant brain tumor patients were in the midline shift group, as determined by the postoperative histopathological diagnosis (P < 0.05). Patients in the midline shift group also had longer anesthesia and surgical times (P < 0.05). CONCLUSION In patients undergoing a standardized anesthetic for awake craniotomy for tumor resection, the presence of preoperative midline shift did not correlate with postoperative nausea.
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Affiliation(s)
- M W Ouyang
- Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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26
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Solera Ruiz I, Uña Orejón R, Valero I, Laroche F. [Awake craniotomy. Considerations in special situations]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:392-8. [PMID: 23433726 DOI: 10.1016/j.redar.2013.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 01/09/2013] [Indexed: 11/19/2022]
Abstract
Awake craniotomy was the earliest surgical procedure known, and it has become fashionable again. In the past it was used for the surgical management of intractable epilepsy, but nowadays, its indications are increasing, and it is a widely recognized technique for the resection of mass lesions involving the eloquent cortex, and for deep brain stimulation. The procedure is safe, provides excellent results, and saves money and resources. The anesthesiologist should know the principles underlying neuroanesthesia, the technique of scalp blockade, and the sedation protocols, as well as feeling comfortable with advanced airway management. The main anesthetic aim is to keep patients cooperating when required (analgesia-based anesthesia). This review attempts to summarize the most recent evidence from the clinical literature, a long as the number of patients undergoing craniotomies in the awake state are increasing, specifically in the pediatric population.
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Affiliation(s)
- I Solera Ruiz
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital de Torrejón, Torrejón de Ardoz, Madrid, España.
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27
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Is microvascular decompression surgery a high risk for postoperative nausea and vomiting in patients undergoing craniotomy? J Anesth 2013; 27:725-30. [PMID: 23649917 DOI: 10.1007/s00540-013-1621-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 04/20/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Patients undergoing microvascular decompression surgery often experience postoperative nausea and vomiting (PONV). However, there is little information about the incidence of PONV after microvascular decompression. We hypothesized that microvascular decompression is an especially high-risk procedure for PONV in patients undergoing neurosurgery, and investigated risk factors related to PONV after neurosurgery. METHODS All patients who underwent craniotomy in our institution during a period of 2 years were investigated retrospectively. Medical charts were reviewed to identify PONV during the 24-h postoperative period and related risk factors. Multivariate logistic regression analysis was conducted to elucidate the impact of microvascular decompression on PONV after craniotomy. RESULTS Among 556 craniotomy cases, 350 patients met the inclusion criteria. Multivariate logistic regression analysis showed that microvascular decompression was an independent risk factor for PONV after craniotomy (odds ratio 5.38, 3.02-9.60), in addition to female gender, non-smoker status, amount of intraoperative fentanyl administered, and cerebrovascular surgery. CONCLUSION In this retrospective study, microvascular decompression surgery was an especially high-risk factor for PONV in patients undergoing craniotomy. It may be necessary to adopt a combination of prophylactic methods to reduce the incidence of PONV after microvascular decompression.
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Nossek E, Matot I, Shahar T, Barzilai O, Rapoport Y, Gonen T, Sela G, Grossman R, Korn A, Hayat D, Ram Z. Intraoperative Seizures During Awake Craniotomy. Neurosurgery 2013; 73:135-40; discussion 140. [DOI: 10.1227/01.neu.0000429847.91707.97] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Awake craniotomy (AC) for removal of intra-axial brain tumors is a well-established procedure. However, the occurrence and consequences of intraoperative seizures during AC have not been well characterized.
OBJECTIVE:
To analyze the incidence, risk factors, and consequences of seizures during AC.
METHODS:
The database of AC at Tel Aviv Medical Center between 2003 to 2011 was reviewed. Occurrences of intraoperative seizures were analyzed with respect to medical history, medications, tumor characteristics, and postoperative outcome.
RESULTS:
Of the 549 ACs performed during the index period, 477 with complete records were identified. Sixty patients (12.6%) experienced intraoperative seizures. The AC procedure failed in 11 patients (2.3%) due to seizures. Patients with intraoperative seizures were significantly younger than nonseizing patients (45 ± 14 years vs 52 ± 16 years, P = .003), had a higher incidence of frontal lobe involvement (86% vs % 57%, P < .0001), and had higher prevalence of a history of seizures (P = .008). Short-term motor deterioration developed postoperatively in a higher percentage of patients with intraoperative seizures (20% vs 10.1%, P = .02) with a longer hospitalization period (4.0 ± 3.0 days vs 3.0 ± 3.0 days, P = .045).
CONCLUSION:
Although in most cases intraoperative seizures will not result in AC failure, the surgical team should be prepared to treat them promptly to avoid intractable seizures. Intraoperative seizures are more common in younger patients with a tumor in the frontal lobe and those with a history of seizures. Moreover, they are associated with a higher incidence of transient postoperative motor deterioration and protracted length of hospital stay.
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Affiliation(s)
- Erez Nossek
- Departments of Neurosurgery, Tel Aviv University, Tel Aviv, Israel
| | - Idit Matot
- Anesthesia and Intensive Care, Tel Aviv Medical Center
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Shahar
- Departments of Neurosurgery, Tel Aviv University, Tel Aviv, Israel
| | - Ori Barzilai
- Departments of Neurosurgery, Tel Aviv University, Tel Aviv, Israel
| | - Yoni Rapoport
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Gonen
- Departments of Neurosurgery, Tel Aviv University, Tel Aviv, Israel
| | - Gal Sela
- Departments of Neurosurgery, Tel Aviv University, Tel Aviv, Israel
| | - Rachel Grossman
- Departments of Neurosurgery, Tel Aviv University, Tel Aviv, Israel
| | - Akiva Korn
- Departments of Neurosurgery, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Hayat
- Anesthesia and Intensive Care, Tel Aviv Medical Center
| | - Zvi Ram
- Departments of Neurosurgery, Tel Aviv University, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Nossek E, Matot I, Shahar T, Barzilai O, Rapoport Y, Gonen T, Sela G, Korn A, Hayat D, Ram Z. Failed awake craniotomy: a retrospective analysis in 424 patients undergoing craniotomy for brain tumor. J Neurosurg 2013; 118:243-9. [DOI: 10.3171/2012.10.jns12511] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Awake craniotomy for removal of intraaxial tumors within or adjacent to eloquent brain regions is a well-established procedure. However, awake craniotomy failures have not been well characterized. In the present study, the authors aimed to analyze and assess the incidence and causes for failed awake craniotomy.
Methods
The database of awake craniotomies performed at Tel Aviv Medical Center between 2003 and 2010 was reviewed. Awake craniotomy was considered a failure if conversion to general anesthesia was required, or if adequate mapping or monitoring could not have been achieved.
Results
Of 488 patients undergoing awake craniotomy, 424 were identified as having complete medical, operative, and anesthesiology records. The awake craniotomies performed in 27 (6.4%) of these 424 patients were considered failures. The main causes of failure were lack of intraoperative communication with the patient (n = 18 [4.2%]) and/or intraoperative seizures (n = 9 [2.1%]). Preoperative mixed dysphasia (p < 0.001) and treatment with phenytoin (p = 0.0019) were related to failure due to lack of communication. History of seizures (p = 0.03) and treatment with multiple antiepileptic drugs (p = 0.0012) were found to be related to failure due to intraoperative seizures. Compared with the successful awake craniotomy group, a significantly lower rate of gross-total resection was achieved (83% vs 54%, p = 0.008), there was a higher incidence of short-term speech deterioration postoperatively (6.1% vs 23.5%, p = 0.0017) as well as at 3 months postoperatively (2.3% vs 15.4%, p = 0.0002), and the hospitalization period was longer (4.9 ± 6.2 days vs 8.0 ± 10.1 days, p < 0.001). Significantly more major complications occurred in the failure group (4 [14.8%] of 27) than in the successful group (16 [4%] of 397) (p = 0.037).
Conclusions
Failures of awake craniotomy were associated with a lower incidence of gross-total resection and increased postoperative morbidity. The majority of awake craniotomy failures were preventable by adequate patient selection and avoiding side effects of drugs administered during surgery.
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Affiliation(s)
| | - Idit Matot
- 2Anesthesia and Intensive Care, Tel Aviv Medical Center, and
- 3Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Yoni Rapoport
- 3Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Gal Sela
- 1Departments of Neurosurgery and
| | | | - Daniel Hayat
- 2Anesthesia and Intensive Care, Tel Aviv Medical Center, and
| | - Zvi Ram
- 1Departments of Neurosurgery and
- 3Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Indication for surgery and the risk of postoperative nausea and vomiting after craniotomy: a case-control study. J Neurosurg Anesthesiol 2013; 24:325-30. [PMID: 22828153 DOI: 10.1097/ana.0b013e3182611a30] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The primary hypothesis of the study is that acoustic neuroma (AN) surgery and microvascular decompression (MVD) of cranial nerves increase the risk of postoperative nausea and vomiting (PONV). METHODS We designed a retrospective case-control study matched on age, sex, and year of surgery (≤2005 and >2005). Year of surgery was noted as a potential confounder, because routine antiemetic prophylaxis was strongly encouraged at the study site in 2005. Cases of PONV in the recovery room were matched to controls in a 1:2 manner using a perioperative database. Charts were then reviewed for the following data: American Society of Anesthesiologists grade, smoking status, craniotomy location, craniotomy indication, and type of anesthetic administered. RESULTS The final analysis included 117 cases that were matched with 185 controls. Patients had a mean age of 50 years (SD=13), and 65% were female. Overall, the majority of craniotomies were supratentorial (70%) and performed for tumor resection (41%). On multivariable analysis, MVD [odds ratio (OR)=6.7; 95% confidence interval (CI), 2.0-22.7; P=0.002], AN (OR=3.3; 95% CI, 1.0-11.0; P=0.05), and epilepsy surgery (OR=2.8; 95% CI, 1.1-7.5; P=0.04) were associated with an increased likelihood of PONV when compared with tumor surgery. There was effect modification of total intravenous anesthesia by location of surgery (P-interaction=0.02). The benefit of total intravenous anesthesia on PONV was observed in supratentorial (OR=0.41; 95% CI, 0.17-0.96; P=0.04) but not infratentorial location (OR=2.6; 95% CI, 0.78-8.7; P=0.11). CONCLUSIONS MVD and AN resection were associated with an increased likelihood of PONV compared with craniotomies performed for other tumor resection.
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Benatar-Haserfaty J, Tardáguila Sancho P. [Anesthesia for craniotomy in the conscious patient]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:264-74. [PMID: 23337779 DOI: 10.1016/j.redar.2012.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 11/14/2012] [Indexed: 11/27/2022]
Abstract
Craniotomy in the conscious patient (CPC) enables the neurological changes to be assessed during the mapping in epilepsy surgery, the location of the electrodes during deep brain stimulation surgery, and tumor resection in eloquent areas of the brain. CPC is a useful technique for radical surgery in order to minimize the damage to the functional areas of the brain. The anesthesiologist must ensure, adequate patient comfort, analgesia and ensure optimal collaboration. The appropriate selection of potential candidates for CPC should be made jointly with all professionals involved in the case. Knowledge of the different phases of CPC, coordination and communication among specialists, the right management of the pharmacology, and anesthetic techniques specific to CPC, along with the ability of psycho-emotional communication with the patient, determine the success of the procedure to be performed in the culture of patient safety. The aim of this review was to describe the anesthetic management, comprehensive considerations, and intraoperative neurophysiological tests for CPC.
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Affiliation(s)
- J Benatar-Haserfaty
- Servicio de Anestesiología, Hospital Universitario Ramón y Cajal, Madrid, España.
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Bergese S, Viloria A, Uribe A, Antor A, Fernandez S. Aprepitant versus ondansetron in preoperative triple-therapy treatment of nausea and vomiting in neurosurgery patients: study protocol for a randomized controlled trial. Trials 2012; 13:130. [PMID: 22862827 PMCID: PMC3475143 DOI: 10.1186/1745-6215-13-130] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 07/16/2012] [Indexed: 11/14/2022] Open
Abstract
Background The incidence of postoperative nausea and vomiting (PONV) is 50% to 80% after neurosurgery. The common prophylactic treatment for postoperative nausea and vomiting is a triple therapy of droperidol, promethazine and dexamethasone. Newer, more effectives methods of prophylaxis are being investigated. We designed this prospective, double-blind, single-center study to compare the efficacy of ondansetron, a neurokinin-1 antagonist, and aprepitant, as a substitute for droperidol, in the prophylactic treatment of postoperative nausea and vomiting after neurosurgery. Methods After obtaining institutional review board approval; 176 patients, 18 to 85 years of age with American Society of Anesthesiologists (ASA) classifications I to III, who did not receive antiemetics 24 h before surgery and were expected to undergo general anesthesia for neurosurgery lasting longer than 2 h were included in this study. After meeting the inclusion and exclusion criteria and providing written informed consent, patients were randomly assigned in a 1:1 ratio to one of two treatment groups: aprepitant or ondansetron. The objective of this study was to conduct a randomized, double-blind, double-dummy, parallel-group and single-center trial to compare and evaluate the efficacies of aprepitant versus ondansetron. Patients received oral aprepitant 40 mg OR oral dummy pill within 2 h prior to induction. At induction, a combination of intravenous dexamethasone 10 mg, promethazine 25 mg, and ondansetron 4 mg OR dummy injection was administered. Therefore, all patients received one dummy treatment and three active PONV prophylactic medications: dexamethasone 10 mg, promethazine 25 mg, and either aprepitant 40 mg OR ondansetron 4 mg infusion. The primary outcome measures were the episodes and severity of nausea and vomiting; administration of rescue antiemetic; and opioid consumption for 120 h postoperatively. Standard safety assessments included adverse event reports, physical and laboratory data, awakening time and duration of recovery from anesthesia. Discussion The results of this comparative study could potentially identify an improved treatment regimen that may decrease the incidence and severity of postoperative nausea and vomiting in patients undergoing neurosurgery. Also, this will serve to enhance patient recovery and overall satisfaction of neurosurgical patients in the immediate postoperative period. Trial registration Registered at The Ohio State University Biomedical Sciences Institutional Review Board: Protocol Number: 2007 H0053
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Affiliation(s)
- Sergio Bergese
- Ohio State University Medical Center, Columbus, OH 43210, USA.
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Erickson KM, Cole DJ. Anesthetic considerations for awake craniotomy for epilepsy and functional neurosurgery. Anesthesiol Clin 2012; 30:241-268. [PMID: 22901609 DOI: 10.1016/j.anclin.2012.05.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The two most common neurosurgical procedures that call for an awake patient include epilepsy surgery and functional neurosurgery. Monitoring patients in the awake state allows more aggressive resection of epileptogenic foci in functionally important brain regions. Careful patient selection and preparation combined with attentive monitoring and anticipation of events are fundamental to a smooth awake procedure. Current pharmacologic agents and techniques at the neuroanesthesiologist's disposal facilitate an increasing number of procedures performed in awake patients.
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Affiliation(s)
- Kirstin M Erickson
- Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street SE, Rochester, MN 55901, USA.
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Martino J, Gómez E, Marco de Lucas E, Martínez M, Ocon R, Valle-Folgueral JM, Vega M, Vázquez-Barquero A. [Controversy in the management of WHO grade II gliomas in eloquent brain areas: recent literature review]. Neurocirugia (Astur) 2012; 23:70-8. [PMID: 22578606 DOI: 10.1016/j.neucir.2011.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 07/17/2011] [Indexed: 11/28/2022]
Abstract
Recent studies have shown that diffuse grade II gliomas (GGII) located in eloquent brain areas represent over 80% of all GGII. The optimal management of these tumours is still controversial. It has long been considered that surgery is not an option for GGII within eloquent areas, due to the high risk of inducing postoperative sequelae in patients with normal neurological explorations. However, the safety of these surgeries has significantly improved in recent years due to the rapid development of techniques enabling a precise mapping of brain functions. Noninvasive functional neuroimaging techniques have been recently developed, enabling cortical mapping of the entire brain prior to surgical procedures. Such precise data provide a preoperative estimation of the location of eloquent areas in relation to the tumour, which is essential for surgical planning and preoperative assessment of morbidity for various surgical approaches. The intraoperative electrical stimulation (IES) mapping technique consists in the application of a bipolar electrode on the brain tissue, enabling an accurate location of brain functions. This provides unique assistance in GGII resection, as it generates a discrete and transient "virtual" lesion within the eloquent tissue. Tumour removal is then tailored according to functional boundaries in order to optimise the quality of resection and to minimise the risk of postoperative sequelae, preserving quality of life. For patients with a GGII in an eloquent area, the possibility of an early resection should be evaluated by a multidisciplinary neuro-oncology team specialising in the management of such tumours.
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Affiliation(s)
- Juan Martino
- Departamento de Neurocirugía, Hospital Universitario Marqués de Valdecilla e Instituto de Formación e Investigación Marqués de Valdecilla (IFIMAV), Santander, Cantabria, España
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Scalp Block for Awake Craniotomy in a Patient With a Frontal Bone Mass: A Case Report. Anesth Pain Med 2012. [DOI: 10.5812/aapm.3608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Latz B, Mordhorst C, Kerz T, Schmidt A, Schneider A, Wisser G, Werner C, Engelhard K. Postoperative nausea and vomiting in patients after craniotomy: incidence and risk factors. J Neurosurg 2010; 114:491-6. [PMID: 21029035 DOI: 10.3171/2010.9.jns10151] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to assess the incidence and risk factors of postoperative nausea and vomiting (PONV) after craniotomy because most available data about PONV in neurosurgical patients are retrospective in nature or derive from small prospective studies. METHODS Postoperative nausea and vomiting was prospectively assessed within 24 hours after surgery in 229 patients requiring supratentorial or infratentorial craniotomy. To rule out the relevance of the neurosurgical procedure itself to the development of PONV, the observed incidence of vomiting was compared with the rate of vomiting predicted with a surgery-independent risk score (Apfel postoperative vomiting score). RESULTS The overall incidence of PONV after craniotomy was 47%. Logistic regression identified female sex as a risk factor for postoperative nausea (OR 4.25, 95% CI 2.3-7.8) and vomiting (OR 2.62, 95% CI 1.4-4.9). Both the incidence of nausea (OR 3.76, 95% CI 2.06-6.88) and vomiting (OR 4.48, 95% CI 2.4-8.37) were increased in patients not receiving steroids. Postoperative nausea and vomiting occurred after infratentorial as well as after supratentorial procedures. The observed incidence of vomiting within 24 hours after surgery was higher (49%) than would be predicted with the Apfel surgery-independent risk score (31%; p = 0.0004). CONCLUSIONS The overall incidence of PONV within 24 hours after craniotomy was approximately 50%. One possible reason is that intracranial surgeries pose an additional and independent risk factor for vomiting, especially in female patients. Patients undergoing craniotomy should be identified as high-risk patients for PONV.
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Affiliation(s)
- Björn Latz
- Klinik für Anästhesiologie, Universitätsmedizin der Johannes Gutenberg–Universität Mainz, Germany.
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Bello L, Fava E, Casaceli G, Bertani G, Carrabba G, Papagno C, Falini A, Gaini SM. Intraoperative mapping for tumor resection. Neuroimaging Clin N Am 2010; 19:597-614. [PMID: 19959007 DOI: 10.1016/j.nic.2009.08.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This article describes the rationale, indications, and modality for intraoperative brain mapping for safe and effective surgical removal of tumors located within functional brain areas.
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Affiliation(s)
- Lorenzo Bello
- Department of Neurological Sciences, Università degli Studi di Milano, 20122. Milano, Italy.
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Bello L, Fava E, Carrabba G, Papagno C, Gaini SM. Present day's standards in microsurgery of low-grade gliomas. Adv Tech Stand Neurosurg 2010; 35:113-57. [PMID: 20102113 DOI: 10.1007/978-3-211-99481-8_5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Low-grade gliomas are slow growing intrinsic lesions that induces a progressive functional reshaping of the brain. Surgical removal of these lesions requires the combined efforts of a multidiscipinary team of neurosurgeon, neuroradiologist, neuropsychologist, neurophysiologist, and neurooncologists that all together contribute in the definition of the location, extension, and extent of functional involvement that a specific lesion has induced in a particular patient. Each tumor has induced particular and specific changes of the functional network, that varies among patients. This requires that each treatment plan should be tailored to the tumor and to the patient. When this is reached, surgery should be accomplished according to functional and anatomical boundaries, and has to aim to the maximal resection with the maximal patient functional preservation. This can be reached at the time of the initial surgery, depending on the functional organization of the brain, or may require additional surgeries, eventually intermingled with adjuvant treatments. The use of so called brain mapping techniques extend surgical indications, improve extent of resection with greater oncological impact, minimization of morbidity and increase in quality of life. To achieve the goal of a satisfactory tumor resection associated with the full preservation of the patients abilities, a series of neuropsychological, neurophysiological, neuroradiological and intraoperative investigations have to be performed. In this chapter, we will describe the rationale, the indications and the modality for performing a safe and rewarding surgical removal of low-grade gliomas by using these techniques, as well as the functional and oncological results.
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Affiliation(s)
- L Bello
- Neurosurgery, Department of Neurological Sciences, Università degli Studi di Milano, Milano, Italy
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Abstract
Awake craniotomy has become an increasingly frequent procedure. In this paper, the principles of its anaesthetic management are reviewed. The means allowing achievement of anaesthetic objectives are described, with emphasis on points that determine success of the procedure. A careful and adequate selection and preparation of patients are mandatory, and the intervening team must be a skilled team. Choosing an awake technique or general anaesthesia depends on several factors, including the risk of obstructive apnoea, seizures, nausea and vomiting, patient's ability to cooperate, and localization of lesions. The main challenge of intraoperative anaesthetic management relies on the ability of rapidly adjusting the level of sedation and analgesia according to the sequence of surgical events, while ensuring haemodynamic stability, adequate ventilation, and minimal interference with eventual electrophysiological recordings. Throughout the procedure, complications must be anticipated and managed according to predefined guidelines. More prospective randomized clinical trials are still needed to improve safety and efficacy of awake craniotomies, as well as to validate this technique in comparison with more conventional anaesthetic management.
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Bertani G, Fava E, Casaceli G, Carrabba G, Casarotti A, Papagno C, Castellano A, Falini A, Gaini SM, Bello L. Intraoperative mapping and monitoring of brain functions for the resection of low-grade gliomas: technical considerations. Neurosurg Focus 2009; 27:E4. [PMID: 19795953 DOI: 10.3171/2009.8.focus09137] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Low-grade gliomas ([LGGs] WHO Grade II) are slow-growing intrinsic cerebral lesions that diffusely infiltrate the brain parenchyma along white matter tracts and almost invariably show a progression toward malignancy. The treatment of these tumors forces the neurosurgeon to face uncommon difficulties and is still a subject of debate. At the authors' institution, resection is the first option in the treatment of LGGs. It requires the combined efforts of a multidisciplinary team of neurosurgeons, neuroradiologists, neuropsychologists, and neurophysiologists, who together contribute to the definition of the location, extension, and extent of functional involvement that a specific lesion has caused in a particular patient. In fact, each tumor induces specific modifications of the brain functional network, with high interindividual variability. This requires that each treatment plan is tailored to the characteristics of the tumor and of the patient. Consequently, surgery is performed according to functional and anatomical boundaries to achieve the maximal resection with maximal functional preservation. The identification of eloquent cerebral areas, which are involved in motor, language, memory, and visuospatial functions and have to be preserved during surgery, is performed through the intraoperative use of brain mapping techniques. The use of these techniques extends surgical indications and improves the extent of resection, while minimizing the postoperative morbidity and safeguarding the patient's quality of life. In this paper the authors present their paradigm for the surgical treatment of LGGs, focusing on the intraoperative neurophysiological monitoring protocol as well as on the brain mapping technique. They briefly discuss the results that have been obtained at their institution since 2005 as well as the main critical points they have encountered when using this approach.
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Affiliation(s)
- Giulio Bertani
- Division of Neurosurgery, Department of Neurological Sciences, Università degli Studi di Milano, 20122 Milan, Italy
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Neufeld SM, Newburn-Cook CV, Schopflocher D, Dundon B, Yu H, Drummond JE. Children's vomiting following posterior fossa surgery: A retrospective study. BMC Nurs 2009; 8:7. [PMID: 19594935 PMCID: PMC2724508 DOI: 10.1186/1472-6955-8-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Accepted: 07/13/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nausea and vomiting is a problem for children after neurosurgery and those requiring posterior fossa procedures appear to have a high incidence. This clinical observation has not been quantified nor have risk factors unique to this group of children been elucidated. METHODS A six year retrospective chart audit at two Canadian children's hospitals was conducted. The incidence of nausea and vomiting was extracted. Hierarchical multivariable logistic regression was used to quantify risk and protective factors at 120 hours after surgery and early vs. late vomiting. RESULTS The incidence of vomiting over a ten day postoperative period was 76.7%. Documented vomiting ranged from single events to greater than 20 over the same period. In the final multivariable model: adolescents (age 12 to <17) were less likely to vomit by 120 hours after surgery than other age groups; those who received desflurane, when compared to all other volatile anesthetics, were more likely to vomit, yet the use of ondansetron with desflurane decre kelihood. Children who had intraoperative ondansetron were more likely to vomit in the final multivariable model (perhaps because of its use, in the clinical judgment of the anesthesiologist, for children considered at risk). Children who started vomiting in the first 24 hours were more likely to be school age (groups 4 to <7 and 7 to <12) and receive desflurane. Nausea was not well documented and was therefore not analyzed. CONCLUSION The incidence of vomiting in children after posterior fossa surgery is sufficient to consider all children requiring these procedures to be at high risk for POV. Nausea requires better assessment and documentation.
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Affiliation(s)
| | | | | | | | - Herta Yu
- Hospital for Sick Children, Toronto, Ontario, Canada
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See JJ, Lew TWK, Kwek TK, Chin KJ, Wong MFM, Liew QY, Lim SH, Ho HS, Chan Y, Loke GPY, Yeo VST. Anaesthetic Management of Awake Craniotomy for Tumour Resection. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2008. [DOI: 10.47102/annals-acadmedsg.v36n5p319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Introduction: Awake craniotomy allows accurate localisation of the eloquent brain, which is crucial during brain tumour resection in order to minimise risk of neurologic injury. The role of the anaesthesiologist is to provide adequate analgesia and sedation while maintaining ventilation and haemodynamic stability in an awake patient who needs to be cooperative during neurological testing. We reviewed the anaesthetic management of patients undergoing an awake craniotomy procedure.
Materials and Methods: The records of all the patients who had an awake craniotomy at our institution from July 2004 till June 2006 were reviewed. The anaesthesia techniques and management were examined. The perioperative complications and the outcome of the patients were noted.
Results: There were 17 procedures carried out during the study period. Local anaesthesia with moderate to deep sedation was the technique used in all the patients. Respiratory complications occurred in 24% of the patients. Hypertension was observed in 24% of the patients. All the complications were transient and easily treated. During cortical stimulation, motor function was assessed in 16 patients (94%). Three patients (16%) had lesions in the temporalparietal region and speech was assessed intraoperatively. Postoperative motor weakness was seen in 1 patient despite uneventful intraoperative testing. No patient required intensive care unit stay. The median length of stay in the high dependency unit was 1 day and the median length of hospital stay was 9 days. There was no in-hospital mortality.
Conclusion: Awake craniotomy for brain tumour excision can be successfully performed under good anaesthetic conditions with careful titration of sedation. Our series showed it to be a well-tolerated procedure with a low rate of complications. The benefits of maximal tumour excision can be achieved, leading to potentially better patient outcome.
Key words: Brain neoplasm, Neurosurgery, Postoperative complications
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Prevention and control of postoperative nausea and vomiting in post-craniotomy patients. Best Pract Res Clin Anaesthesiol 2008; 21:575-93. [PMID: 18286838 DOI: 10.1016/j.bpa.2007.06.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Postoperative nausea and vomiting (PONV) are the most frequent side-effects in the postoperative period, impairing subjective well-being and having economic impact due to delayed discharge. However, emetic symptoms can also cause major medical complications, and post-craniotomy patients may be at an increased risk. A review and critical appraisal of the existing literature on PONV in post-craniotomy patients, and a comparison of these findings with the current knowledge on PONV in the general surgical population, leads to the following conclusions: (1) Despite the lack of a documented case of harm caused by retching or vomiting in a post-craniotomy patient, the potential risk caused by arterial hypertension and high intra-abdominal/intra-thoracic pressure leading to high intracranial pressure, forces to avoid PONV in these patients. (2) There is unclarity about a specifically increased (or decreased) risk for PONV in post-craniotomy patients compared with other surgical procedures. (3) The decision whether or not to administer an antiemetic should not be based primarily on risk scores for PONV but on the likelihood for potential catastrophic consequences of PONV. If such a risk cannot be ruled out, a multimodal antiemetic approach should be considered regardless of the individual risk. (4) Randomized controlled trials with antiemetics in post-craniotomy patients are limited with respect to sample size and methodological quality. This also impacts upon the meaning of meta-analyses performed with trials that showed marked heterogeneity and inconclusive results. (5) No studies on the treatment of established PONV are available. This highlights the need to transfer knowledge about PONV treatment from other surgical procedures. (6) Despite the possibility that PONV in post-craniotomy patients can be triggered by specific conditions (e.g. surgery near the area postrema at the floor of the fourth ventricle with the vomiting centre located nearby), recommendations based on trials in post-craniotomy patients may be flawed. Thus, general knowledge on prevention and treatment of PONV must adopted for craniotomy settings.
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Abstract
A variety of anesthetic methods, with and without airway manipulation, are available to facilitate awake intraoperative examinations and cortical stimulation, which allow more aggressive resection of epileptogenic foci in functionally important brain regions. Careful patient selection and preparation combined with attentive cooperation of the medical team are the foundation for a smooth awake procedure. With improved pharmacologic agents and variety of techniques at the neuroanesthesiologist's disposal, awake craniotomy has become an elegant approach to epileptic focus resection in functional cortex.
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MESH Headings
- Anesthesia, General/adverse effects
- Anesthesia, General/methods
- Anesthesia, Intravenous/adverse effects
- Anesthesia, Intravenous/methods
- Anesthesia, Local
- Anesthetics, Intravenous/administration & dosage
- Anesthetics, Intravenous/adverse effects
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/adverse effects
- Brain/surgery
- Brain Mapping
- Craniotomy
- Epilepsy/surgery
- Humans
- Monitoring, Intraoperative
- Preoperative Care
- Wakefulness
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Affiliation(s)
- Kirstin M Erickson
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN 55901, USA.
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Serletis D, Bernstein M. Prospective study of awake craniotomy used routinely and nonselectively for supratentorial tumors. J Neurosurg 2007; 107:1-6. [PMID: 17639865 DOI: 10.3171/jns-07/07/0001] [Citation(s) in RCA: 212] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors prospectively assessed the value of awake craniotomy used nonselectively in patients undergoing resection of supratentorial tumors.
Methods
The demographic features, presenting symptoms, tumor location, histological diagnosis, outcomes, and complications were documented for 610 patients who underwent awake craniotomy for supratentorial tumor resection. Intraoperative brain mapping was used in 511 cases (83.8%). Mapping identified eloquent cortex in 115 patients (22.5%) and no eloquent cortex in 396 patients (77.5%).
Results
Neurological deficits occurred in 89 patients (14.6%). In the subset of 511 patients in whom brain mapping was performed, 78 (15.3%) experienced postoperative neurological worsening. This phenomenon was more common in patients with preoperative neurological deficits or in those individuals in whom mapping successfully identified eloquent tissue. Twenty-five (4.9%) of the 511 patients suffered intraoperative seizures, and two of these individuals required intubation and induction of general anesthesia after generalized seizures occurred.
Four (0.7%) of the 610 patients developed wound complications. Postoperative hematomas developed in seven patients (1.1%), four of whom urgently required a repeated craniotomy to allow evacuation of the clot. Two patients (0.3%) required readmission to the hospital soon after being discharged. There were three deaths (0.5%).
Conclusions
Awake craniotomy is safe, practical, and effective during resection of supratentorial lesions of diverse pathological range and location. It allows for intraoperative brain mapping that helps identify and protect functional cortex. It also avoids the complications inherent in the induction of general anesthesia. Awake craniotomy provides an excellent alternative to surgery of supratentorial brain lesions in patients in whom general anesthesia has been induced.
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Affiliation(s)
- Demitre Serletis
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
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Leslie K, Williams DL. Postoperative pain, nausea and vomiting in neurosurgical patients. Curr Opin Anaesthesiol 2006; 18:461-5. [PMID: 16534276 DOI: 10.1097/01.aco.0000182564.25057.fa] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Postoperative pain and postoperative nausea and vomiting are significant problems for neurosurgical patients and their carers. The treatment of these problems is widely perceived to be inadequate, however, especially in patients undergoing craniotomy, and there are few large, randomized controlled trials. The main issue has been fear of side effects, especially those masking neurological signs. A review of the recent literature therefore is justified. RECENT FINDINGS Very little new information has been added to the literature about pain management in craniotomy patients, and postoperative nausea and vomiting management in neurosurgery patients as a whole. The main themes in the literature have been the introduction of multimodal analgesia for craniotomy patients, using simple analgesics as adjuvants to opioids, and innovative neuroaxial analgesia techniques in spinal surgery patients. SUMMARY There is still a lot of scope to research and refine pain and postoperative nausea and vomiting management in cranial and spinal neurosurgical patients. Large-scale studies are required to define the current state of practice, determine effective treatments and define the incidence of side-effects.
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Affiliation(s)
- Kate Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia.
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Schulz U, Keh D, Fritz G, Barner C, Kerner T, Schneider GH, Trottenberg T, Kupsch A, Boemke W. „Schlaf-Wach-Schlaf“-Technik zur CS Wachkraniotomie. Anaesthesist 2006; 55:585-98. [PMID: 16688387 DOI: 10.1007/s00101-006-1023-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Awake craniotomy in tumor and epilepsy surgery or for the implantation of electrodes for deep brain stimulation requires specific anesthesiological strategies. Propofol allows for quick emergence and has little effect on the respiratory function of the usually spontaneously breathing patient. Pain control may be instituted by hemiscalp block for trepanation or local infiltration for deep brain electrode implantation. In addition, low dose remifentanil is recommended for trepanation (i.e. tumor or epilepsy surgery). The airway may be secured by an ordinary Magill tube placed transnasally with its tip underneath the epiglottis. To protect the patient against vomiting an adequate antiemetic prophylaxis is required.
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Affiliation(s)
- U Schulz
- Kliniken für Anästhesiologie und operative Intensivmedizin, Campus Virchow-Klinikum und Campus Charité Mitte, Universitätsmedizin, Augustenburger Platz 1, 13353 , Berlin, Germany
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Duffau H. New concepts in surgery of WHO grade II gliomas: functional brain mapping, connectionism and plasticity – a review. J Neurooncol 2006; 79:77-115. [PMID: 16607477 DOI: 10.1007/s11060-005-9109-6] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Accepted: 12/21/2005] [Indexed: 10/24/2022]
Abstract
Despite a recent literature supporting the impact of surgery on the natural history of low-grade glioma (LGG), the indications of resection still remain a matter of debate, especially because of the frequent location of these tumors within eloquent brain areas - thus with a risk to induce a permanent postoperative deficit. Therefore, since the antagonist nature of this surgery is to perform the most extensive glioma removal possible, while preserving the function and the quality of life, new concepts were recently applied to LGG resection in order to optimize the benefit/risk ratio of the surgery.First, due to the development of functional mapping methods, namely perioperative neurofunctional imaging and intrasurgical direct electrical stimulation, the study of cortical functional organization is currently possible for each patient - in addition to an extensive neuropsychological assessment. Such knowledge is essential because of the inter-individual anatomo-functional variability, increased in tumors due to cerebral plasticity phenomena. Thus, brain mapping enables to envision and perform a resection according to individual functional boundaries.Second, since LGG invades not only cortical but also subcortical structures, and shows an infiltrative progression along the white matter tracts, new techniques of anatomical tracking and functional mapping of the subcortical white matter pathways were also used with the goal to study the individual effective connectivity - which needs imperatively to be preserved during the resection.Third, the better understanding of brain plasticity mechanisms, induced both by the slow-growing LGG and by the surgery itself, were equally studied in each patient and applied to the surgical strategy by incorporating individual dynamic potential of reorganization into the operative planning. The integration of these new concepts of individual functional mapping, connectivity and plastic potential to the surgery of LGG has allowed an extent of surgical indications, an optimization of the quality of resection (neuro-oncological benefit), and a minimization of the risk of sequelae (benefit on the quality of life). In addition, such a strategy has also fundamental applications, since it represents a new door to the connectionism and cerebral plasticity.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, UMR-S678 Inserm, Hôpital Salpêtrière, Paris, France
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Hartsell T, Long D, Kirsch JR. The efficacy of postoperative ondansetron (Zofran) orally disintegrating tablets for preventing nausea and vomiting after acoustic neuroma surgery. Anesth Analg 2005; 101:1492-1496. [PMID: 16244017 DOI: 10.1213/01.ane.0000181007.01219.38] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Postoperative nausea and vomiting is a frequent complication of craniotomy. We evaluated the ability of intraoperative IV ondansetron followed by postoperative ondansetron in an orally disintegrating tablet formulation to reduce the frequency and severity of postoperative nausea and vomiting in a prospective, randomized, placebo-controlled double-blind trial of 60 patients undergoing acoustic neuroma resection. Each patient received intraoperative ondansetron (4 mg IV) or placebo 30 min before case end. Postoperatively, patients received ondansetron in an orally disintegrating tablet formulation (8 mg BID) or placebo twice a day for up to 72 h. Metoclopramide was available as rescue therapy for both groups. Severity of nausea (as measured on a 10-cm visual scale), number of emetic episodes, and requirement for rescue therapy were recorded. In the immediate postoperative period, nausea severity was less in patients treated with ondansetron than placebo (3.3 +/- 4.1 versus 7.3 +/- 4.2; P < 0.001) and fewer patients experienced vomiting (3 of 28 versus 11 of 32; chi2 P < 0.01). More patients required some form of rescue treatment in the placebo group on the first postoperative day (26 of 32 versus 16 of 28; chi2 P < 0.01). We conclude that after acoustic neuroma surgery IV ondansetron treatment prevents immediate postoperative nausea and vomiting. Postoperative treatment with ondansetron in an orally disintegrating tablet formulation was associated with less frequent rescue therapy as compared with placebo on the first postoperative day.
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Affiliation(s)
- Theresa Hartsell
- *Departments of Anesthesiology and Critical Care Medicine and †Neurosurgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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