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Rafieezadeh A, Zangbar B, Zeeshan M, Gandhi C, Al-Mufti F, Jehan F, Kirsch J, Rodriguez G, Samson D, Prabhakaran K. Predictors of mortality after craniotomy for geriatric traumatic brain injury. Injury 2024; 55:111585. [PMID: 38704345 DOI: 10.1016/j.injury.2024.111585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/02/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND With a sustained increase in the proportion of elderly trauma patients, geriatric traumatic brain injury (TBI) is a significant source of morbidity, mortality and resource utilization. The aim of our study was to assess the predictors of mortality in geriatric TBI patients who underwent craniotomy. METHODS We performed a 4-year analysis of ACS-TQIP database (2016-2019) and included all geriatric trauma patients (≥65y) with isolated severe TBI who underwent craniotomy. We calculated 11- point modified frailty index (mFI) for patients. Our primary and secondary outcomes were mortality and unfavorable outcome, respectively. Multivariate regression analysis was performed to identify the predictors of outcomes. Patients with mFI ≥ 0.25 were defined as Frail, whereas patient with mFI of 0.08 or higher (<0.25) were identified as pre-frail; Non-frail patients were identified as mFI of <0.08. RESULTS We analyzed data from 20,303 patients. The mortality rate was 17.7 % (3,587 patients). Having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 2.251, p < 0.001), and pre-hospital anticoagulant use (OR = 1.306, p < 0.001) increased the risks of mortality. Frailty, as a continuous variable, was not considered as a risk factor for mortality (p = 0.058) but after categorization, it was shown that compared to non-frails, patients with pre-frailty (OR = 1.946, p = 0.011) and frailty (OR = 1.786, p = 0.026) had increased risks of mortality. Higher mFI (OR = 4.841), age (OR = 1.034), ISS (OR = 1.052), having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 1.758), and use of anticoagulants (OR = 1.117) were significant risk factors for unfavorable outcomes (p < 0.001, for all). CONCLUSIONS Having more than two types of intra-cranial hemorrhage and pre-hospital anticoagulant use were significant risk factors for mortality. The study's findings also suggest that frailty may not be a sufficient predictor of mortality after craniotomy in geriatric patients with TBI. However, frailty still affects the discharge disposition and favorable outcome. LEVEL OF EVIDENCE Level III retrospective study.
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Affiliation(s)
- Aryan Rafieezadeh
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Bardiya Zangbar
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States.
| | - Muhammad Zeeshan
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Chirag Gandhi
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Fawaz Al-Mufti
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Faisal Jehan
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Jordan Kirsch
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Gabriel Rodriguez
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - David Samson
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Kartik Prabhakaran
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
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Sato T, Ando T, Ozeki K, Asano I, Kuwatsuka Y, Ando M, Motomura K, Nishiwaki K. Prospective Randomized Controlled Trial Comparing Anesthetic Management With Remimazolam Besylate and Flumazenil Versus Propofol During Awake Craniotomy Following an Asleep-awake-asleep Method. J Neurosurg Anesthesiol 2024:00008506-990000000-00113. [PMID: 38836295 DOI: 10.1097/ana.0000000000000975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/23/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Awake craniotomy is performed to resect brain tumors in eloquent brain areas to maximize tumor reduction and minimize neurological damage. Evidence suggests that intraoperative anesthetic management of awake craniotomy with remimazolam is safe. We compared the time to arousal and efficacy of anesthetic management with remimazolam and propofol during awake craniotomy. METHODS In a single-institution randomized, prospective study, patients who underwent elective awake craniotomy were randomized to receive remimazolam and reversal with flumazenil (group R) or propofol (group P). The primary end point was time to awaken. Secondary end points were time to loss of consciousness during induction of anesthesia, the frequency of intraoperative complications (pain, hypertension, seizures, nausea, vomiting, and delayed arousal), and postoperative nausea and vomiting. Intraoperative task performance was assessed using a numerical rating scale (NRS) score. RESULTS Fifty-eight patients were recruited, of which 52 (26 in each group) were available for the efficacy analysis. Patients in group R had faster mean (±SD) arousal times than those in the P group (890.8±239.8 vs. 1075.4±317.5 s; P=0.013)and higher and more reliable intraoperative task performance (NRS score 8.81±1.50 vs. 7.69±2.36; P=0.043). There were no significant intraoperative complications. CONCLUSIONS Compared with propofol, remimazolam was associated with more rapid loss of consciousness and, after administration of flumazenil, with faster arousal times and improved intraoperative task performance.
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Affiliation(s)
| | | | | | | | | | | | - Kazuya Motomura
- Department of Neurosurgery, Nagoya University School of Medicine, Aichi, Japan
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Bharadwaj HR, Awuah WA, Adebusoye FT, Tan JK, Ali SH, Pacheco-Barrios N, Papadakis M. Awake craniotomies in South America: Advancements, challenges, and future prospects. J Cent Nerv Syst Dis 2024; 16:11795735241238681. [PMID: 38487717 PMCID: PMC10938621 DOI: 10.1177/11795735241238681] [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: 05/07/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND: Awake craniotomy has emerged as an advanced surgical technique, characterized by keeping the patient awake during brain surgery. In South America, awake craniotomies have grained traction in neurosurgical practices across various medical centres and hospitals, with notable practitioners contributing to its growth and refinement in the region. PURPOSE: This study aims to explore the integration and impact of awake craniotomies in South American neurosurgical practices. The focus is on understanding the benefits, challenges, and potential transformative effects of the procedure in the region. RESEARCH DESIGN: A comprehensive narrative review and analysis through a thorough examination of the existing literature. RESULTS: The findings indicate that awake craniotomies in South America offer substantial benefits, including cost savings thorugh reduced hospitalization time, quicker recovery and decreased morbidity. Enhanced safety, effective pain management and reduced anaesthesia also contribute to this. CONCLUSION: Whilst the adaptation of awake craniotomies in South America holds great promise in transforming neurosurgical care in the region, significant challenges hinder its widespread adoption. Inadequate infrastructure, limited access to equipment, financial instability, and shortages in trained healthcare providers represent challenges that need to be addressed.
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Affiliation(s)
- Hareesha R. Bharadwaj
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | | | | | - Joecelyn K. Tan
- Faculty of Medicine, University of St Andrews, St Andrews, UK
| | - Syed H. Ali
- Dow University of Health Sciences, Dow Medical College, Karachi, Pakistan
| | | | - Marios Papadakis
- Department of Surgery II, University Hospital Witten-Herdecke, University of Witten-Herdecke, Wuppertal, Germany
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Tang L, Tan TK. Anaesthetic considerations and challenges during awake craniotomy. Singapore Med J 2024:00077293-990000000-00087. [PMID: 38305272 DOI: 10.4103/singaporemedj.smj-2022-053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/10/2023] [Indexed: 02/03/2024]
Abstract
ABSTRACT This article summarises the key anaesthetic considerations and challenges surrounding the perioperative management of a patient undergoing awake craniotomy. The main goals include patient comfort, facilitation of patient cooperation during the critical awake phase and maintenance of optimal operating conditions. These are achieved through appropriate patient selection and preparation, familiarity with the complexity of each surgical phase and potential complications that may arise, as well as maintenance of close communication among all team members. Challenges such as loss of patient cooperation, loss of airway, intraoperative nausea and vomiting, seizures, cerebral oedema, hypertension, blood loss and use of intraoperative magnetic resonance imaging are discussed. The importance of teamwork, competence, vigilance and clear management strategies for potential complications to maximise patient outcomes is also highlighted.
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Affiliation(s)
- Leonard Tang
- Department of Anaesthesia, Singapore General Hospital, Singapore
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Pochebyt M, Herron SM, Pan SJ, Burbridge M, Bombardieri AM. Regional anesthesia for head and neck neurosurgical procedures: a narrative review in adult and pediatric patients. Int Anesthesiol Clin 2024; 62:10-20. [PMID: 38063033 DOI: 10.1097/aia.0000000000000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Maxim Pochebyt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Medicine, Stanford, California
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Mofatteh M, Mashayekhi MS, Arfaie S, Adeleye AO, Jolayemi EO, Ghomsi NC, Shlobin NA, Morsy AA, Esene IN, Laeke T, Awad AK, Labuschagne JJ, Ruan R, Abebe YN, Jabang JN, Okunlola AI, Barrie U, Lekuya HM, Idi Marcel E, Kabulo KDM, Bankole NDA, Edem IJ, Ikwuegbuenyi CA, Nguembu S, Zolo Y, Bernstein M. Awake Craniotomy in Africa: A Scoping Review of Literature and Proposed Solutions to Tackle Challenges. Neurosurgery 2023; 93:274-291. [PMID: 36961213 PMCID: PMC10319364 DOI: 10.1227/neu.0000000000002453] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/10/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Awake craniotomy (AC) is a common neurosurgical procedure for the resection of lesions in eloquent brain areas, which has the advantage of avoiding general anesthesia to reduce associated complications and costs. A significant resource limitation in low- and middle-income countries constrains the usage of AC. OBJECTIVE To review the published literature on AC in African countries, identify challenges, and propose pragmatic solutions by practicing neurosurgeons in Africa. METHODS We conducted a scoping review under Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review guidelines across 3 databases (PubMed, Scopus, and Web of Science). English articles investigating AC in Africa were included. RESULTS Nineteen studies consisting of 396 patients were included. Egypt was the most represented country with 8 studies (42.1%), followed by Nigeria with 6 records (31.6%). Glioma was the most common lesion type, corresponding to 120 of 396 patients (30.3%), followed by epilepsy in 71 patients (17.9%). Awake-awake-awake was the most common protocol used in 7 studies (36.8%). Sixteen studies (84.2%) contained adult patients. The youngest reported AC patient was 11 years old, whereas the oldest one was 92. Nine studies (47.4%) reported infrastructure limitations for performing AC, including the lack of funding, intraoperative monitoring equipment, imaging, medications, and limited human resources. CONCLUSION Despite many constraints, AC is being safely performed in low-resource settings. International collaborations among centers are a move forward, but adequate resources and management are essential to make AC an accessible procedure in many more African neurosurgical centers.
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Affiliation(s)
- Mohammad Mofatteh
- School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | | | - Saman Arfaie
- School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Amos Olufemi Adeleye
- Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Nathalie C. Ghomsi
- Neurosurgery Department, Felix Houphouet Boigny Unversity Abidjan, Cote d’Ivoire
| | - Nathan A. Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ahmed A. Morsy
- Department of Neurosurgery, Zagazig University, Zagazig, Egypt
| | - Ignatius N. Esene
- Neurosurgery Division, Faculty of Health Sciences, University of Bamenda, Bambili, Cameroon
| | - Tsegazeab Laeke
- Neurosurgery Division, Department of Surgery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ahmed K. Awad
- Faculty of Medicine, Ain-shams University, Cairo, Egypt
| | - Jason J. Labuschagne
- Department of Neurosurgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Richard Ruan
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Yared Nigusie Abebe
- Department of Neurosurgery, Haramaya University Hiwot Fana Comprehensive Specialized Hospital, Harar, Ethiopia
| | | | - Abiodun Idowu Okunlola
- Department of Surgery, Federal Teaching Hospital Ido Ekiti and Afe Babalola University, Ado Ekiti, Nigeria
| | - Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Hervé Monka Lekuya
- Department of Neurosurgery, Makerere University/Mulago Hospital, Kampala, Uganda
| | - Ehanga Idi Marcel
- Department of Neurosurgery, College of Surgeons of East, Central and Southern Africa/Mulago Hospital, Kampala, Uganda
| | - Kantenga Dieu Merci Kabulo
- Department of Neurosurgery, Jason Sendwe General Provincial Hospital, Lubumbashi, Democratic Republic of the Congo
| | - Nourou Dine Adeniran Bankole
- Department of Neurosurgery, Hôpital Des Spécialités, WFNS Rabat Training Center For Young, African Neurosurgeons, Faculty of Medicine, Mohammed V University, Rabat, Morocco
| | - Idara J. Edem
- Department of Surgery, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
| | | | - Stephane Nguembu
- Department of Neurosurgery, Higher Institute of Health Sciences, Université des Montagnes, Bangangté, Cameroon
| | - Yvan Zolo
- Global Surgery Division, University of Cape Town, Cape Town, South Africa
| | - Mark Bernstein
- Division of Neurosurgery, Department of Surgery, University of Toronto, University Health Network, Toronto, Ontario, Canada
- Temmy Latner Center for Palliative Care, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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D'Onofrio G, Izzi A, Manuali A, Bisceglia G, Tancredi A, Marchello V, Recchia A, Tonti MP, Icolaro N, Fazzari E, Carotenuto V, De Bonis C, Savarese L, Gorgoglione LP, Del Gaudio A. Anesthetic Management for Awake Craniotomy Applied to Neurosurgery. Brain Sci 2023; 13:1031. [PMID: 37508963 PMCID: PMC10377309 DOI: 10.3390/brainsci13071031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Our anesthetic technique proposed for awake craniotomy is the monitored anesthesia care (MAC) technique, with the patient in sedation throughout the intervention. Our protocol involves analgo-sedation through the administration of dexmedetomidine and remifentanil in a continuous intravenous infusion, allowing the patient to be sedated and in comfort, but contactable and spontaneously breathing. Pre-surgery, the patient is pre-medicated with intramuscular clonidine (2 µg/kg); it acts both as an anxiolytic and as an adjuvant in pain management and improves hemodynamic stability. In the operating setting, dexmedetomidine in infusion and remifentanil in target controlled infusion (TCI) for effect are started. The purpose of the association is to exploit the pharmacodynamics of dexmedetomidine which guarantees the control of respiratory drive, and the pharmacokinetics of remifentanil characterized by insensitivity to the drug. Post-operative management: at the end of the surgical procedure, the infusion of drugs was suspended. Wake-up craniotomy is associated with reduced hospital costs compared to craniotomy performed in general anesthesia, mainly due to reduced costs in the operating room and shorter hospital stays. Greater patient satisfaction and the benefits of avoiding hospital stay have led to the evolution of outpatient intracranial neurosurgery.
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Affiliation(s)
- Grazia D'Onofrio
- Clinical Psychology Service, Health Department, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Antonio Izzi
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Aldo Manuali
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Giuliano Bisceglia
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Angelo Tancredi
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Vincenzo Marchello
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Andreaserena Recchia
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Maria Pia Tonti
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Nadia Icolaro
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Elena Fazzari
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Vincenzo Carotenuto
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Costanzo De Bonis
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Luciano Savarese
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Leonardo Pio Gorgoglione
- Complex Unit of Neurosurgery, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Alfredo Del Gaudio
- Complex Unit of Anaesthesia-2, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
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Paquin-Lanthier G, Subramaniam S, Leong KW, Daniels A, Singh K, Takami H, Chowdhury T, Bernstein M, Venkatraghavan L. Risk Factors and Characteristics of Intraoperative Seizures During Awake Craniotomy: A Retrospective Cohort Study of 562 Consecutive Patients With a Space-occupying Brain Lesion. J Neurosurg Anesthesiol 2023; 35:194-200. [PMID: 34411059 DOI: 10.1097/ana.0000000000000798] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/23/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Intraoperative seizures (IOSs) during awake craniotomy (AC) are associated with significant morbidity. The reported incidence of IOS is between 3% and 30%. The aim of this study was to identify risk factors for IOS during AC for elective resection or biopsy of a space-occupying brain lesion. METHODS In this retrospective study, we reviewed the records of all awake craniotomies performed by a single neurosurgeon at a single university hospital between July 2006 and December 2018. IOS was defined as a clinically apparent seizure that occurred in the operating room and was documented in the medical records. Explanatory variables were chosen based on previously published literature on risk factors for IOS. RESULTS Five hundred and sixty-two patients had a total of 607 AC procedures during the study period; 581 cases with complete anesthesia records were included in analysis. Twenty-nine (5.0%) IOS events were reported during 29 (5%) awake craniotomies. Most seizures (27/29; 93%) were focal in nature and did not limit planned intraoperative stimulation mapping. Variables associated with IOS at a univariate P -value <0.1 (frontal location of tumor, preoperative radiotherapy, preoperative use of antiepileptic drugs, intraoperative use of dexmedetomidine, and intraoperative stimulation mapping) were included in a multivariable logistic regression. Frontal location of tumor (adjusted odds ratio: 5.68, 95% confidence interval: 2.11-15.30) and intraoperative dexmedetomidine use (adjusted odds ratio: 2.724, 95% confidence interval: 1.24-6.00) were independently associated with IOS in the multivariable analysis. CONCLUSIONS This study identified a low incidence (5%) of IOS during AC. The association between dexmedetomidine and IOS should be further studied in randomized trials as this is a modifiable risk factor.
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Affiliation(s)
| | | | | | | | | | - Hirokazu Takami
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada
| | | | - Mark Bernstein
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada
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Drosos E, Maye H, Youshani AS, Ehsan S, Burnand C, D’Urso PI. Awake brain surgery for autistic patients: Is it possible? Surg Neurol Int 2022; 13:543. [DOI: 10.25259/sni_719_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/03/2022] [Indexed: 11/21/2022] Open
Abstract
Background:
Awake neurosurgery is currently the mainstay for eloquent brain lesions. Opting for an awake operation is affected by a number of patient-related factors. We present a case of a patient with autistic spectrum disorder (ASD) that was successfully operated for a brain tumor through awake craniotomy. To the best of our knowledge, this is the first reported case in the literature.
Case Description:
A 42-year-old patient, with known ASD since his childhood, underwent awake craniotomy for a left supplementary motor area tumor. Detailed preoperative preparation of the patient was done to identify special requirements and establish a good patient-team relationship. Intraoperatively, continuous language and motor testing were performed. Conversation and music were the main distractors used. Throughout the operation, the patient remained calm and cooperative, even during a focal seizure. Mapping allowed for >80% resection of the tumor. Postoperatively, the patient recovered without any deficits.
Conclusion:
This case shows that with growing experience and meticulous preparation, the limits of awake craniotomy can be expanded to include more patients that were previously considered unfit.
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Affiliation(s)
- Evangelos Drosos
- Department of Neurosurgery, Manchester Center for Clinical Neurosciences, Salford, United Kingdom
| | - Helen Maye
- Department of Neurosurgery, Manchester Center for Clinical Neurosciences, Salford, United Kingdom
| | - Amir Saam Youshani
- Department of Neurosurgery, Manchester Center for Clinical Neurosciences, Salford, United Kingdom
| | - Sheeba Ehsan
- Department of Neuropsyhology, Manchester Center for Clinical Neurosciences, Salford, United Kingdom
| | - Cally Burnand
- Department of Anesthesiology, Manchester Center for Clinical Neurosciences, Salford, United Kingdom
| | - Pietro Ivo D’Urso
- Department of Neurosurgery, Manchester Center for Clinical Neurosciences, Salford, United Kingdom
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Anaesthesia for neurosurgery. ANAESTHESIA & INTENSIVE CARE MEDICINE 2022. [DOI: 10.1016/j.mpaic.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Zhou Q, Han Y, Chen J. The Efficacy of Remifentanil Combined with Propofol in Craniotomy for Tumor Was Evaluated by Wake Quality, Hemodynamics, and Adverse Reactions. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4861043. [PMID: 35898678 PMCID: PMC9314166 DOI: 10.1155/2022/4861043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/19/2022] [Accepted: 06/29/2022] [Indexed: 11/18/2022]
Abstract
In order to investigate the effect of remifentanil combined with propofol on awakening of craniotomy for tumor, a retrospective analysis is conducted. 86 patients who underwent craniotomy for brain tumor in our hospital from July 2020 to December 2021 are chosen to observe the quality of awakening, hemodynamic parameters, and the occurrence of adverse reactions. All patients are divided into group A (n = 43) and group B (n = 43) according to the use of anesthesia drugs. The intraoperative awakening quality and the hemodynamic parameters during different periods of the two groups are compared. The experimental results show that the incidence of postoperative adverse reactions in group B is significantly lower than that in group A (P < 0.05). It is clearly evident that remifentanil combined with protocol has good intraoperative wake-up effect in craniotomy for tumor and maintain the hemodynamic stability of patients. Also, it can obtain high wake-up quality and effectively reduce postoperative adverse reactions.
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Affiliation(s)
- Qiang Zhou
- Department of Anesthesiology, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Yanan Han
- Department of Operation Room, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Jun Chen
- Department of Anesthesiology, Tianjin Huanhu Hospital, Tianjin 300350, China
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Xie T, Wu Z, Schalk G, Tong Y, Vato A, Raviv N, Guo Q, Ye H, Sheng X, Zhu X, Brunner P, Chen L. Automated intraoperative central sulcus localization and somatotopic mapping using median nerve stimulation. J Neural Eng 2022; 19. [PMID: 35785769 PMCID: PMC9534515 DOI: 10.1088/1741-2552/ac7dfd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 07/04/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Accurate identification of functional cortical regions is essential in neurological resection. The central sulcus (CS) is an important landmark that delineates functional cortical regions. Median nerve stimulation (MNS) is a standard procedure to identify the position of the CS intraoperatively. In this paper, we introduce an automated procedure that uses MNS to rapidly localize the CS and create functional somatotopic maps. APPROACH We recorded electrocorticographic signals from 13 patients who underwent MNS in the course of an awake craniotomy. We analyzed these signals to develop an automated procedure that determines the location of the CS and that also produces functional somatotopic maps. MAIN RESULTS The comparison between our automated method and visual inspection performed by the neurosurgeon shows that our procedure has a high sensitivity (89%) in identifying the CS. Further, we found substantial concordance between the functional somatotopic maps generated by our method and passive functional mapping (92% sensitivity). SIGNIFICANCE Our automated MNS-based method can rapidly localize the CS and create functional somatotopic maps without imposing additional burden on the clinical procedure. With additional development and validation, our method may lead to a diagnostic tool that guides neurosurgeon and reduces postoperative morbidity in patients undergoing resective brain surgery.
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Affiliation(s)
- Tao Xie
- Department of Neurosurgery, Washington University School of Medicine in Saint Louis, 660 S. Euclid Avenue, St Louis, Missouri, 63110-1010, UNITED STATES
| | - Zehan Wu
- Dept. of Neurosurgery, Huashan Hospital Fudan University, 12 Wulumuqi Middle Rd, Shanghai, 200040, CHINA
| | - Gerwin Schalk
- National Center for Adaptive Neurotechnologies, 113 Holland Avenue, Albany, New York, 12208, UNITED STATES
| | - Yusheng Tong
- Dept. of Neurosurgery, Huashan Hospital Fudan University, 12 Wulumuqi Middle Rd, Shanghai, 200040, CHINA
| | - Alessandro Vato
- National Center for Adaptive Neurotechnologies, 113 Holland Avenue, Albany, New York, 12208, UNITED STATES
| | - Nataly Raviv
- National Center for Adaptive Neurotechnologies, 113 Holland Avenue, Albany, New York, 12208, UNITED STATES
| | - Qinglong Guo
- Dept. of Neurosurgery, Huashan Hospital Fudan University, 12 Wulumuqi Middle Rd, Shanghai, 200040, CHINA
| | - Huanpeng Ye
- State Key Laboratory of Mechanical System and Vibration, Shanghai Jiao Tong University, 800 Dongchuan Road, Shanghai, 200240, CHINA
| | - Xinjun Sheng
- State Key Laboratory of Mechanical System and Vibration, Shanghai Jiao Tong University, 800 Dongchuan Road, Shanghai, 200240, CHINA
| | - Xiangyang Zhu
- State Key Laboratory of Mechanical System and Vibration , Shanghai Jiao Tong University, 800 Dongchuan Road, Shanghai, 200240, CHINA
| | - Peter Brunner
- Department of Neurosurgery, Washington University School of Medicine in Saint Louis, 660 S. Euclid Avenue, St Louis, Missouri, 63110-1010, UNITED STATES
| | - Liang Chen
- Dept. of Neurosurgery, Huashan Hospital Fudan University, 12 Wulumuqi Middle Rd, Shanghai, 200040, CHINA
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13
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Plitman E, Chowdhury T, Paquin-Lanthier G, Takami H, Subramaniam S, Leong KW, Daniels A, Bernstein M, Venkatraghavan L. Benzodiazepine Sedation and Postoperative Neurological Deficits after Awake Craniotomy for Brain Tumor - An Exploratory Retrospective Cohort Study. Front Oncol 2022; 12:885164. [PMID: 35515117 PMCID: PMC9065444 DOI: 10.3389/fonc.2022.885164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
An awake craniotomy is a common neurosurgical procedure for excising brain tumor(s) located near or in eloquent areas. The use of benzodiazepine (BZD) for sedation in some patients with neuropathological conditions (e.g., stroke, brain tumors) has been previously linked with re-appearance of neurological deficits including limb incoordination, ataxia, and motor weakness, resulting in complications for the patient along with procedural challenges. Whether or not these findings can be extrapolated to patients undergoing brain tumor resection is largely unknown. The current work primarily sought to compare neurological outcome(s) in the immediate postoperative period between BZD-free and BZD-based sedation techniques in patients undergoing awake craniotomy. Using a database composed of awake craniotomies conducted within a single center and by a single surgeon, patients were retrospectively classified based on midazolam administration into BZD-free sedation (n=125) and BZD-based sedation (n=416) groups. Patients from each group were matched based on age, sex, tumor location, tumor grade, preoperative neurological deficits, non-operative BZD use, and Karnofsky Performance Scale scores, resulting in 108 patients within each group. Postoperative neurological deficits were recorded. Logistic regression analyses were conducted comparing postoperative neurological deficits between the matched groups. Postoperative neurological deficits were more prevalent within the BZD-based sedation group compared to the BZD-free sedation group (adjusted odds ratio (aOR)=1.903, 95% CI=1.018-3.560, p=0.044). In addition, subgroup analysis of the matched cohort showed a relationship between preoperative neurological symptoms and postoperative neurological deficits in the BZD-based sedation group (aOR=3.756, 95% CI=1.390-10.147, p=0.009). Our findings support the notion that the increased incidence of postoperative neurological deficits with BZD sedation may in part be related to the unmasking of preoperative neurological deficits. Further studies are required to confirm this phenomenon.
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Affiliation(s)
- Eric Plitman
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tumul Chowdhury
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Gabriel Paquin-Lanthier
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Hirokazu Takami
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sudhakar Subramaniam
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kok Weng Leong
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Abigail Daniels
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mark Bernstein
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Lashmi Venkatraghavan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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14
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Sato T, Ando T, Asano I, Mori A, Motomura K, Nishiwaki K. Serum Concentration of Ropivacaine After Repeated Administration to Several Parts of the Head During Awake Craniotomy: A Prospective Cohort Study. Front Med (Lausanne) 2022; 9:834334. [PMID: 35602485 PMCID: PMC9114455 DOI: 10.3389/fmed.2022.834334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction During awake craniotomy, effective use of local anesthetics, such as ropivacaine, is critical. Blood concentrations of ropivacaine after repeated administration over a short period during awake craniotomy have not been studied. Materials and Methods In this prospective cohort study, we evaluated serum concentrations of ropivacaine 15 min after each administration during awake craniotomy at Nagoya University Hospital between April 5, 2018 and August 31, 2019 to determine the safe dose. A total of 30 patients scheduled to undergo elective awake craniotomy were included. Patients were injected with 0.375% ropivacaine before the awake phase at the following points: scalp block (T1), headpin area (T2), skin incision area (T3), temporal muscle (T4), and dura mater (T5). Arterial blood samples were collected 15 min after ropivacaine administration. In addition to the blood concentrations of ropivacaine, complications during the awake phase were evaluated as secondary endpoints. Results The mean total dose of ropivacaine was 5.01 ± 0.68 mg/kg (maximum total dose: 6.30 mg/kg). The mean interval from T1 to T5 was 128.0 ± 17.7 min. The maximum serum concentration did not exceed the toxicity threshold of 4.3 μg/mL in any patient (mean serum concentration: T1, 1.23 ± 0.36 μg/mL; T5, 0.82 ± 0.26 μg/mL). No addiction symptoms were observed during awakening in any case. Conclusion Our results show that, in cases of awake craniotomy with repeated anesthetic administration, a total dose of up to 5.0 mg/kg is safe, without addiction symptoms. Relatively large amounts of ropivacaine can be safely injected during awake craniotomy.
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Affiliation(s)
- Takehito Sato
- Nagoya University Hospital Department of Anesthesiology, Nagoya, Japan
- *Correspondence: Takehito Sato ;
| | - Takahiro Ando
- Nagoya University Hospital Department of Anesthesiology, Nagoya, Japan
| | - Ichiko Asano
- Nagoya University Hospital Department of Anesthesiology, Nagoya, Japan
| | - Atsushi Mori
- Department of Perioperative Management System, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuya Motomura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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15
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Gray K, Avitsian R, Kakumanu S, Venkatraghavan L, Chowdhury T. The Effects of Anesthetics on Glioma Progression: A Narrative Review. J Neurosurg Anesthesiol 2022; 34:168-175. [PMID: 32658099 DOI: 10.1097/ana.0000000000000718] [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: 12/20/2019] [Accepted: 06/15/2020] [Indexed: 11/26/2022]
Abstract
There are many established factors that influence glioma progression, including patient age, grade of tumor, genetic mutations, extent of surgical resection, and chemoradiotherapy. Although the exposure time to anesthetics during glioma resection surgery is relatively brief, the hemodynamic changes involved and medications used, as well as the stress response throughout the perioperative period, may also influence postoperative outcomes in glioma patients. There are numerous studies that have demonstrated that choice of anesthesia influences non-brain cancer outcomes; of particular interest are those describing that the use of total intravenous anesthesia may yield superior outcomes compared with volatile agents in in vitro and human studies. Much remains to be discovered on the topic of anesthesia's effect on glioma progression.
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Affiliation(s)
| | - Rafi Avitsian
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Saranya Kakumanu
- Department of Radiation Oncology, Cancer Care Manitoba, Winnipeg, MB
| | - Lashmi Venkatraghavan
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, Toronto, ON, Canada
| | - Tumul Chowdhury
- Department of Anesthesiology, Perioperative, and Pain Medicine, Health Sciences Center, University of Manitoba
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16
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Stauffer A, Tortora A, Marbacher S, Frey J, Gschwind M, Weinmann C, Gruber P, Berberat J, Luedi MM, Andereggen L. Refractory photophobia elicited during awake craniotomy for the resection of a temporal high-grade glioma. J Clin Anesth 2022; 78:110650. [PMID: 35030494 DOI: 10.1016/j.jclinane.2022.110650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 10/19/2022]
Affiliation(s)
| | - Angelo Tortora
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland; Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Julia Frey
- Neuropsychology Unit, Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - Markus Gschwind
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Philipp Gruber
- Department of Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Jatta Berberat
- Department of Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland; Faculty of Medicine, University of Bern, Bern, Switzerland.
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17
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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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18
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Xu Y, Vagnerova K. Anesthetic Management of Asleep and Awake Craniotomy for Supratentorial Tumor Resection. Anesthesiol Clin 2021; 39:71-92. [PMID: 33563387 DOI: 10.1016/j.anclin.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Understanding how anesthetics impact cerebral physiology, cerebral blood flow, brain metabolism, brain relaxation, and neurologic recovery is crucial for optimizing anesthesia during supratentorial craniotomies. Intraoperative goals for supratentorial tumor resection include maintaining cerebral perfusion pressure and cerebral autoregulation, optimizing surgical access and neuromonitoring, and facilitating rapid, cooperative emergence. Evidence-based studies increasingly expand the impact of anesthetic care beyond immediate perioperative care into both preoperative optimization and minimizing postoperative consequences. New evidence is needed for neuroanesthesia's role in neurooncology, in preventing conversion from acute to chronic pain, and in decreasing risk of intraoperative ischemia and postoperative delirium.
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Affiliation(s)
- Yifan Xu
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code UH2, Portland, OR 97239, USA.
| | - Kamila Vagnerova
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code UH2, Portland, OR 97239, USA
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19
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Sato T, Nishiwaki K. Accuracy of landmark scalp blocks performed during asleep-awake-asleep awake craniotomy: a retrospective study. JA Clin Rep 2021; 7:8. [PMID: 33420848 PMCID: PMC7797012 DOI: 10.1186/s40981-021-00412-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Takehito Sato
- Department of Anesthesiology, Nagoya University hospital, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, 466-8550, Japan.
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Nagoya University hospital, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, 466-8550, Japan
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20
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Kim SH, Choi SH. Anesthetic considerations for awake craniotomy. Anesth Pain Med (Seoul) 2020; 15:269-274. [PMID: 33329824 PMCID: PMC7713838 DOI: 10.17085/apm.20050] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/17/2020] [Indexed: 11/17/2022] Open
Abstract
Awake craniotomy is a gold standard of care for resection of brain tumors located within or close to the eloquent areas. Both asleep-awake-asleep technique and monitored anesthesia care have been used effectively for awake craniotomy and the choice of optimal anesthetic approach is primarily based on the preferences of the anesthesiologist and surgical team. Propofol, remifentanil, dexmedetomidine, and scalp nerve block provide the reliable conditions for intraoperative brain mapping. Appropriate patient selection, adequate perioperative psychological support, and proper anesthetic management for individual patients in each stage of surgery are crucial for procedural safety, success, and patient satisfaction.
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Affiliation(s)
- Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Ho Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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