Case Report of an Awake Craniotomy in a Patient With Eisenmenger Syndrome

Anaesthetic management in neurosurgery in a patient with Eisenmenger syndrome and Down syndrome. A case report

Adults patients with congenital heart disease increasingly present for non cardiac surgery. The anesthetic management this type of patients in neurosurgery requires a meticulous surgical anesthetic planning. The need for urgent intervention, with the presence of a congenital heart disease evolved to Eisenmenger syndrome, associated to a difficult airway, is a challenge for the anesthesiologist. The use of dexmedetomidine may be a valid alternative. We present the case of a patient with Down syndrome, and Eisenmenger syndrome who underwent drainage of brain abscess from the emergency department and was subsequently scheduled for reintervention. We compare the different anesthetic techniques used in both procedures, analyzing the implications they had on the main physiopathological alterations presented by the patient.

Anaesthetic management in neurosurgery in a patient with Eisenmenger syndrome and Down syndrome. A case report

Adults patients with congenital heart disease increasingly present for non cardiac surgery. The anesthetic management this type of patients in neurosurgery requires a meticulous surgical anesthetic planning. The need for urgent intervention, with the presence of a congenital heart disease evolved to Eisenmenger Syndrome, associated to a difficult airway, is a challenge for the anesthesiologist. The use of dexmedetomidine may be a valid alternative. We present the case of a patient with Down syndrome, and Eisenmenger syndrome who underwent drainage of brain abscess from the emergency department and was subsequently scheduled for reintervention. We compare the different anesthetic techniques used in both procedures, analyzing the implications they had on the main physiopathological alterations presented by the patient.

Awake Surgical Management of Third Ventricular Tumors: A Preliminary Safety, Feasibility, and Clinical Applications Study

BACKGROUND

Endoscopic and microneurosurgical approaches to third ventricular lesions are commonly performed under general anesthesia.

OBJECTIVE

To report our initial experience with awake transsulcal parafascicular corridor surgery (TPCS) of the third ventricle and its safety, feasibility, and limitations.

METHODS

A total of 12 cases are reviewed: 6 colloid cysts, 2 central neurocytomas, 1 papillary craniopharyngioma, 1 basal ganglia glioblastoma, 1 thalamic glioblastoma, and 1 ependymal cyst. Lesions were approached using TPCS through the superior frontal sulcus. Pre-, intra-, and postoperative neurocognitive (NC) testing were performed on all patients.

RESULTS

No cases required conversion to general anesthesia. Awake anesthesia changed intraoperative management in 4/12 cases with intraoperative cognitive changes that required port re-positioning; 3/4 recovered. Average length of stay (LOS) was 6.1 d ± 6.6. Excluding 3 outliers who had preoperative NC impairment, the average LOS was 2.5 d ± 1.2. Average operative time was 3.00 h ± 0.44. Average awake anesthesia time was 5.05 h ± 0.54. There were no mortalities.

CONCLUSION

This report demonstrated the feasibility and safety of awake third ventricular surgery, and was not limited by pathology, size, or vascularity. The most significant factor impacting LOS was preoperative NC deficit. The most significant risk factor predicting a permanent NC deficit was preoperative 2/3 domain impairment combined with radiologic evidence of invasion of limbic structures – defined as a “NC resilience/reserve” in our surgical algorithm. Larger efficacy studies will be required to demonstrate the validity of the algorithm and impact on long-term cognitive outcomes, as well as generalizability of awake TPCS for third ventricular surgery.

Anaesthesiologist's Approach to Awake Craniotomy

Awake craniotomy, which was initially used for the surgical treatment of epilepsy, is performed for the resection of tumours in the vicinity of some eloquent areas of the cerebral cortex which is essential for language and motor functions. It is also performed for stereotactic brain biopsy, ventriculostomy, and supratentorial tumour resections. In some institutions, avoiding risks of general anaesthesia, shortened hospitalization and reduced use of hospital resources may be the other indications for awake craniotomy. Anaesthesiologists aim to provide safe and effective surgical status, maintaining a comfortable and pain-free condition for the patient during surgical procedure and prolonged stationary position and maintaining patient cooperation during intradural interventions. Providing anaesthesia for awake craniotomy require scalp blockage, specific sedation protocols and airway management. Long-acting local anaesthetic agents like bupivacaine or levobupivacaine are preferred. More commonly, propofol, dexmedetomidine and remifentanyl are used as sedative agents. A successful anaesthesia for awake craniotomy depends on the personal experience and detailed planning of the anaesthetic procedure. The aim of this review was to present an anaesthetic technique for awake craniotomy under the light of the literature.