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Akavipat P, Sookplung P, Lekprasert V, Kasemsiri C, Lerdsirisophon S. Dexmedetomidine for awake craniotomy: Systematic review and meta-analysis. J Clin Neurosci 2024; 127:110765. [PMID: 39079421 DOI: 10.1016/j.jocn.2024.110765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/10/2024] [Accepted: 07/22/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION For awake craniotomy, monitored anaesthesia care (MAC) had shown relatively lower failure rates. Nevertheless, the conclusion of the appropriate anaesthetic agents, and complications, has not been proposed. Therefore, the systematic review and meta-analysis was done to compare the clinical profile, surgical outcomes, and anesthesia-related complications between dexmedetomidine-based and non-dexmedetomidine regimens during monitored anesthesia care (MAC) for this procedure. EVIDENCE ACQUISITION Published clinical trials described MAC, including the amount of anaesthetic drugs, or the number of patients for awake craniotomy between January 1st, 2009 and March 31st, 2022 were reviewed through PubMed, Scopus, Google Scholar, and grey literature index. The standard methodological procedures were following the PRISMA statement with the PROSPERO registration. Twenty-two articles with 2,137 awake craniotomy patients identified as epilepsy surgery, deep brain stimulation procedure, and intracranial surgery closed to an eloquent area with intraoperative awakening for neuro-evaluation were included. The relative risk (RR) regarding surgical outcomes, and anaesthesia-related complications were compared. EVIDENCE SYNTHESIS Dexmedetomidine-based versus non-dexmedetomidine anaesthetic regimen revealed no statistically significant differences in surgical outcomes (RR 1.08, 95 %CI 0.94-1.24), conversion to general anaesthesia (RR 0.45, 95 %CI 0.05-3.83), respiratory complications (RR 0.4, 95 %CI 0.12-1.27), and intraoperative nausea and vomiting (RR 0.30, 95 %CI 0.08-1.14). However, the intraoperative seizure was higher in non-dexmedetomidine group (RR 4.26, 95 %CI 1.49-12.16). CONCLUSION MAC for awake craniotomy with dexmedetomidine seems to be effective and safe. Randomized controlled trials with standard protocol in specific group of patients and surgical interventions would further demonstrate a clear benefit of dexmedetomidine in awake craniotomy under MAC.
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Affiliation(s)
- Phuping Akavipat
- Department of Anesthesiology, Neurological Institute of Thailand, Bangkok 10400, Thailand.
| | - Pimwan Sookplung
- Department of Anesthesiology, Neurological Institute of Thailand, Bangkok 10400, Thailand
| | - Varinee Lekprasert
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Cataleya Kasemsiri
- Department of Anesthesiology, Faculty of Medicine, Khon kaen University, Khon Kaen 40002, Thailand
| | - Surunchana Lerdsirisophon
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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Bala A, Olejnik A, Dziedzic T, Piwowarska J, Podgórska A, Marchel A. What helps patients to prepare for and cope during awake craniotomy? A prospective qualitative study. J Neuropsychol 2024; 18:30-46. [PMID: 37036087 DOI: 10.1111/jnp.12311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 03/09/2023] [Indexed: 04/11/2023]
Abstract
There is growing interest in awake craniotomies, but some clinicians are concerned that such procedures are poorly tolerated by patients. Therefore, we conducted a study to assess this phenomenon. In this prospective qualitative study, 68 patients who qualified for awake craniotomy were asked to complete the Hospital Anxiety and Depression Scale (HADS)-two days before the surgery and visual analogue scales (VAS) for pain and stress, two days before the surgery and again about two days after. In addition, after their surgery, they took part in a structured interview about what helped them prepare for and cope with the surgery. Most patients tolerated the awake surgery well, scoring low on stress and pain scales. They reported a lower level of stress during the surgery (when questioned afterwards) than before it. Intensity of stress before the surgery correlated negatively with age, positively with HADS anxiety score and positively with stress subsequently experienced during surgery. The level of stress during surgery was associated with stress experienced before the surgery, pain and HADS anxiety and depression scores. Severity of pain during the surgery was positively correlated with stress during surgery and HADS depression and anxiety scores before the surgery. There was no correlation between stress, pain, anxiety and depression and the location of the lesion. Patients have a high tolerance for awake craniotomy. Various factors have an impact on how well patients cope with the operation. Extensive preoperative preparation should be considered a key part of the procedure.
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Affiliation(s)
| | | | - Tomasz Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Piwowarska
- Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Anna Podgórska
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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Yin B, Chen X, Chen J, Zhao W, Li Z. ICGA combined with EP monitoring in microclipping of cerebral aneurysms. Neurosurg Rev 2023; 46:222. [PMID: 37665412 DOI: 10.1007/s10143-023-02111-3] [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: 05/05/2023] [Revised: 06/15/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023]
Abstract
Cerebral aneurysm is one of the common cerebrovascular diseases in neurosurgery, and rupture of cerebral aneurysm is the most important cause of spontaneous subarachnoid hemorrhage. How to precisely clip the aneurysm has been a topic worth discussing, so the authors explore the value of ICGA combined with electrophysiological monitoring in the microclipping of cerebral aneurysms. Using the method of retrospective analysis of cases, 661 patients with cerebral aneurysms admitted to the Department of Neurosurgery, Zhongnan Hospital of Wuhan University, from 2021.8 to 2022.10 were studied, 390 patients with aneurysm clipping were included, and patients with Hunt-Hess classification ≥ 4 were excluded, and whether to use ICGA combined with EP in microclipping of the ruptured and unruptured aneurysm in pterional approach was investigated at the time of discharge, respectively. The MRS and total hospital days were compared to investigate the value of ICGA combined with EP in the microclipping of cerebral aneurysms. All 390 patients enrolled in the group had successful aneurysm clipping, 178 patients were screened for ruptured aneurysm pterional approach and 120 patients for unruptured aneurysm pterional approach access; the MRS at discharge was significantly lower in the ICGA combined with EP group than in the no-EP group for ruptured aneurysm pterional approach microclipping (p < 0.001), and the mean number of days in hospital was significantly lower (p < 0.01). Patients in the ICGA combined with EP group in microclipping of unruptured aneurysms with pterional approach also had significantly lower MRS at discharge compared with patients in the ICGA alone group (p < 0.001), with no statistically significant difference in the mean number of days in hospital (p = 0.09). In open cerebral aneurysm microclipping, ICGA combined with EP monitoring for both ruptured and unruptured aneurysms can effectively reduce the false-negative rate of ICGA, significantly reduce the incidence of postoperative neurological deficits, and shorten the total hospital stay to some extent. ICGA combined with EP monitoring may be an effective means to reduce the rate of false clipping of the penetrating vessels and to avoid stenosis or occlusion of the aneurysm-carrying artery and is worth promoting in microclipping of cerebral aneurysms except for Hunt-Hess ≥ 4.
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Affiliation(s)
- Bokai Yin
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 169 Donghu Road, Wuchang District, Wuhan City, Hubei, 430070, China
- Department of Emergency Medicine, Yiling Hospital Affiliated to Three Gorges University, Yichang City, Hubei, China
| | - Xinjun Chen
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 169 Donghu Road, Wuchang District, Wuhan City, Hubei, 430070, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 169 Donghu Road, Wuchang District, Wuhan City, Hubei, 430070, China
| | - Wenyuan Zhao
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 169 Donghu Road, Wuchang District, Wuhan City, Hubei, 430070, China.
| | - Zhengwei Li
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, 169 Donghu Road, Wuchang District, Wuhan City, Hubei, 430070, China.
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Skrap B, Di Bonaventura R, Di Domenico M, Sturiale CL, Auricchio AM, Maugeri R, Giammalva GR, Iacopino DG, Olivi A, Marchese E, Albanese A. Has intraoperative neuromonitoring changed the surgery for unruptured middle cerebral artery aneurysms? A retrospective comparative study. Neurosurg Rev 2023; 46:191. [PMID: 37535200 PMCID: PMC10400477 DOI: 10.1007/s10143-023-02099-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/30/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
Intraoperative neurophysiological monitoring (IONM) represents one of the available technologies able to assess ischemia and aimed to improve surgical outcome reducing the treatment related morbidity in surgery for intracranial aneurysms. Many studies analyzing the impact of IONM are poised by the heterogeneity bias affecting the cohorts. We report our experience with IONM for surgery of unruptured middle cerebral artery (MCA) aneurysm in order to highlight its influence on functional and radiological outcome and surgical strategy. We retrospectively reviewed all MCA unruptured aneurysms treated between January 2013 and June 2021 by our institutional neurovascular team. Patients were divided into 2 groups according to the use of IONM. A total of 153 patients were included in the study, 52 operated on without IONM and 101 with IONM. The groups did not differ preoperatively regarding clinical status and aneurysm characteristics. Patients operated with IONM had better functional outcomes at discharge as well as at follow-up (p= 0.048, p=0.041) due to lower symptomatic ischemia and better radiological outcome due to lower rate of unexpected aneurysmal remnants (p= 0.0173). The introduction of IONM changed the use of temporary clipping (TeC), increasing its average duration (p= 0.01) improving the safety of dissecting and clipping the aneurysm. IONM in surgery for unruptured MCA aneurysm could improve the efficacy and safety of clipping strategy in the way it showed a role in changing the use of TeC and was associated to the reduction of unexpected aneurysmal remnants' rate and improvement in both short- and long-term patient's outcome.
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Affiliation(s)
- Benjamin Skrap
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Rina Di Bonaventura
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Michele Di Domenico
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Carmelo Lucio Sturiale
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Anna Maria Auricchio
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Rosario Maugeri
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Department of Biomedicine Neurosciences and Advanced Diagnostics, School of medicine, University of Palermo, Palermo, Italy
| | - Giuseppe Roberto Giammalva
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Department of Biomedicine Neurosciences and Advanced Diagnostics, School of medicine, University of Palermo, Palermo, Italy
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Department of Biomedicine Neurosciences and Advanced Diagnostics, School of medicine, University of Palermo, Palermo, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Enrico Marchese
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Alessio Albanese
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
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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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Patchana T, Lopez JA, Majeed G, Ho A, Alarcon T, Plantak N, Vu P, Siddiqi J. The Awake Craniotomy: A Patient’s Experience and A Literature Review. Cureus 2022; 14:e26441. [PMID: 35915692 PMCID: PMC9338386 DOI: 10.7759/cureus.26441] [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: 05/17/2022] [Accepted: 06/29/2022] [Indexed: 11/25/2022] Open
Abstract
We present a case report and a literature review of the awake craniotomy procedure for mass resection, with emphasis on the historical aspects, anatomical and surgical considerations, and, uniquely, a patient’s experience undergoing this procedure. This procedure is a safe and effective method for lesion resection when working in and around eloquent brain. We have described our process of guiding a patient through an awake craniotomy procedure and detailed the patient's experience in this study. We also conducted a systematic literature review of studies involving awake craniotomy over three years, 2018-2021. Lastly, we compared the methodology used by our institution and the current mostly used methods within the neurosurgical community. Several studies were identified using PubMed and Google Scholar. Awake craniotomy is a safe and effective method of achieving a high rate of resection of lesions located in and around the eloquent cortex with a low degree of postoperative neurological deficit.
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Wilkinson MF, Chowdhury T, Kaufmann AM. A novel method for quantitative evaluation of motor evoked potential monitoring during cerebrovascular surgeries. J Clin Neurosci 2022; 98:29-36. [DOI: 10.1016/j.jocn.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 11/08/2021] [Accepted: 01/22/2022] [Indexed: 11/29/2022]
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Zhou HY, Chen HY, Li Y. Anesthetic technique for awake artery malformation clipping with motor evoked potential and somatosensory evoked potential: A case report. World J Clin Cases 2021; 9:8207-8213. [PMID: 34621882 PMCID: PMC8462218 DOI: 10.12998/wjcc.v9.i27.8207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/09/2021] [Accepted: 08/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Awake craniotomy has been widely used for tumor resection, epilepsy surgery, deep brain stimulation, and carotid endarterectomy. The report on awake artery malformation clipping is rare, especially for anesthesia management.
CASE SUMMARY A 62-year-old female diagnosed with malformation of anterior cerebral artery at the right side. We clipped the artery malformation with intraoperative neuromonitoring (IONM) in awake craniotomy. Spontaneous respiration was maintained throughout the procedure by nasopharyngeal airway during the surgery successfully.
CONCLUSION The technique of monitoring anesthesia care can be performed successfully for the patient with IONM.
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Affiliation(s)
- Hong-Yu Zhou
- Department of Anesthesiology, West China Hospital, Chengdu 610041, Sichuan Province, China
| | - Hong-Yang Chen
- Department of Anesthesiology, West China Hospital, Chengdu 610041, Sichuan Province, China
| | - Yu Li
- Department of Anesthesiology, West China Hospital, Chengdu 610041, Sichuan Province, China
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Asimakidou E, Abut PA, Raabe A, Seidel K. Motor Evoked Potential Warning Criteria in Supratentorial Surgery: A Scoping Review. Cancers (Basel) 2021; 13:2803. [PMID: 34199853 PMCID: PMC8200078 DOI: 10.3390/cancers13112803] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 12/31/2022] Open
Abstract
During intraoperative monitoring of motor evoked potentials (MEP), heterogeneity across studies in terms of study populations, intraoperative settings, applied warning criteria, and outcome reporting exists. A scoping review of MEP warning criteria in supratentorial surgery was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sixty-eight studies fulfilled the eligibility criteria. The most commonly used alarm criteria were MEP signal loss, which was always a major warning sign, followed by amplitude reduction and threshold elevation. Irreversible MEP alterations were associated with a higher number of transient and persisting motor deficits compared with the reversible changes. In almost all studies, specificity and Negative Predictive Value (NPV) were high, while in most of them, sensitivity and Positive Predictive Value (PPV) were rather low or modest. Thus, the absence of an irreversible alteration may reassure the neurosurgeon that the patient will not suffer a motor deficit in the short-term and long-term follow-up. Further, MEPs perform well as surrogate markers, and reversible MEP deteriorations after successful intervention indicate motor function preservation postoperatively. However, in future studies, a consensus regarding the definitions of MEP alteration, critical duration of alterations, and outcome reporting should be determined.
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Affiliation(s)
- Evridiki Asimakidou
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
| | - Pablo Alvarez Abut
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
- Department of Neurosurgery, Clínica 25 de Mayo, 7600 Mar del Plata, Argentina
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
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Kumar S, Sahana D, Menon G. Optimal Use of Temporary Clip Application during Aneurysm Surgery - In Search of the Holy Grail. Asian J Neurosurg 2021; 16:237-242. [PMID: 34268145 PMCID: PMC8244713 DOI: 10.4103/ajns.ajns_465_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/29/2021] [Indexed: 11/04/2022] Open
Abstract
Temporary clips are invaluable safety tools during the clipping of an aneurysm. Controversies regarding maximum permissible duration and safety, however, remain unanswered. This descriptive narrative attempts to review the literature to provide valuable insights on controversies clouding the use of temporary clips among neurosurgeons. Popular databases, including Pub Med, Medline/Medscape, Scopus, Cochrane, Embase, Google Scholar, were searched to find available literature on temporary clips. The searched MeSH terms were "Temporary Clip," "Temporary Clipping," "Cerebral Aneurysm," and "Aneurysm." Temporary clips have been in use since 1928 and have undergone considerable structural and technical modifications. A temporary clip's optimal safety limit is not yet defined with literature evidence ranging from immediate to 93 min. It is not yet definite whether temporary clips application aggravates vasospasm, but emergency temporary clips application, especially in poor-grade aneurysmal subarachnoid hemorrhage patients, is associated with poor outcomes. A temporary clip needs to be applied with caution in patients treated earlier by endovascular technique and having indwelling stents. Nitinol Stent is feasible, while a Cobalt-Chromium alloy stent does not get occluded and gets deformed under the closing pressure of a temporary clip. Although a temporary clip application is a fundamental strategy during the clipping of an aneurysm; the exact safe duration remains to be decided in randomized control trials. Their utility for the shorter duration is beneficial under un-conclusive evidence of neuroprotective agents and intraoperative monitoring. Neurosurgeons need to consider all aspects of their pros and cons for optimal use.
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Affiliation(s)
- Sanjeev Kumar
- Department of Neurosurgery, DKS Postgraduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Debabrata Sahana
- Department of Neurosurgery, DKS Postgraduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Kim SH, Choi SH. Anesthetic considerations for awake craniotomy. Anesth Pain Med (Seoul) 2020; 15:269-274. [PMID: 33329824 PMCID: PMC7713838 DOI: 10.17085/apm.20050] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/17/2020] [Indexed: 11/17/2022] Open
Abstract
Awake craniotomy is a gold standard of care for resection of brain tumors located within or close to the eloquent areas. Both asleep-awake-asleep technique and monitored anesthesia care have been used effectively for awake craniotomy and the choice of optimal anesthetic approach is primarily based on the preferences of the anesthesiologist and surgical team. Propofol, remifentanil, dexmedetomidine, and scalp nerve block provide the reliable conditions for intraoperative brain mapping. Appropriate patient selection, adequate perioperative psychological support, and proper anesthetic management for individual patients in each stage of surgery are crucial for procedural safety, success, and patient satisfaction.
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Affiliation(s)
- Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Ho Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Motoyama Y, Hayashi H, Kawanishi H, Tsubaki K, Takatani T, Takamura Y, Kotsugi M, Kim T, Yamada S, Nakagawa I, Park YS, Kawaguchi M, Nakase H. Ocular blood flow by laser speckle flowgraphy to detect cerebral ischemia during carotid endarterectomy. J Clin Monit Comput 2020; 35:327-336. [PMID: 32034601 DOI: 10.1007/s10877-020-00475-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/25/2020] [Indexed: 11/29/2022]
Abstract
Laser speckle flowgraphy (LSFG) is a noninvasive technique that can measure relative blood flow velocity in the optic fundus contributed by the ophthalmic artery, the main first branch originating from the internal carotid artery (ICA). The aim of this study was to assess the feasibility of ocular blood flow measurement by LSFG to detect ischemic stress due to carotid clamping during carotid endarterectomy (CEA). Nineteen patients undergoing CEA with ocular blood flow measurement by LSFG and intraoperative monitoring (IOM) were prospectively enrolled between August 2016 and March 2019. The mean blur rate (MBR) of ocular blood flow by LSFG, representing relative blood flow of the branch of the retinal artery originating from the optic nerve head, was compared between before and after carotid clamping during CEA. The correlation between the reduction ratio of MBR and the regional saturation oxygen (rSO2) index by near infrared spectroscopy was investigated. Ocular blood flow measurement by LSFG could not be performed in one patient with a severe cataract. In the other 18 patients, LSFG could be performed in all 106 sessions during surgery. The MBR reduction ratio between before and after carotid clamping ranged from - 12 to 100%. The MBR reduction ratio was positively correlated with the rSO2 index (r = 0.694, 95% confidence interval: 0.336-0.877, p = 0.001). The MBR reduction ratio of ocular blood flow by LSFG after carotid clamping was significantly correlated with the rSO2 index. The ocular blood flow by LSFG could be considered an adjunct modality for evaluating cerebral ischemic tolerance during CEA.
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Affiliation(s)
- Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan. .,Stroke Center, Nara Medical University, Kashihara, Nara, Japan.
| | - Hironobu Hayashi
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Hideaki Kawanishi
- Department of Operation Center, Nara Medical University, Kashihara, Nara, Japan
| | - Kohsuke Tsubaki
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Tsunenori Takatani
- Department of Operation Center, Nara Medical University, Kashihara, Nara, Japan
| | - Yoshiaki Takamura
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.,Stroke Center, Nara Medical University, Kashihara, Nara, Japan
| | - Masashi Kotsugi
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Taekyun Kim
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Shuichi Yamada
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.,Stroke Center, Nara Medical University, Kashihara, Nara, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Young-Su Park
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.,Stroke Center, Nara Medical University, Kashihara, Nara, Japan
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Abstract
PURPOSE OF REVIEW The current review reports on current trends in the anesthetic management of awake craniotomy, including preoperative preparation, sedation schemes, pain management, and prevention of intraoperative complications. RECENT FINDINGS Both approaches for anesthesia for awake craniotomy, asleep-awake-asleep and monitored anesthesia care (MAC), have shown equal efficacy for performing intraoperative brain mapping. Choice of the appropriate scheme is currently based mainly on the preferences of the particular anesthesiologist. Dexmedetomidine has demonstrated high efficacy and safety in MAC for awake craniotomy and has become a rational alternative to propofol. Despite the high efficacy of scalp block and opioids, pain remains a common compliant in awake craniotomy. Appropriate surgical tactics can reduce pain and even prevent postoperative neurological complications. Although the efficacy of prophylaxis of intraoperative seizures with anticonvulsants remains doubtful, levetiracetam can be superior to other drugs for this purpose. SUMMARY Following a great deal of progress in anesthetic management, awake craniotomy, which had been a relatively rare approach, is now a commonly performed procedure for neurosurgical intervention. Modern anesthesia techniques can provide for successful brain mapping in almost any patient. Management of awake craniotomy in high-risk patients is a central task for future research.
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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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Shekhtman OD, Gorozhanin VA, Kulikov AS, Okisheva EA. [Proximal clipping of a large fusiform aneurysm of the A2 segment of the left anterior cerebral artery with awakening of the patient (a case report and literature review)]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 82:97-102. [PMID: 30137043 DOI: 10.17116/neiro201882497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Arterial aneurysms of the A2 segment are very rare (<1%) peripheral aneurysms of the anterior cerebral artery (ACA) territory. Usually, these are saccular aneurysms; there are single reports of fusiform aneurysms of this location. Surgical treatment of these aneurysms involves both microsurgical and endovascular interventions. In the presented case, we used deconstructive surgery (proximal clipping of the aneurysm) with intraoperative awakening of the patient, which verified sufficient collateral blood flow. In the case of focal deficit development, we planned to simultaneously perform an interarterial anastomosis between the A3 segments of the right and left ACAs.
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Affiliation(s)
| | | | - A S Kulikov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - E A Okisheva
- Sechenov First Moscow State Medical University, Moscow, Russia
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Kim JW, Seung WB. Delayed Branching Artery Occlusion Caused by Clip Rotation after Intracranial Aneurysm Clippings. Case Rep Neurol 2018; 10:159-164. [PMID: 30057543 PMCID: PMC6062732 DOI: 10.1159/000490375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 05/16/2018] [Indexed: 12/31/2022] Open
Abstract
Clip rotation after clipping is a major cause of delayed cerebral ischemia and may occur after any of several intraoperative monitoring techniques. We experienced 3 cases of clip rotation in 3 patients after clipping between March 2011 and December 2013. One of these patients has permanent motor weakness of the left upper extremity because of delayed occlusion of the right M1 lenticulostriate artery. The other two developed delayed occlusion of the frontopolar artery or of the A1 perforating artery, but did not have any neurologic deficits. Clinicians need to exercise great care not to compromise distal blood flow after clipping intracranial aneurysms. We present 3 cases in which clip rotation occurred after aneurysm clipping and progressively compromised blood flow of a nearby branching artery.
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Affiliation(s)
- Jin Wook Kim
- Department of Neurosurgery, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Republic of Korea
| | - Won-Bae Seung
- Department of Neurosurgery, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Republic of Korea
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18
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Wilkinson M, Kaufmann AM. Letter to the Editor. Motor evoked potentials: details matter. J Neurosurg 2018; 129:256-257. [DOI: 10.3171/2018.1.jns173124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Idris Z, Kandasamy R, Neoh YY, Abdullah JM, Wan Hassan WMN, Mat Hassan ME. The First Awake Clipping of a Brain Aneurysm in Malaysia and in ASEAN: Achieving International Standards. Malays J Med Sci 2018; 25:1-4. [PMID: 29599629 DOI: 10.21315/mjms2018.25.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 12/31/2017] [Indexed: 10/17/2022] Open
Abstract
World-renowned neurosurgeon, Professor Saleem Abdulrauf, has been featured in several medical journals for his successful "Awake Brain Aneurysm Surgery". Regarded as a "world first", this surgery, involves clipping un-ruptured brain aneurysms while patients are awake. Only one or two neurosurgery centres worldwide are capable of this. Performing the surgery while the patient is awake lowers risks of brain ischemia with neurological deficits and ventilator associated morbidities. The technique has been viewed as the start of a new era in brain surgery. Physicians from the Universiti Sains Malaysia (USM) School of Medical Sciences, at the Health Campus in Kelantan, headed by Professor Dr Zamzuri Idris (neurosurgeon) and Dr Wan Mohd Nazaruddin Wan Hassan (neuroanaesthetist), recently performed a similar procedure, the first such surgery in Malaysia and Southeast Asia. The USM team can therefore be considered to be among the first few to have done this brain surgery and achieved successful patient outcomes.
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Affiliation(s)
- Zamzuri Idris
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia.,Center for Neuroscience Services and Research, Health Campus, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Regunath Kandasamy
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Yee Yik Neoh
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Jafri Malin Abdullah
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia.,Center for Neuroscience Services and Research, Health Campus, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Wan Mohd Nazaruddin Wan Hassan
- Department of Anaesthesia, School of Medical Sciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Mohd Erham Mat Hassan
- Department of Anaesthesia, School of Medical Sciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
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Agarwal N. Letter to the Editor. Intraoperative aneurysm rupture during awake clipping of cerebral aneurysms. J Neurosurg 2018; 128:1906. [PMID: 29570014 DOI: 10.3171/2017.9.jns172142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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21
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Abdulrauf SI, Urquiaga JF, Patel R, Albers JA, Sampat VB, Baumer M, Marvin E, Pierson M, Kragel R, Walsh J. Awake Microvascular Decompression for Trigeminal Neuralgia: Concept and Initial Results. World Neurosurg 2018; 113:e309-e313. [PMID: 29452326 DOI: 10.1016/j.wneu.2018.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/02/2018] [Accepted: 02/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND In this initial series, we evaluated the use of microvascular decompression (MVD) under an awake anesthesia protocol ("awake" MVD) to assess whether intraoperative pain evaluation can identify and mitigate insufficient decompression of the trigeminal nerve, improving surgical outcomes, and possibly expand the indications of MVD in patients with comorbidities that would preclude the use of general endotracheal anesthesia (GEA). METHODS An Institutional Review Board-approved prospective study of 10 consecutive adults who underwent MVD for trigeminal neuralgia (TN) was conducted. The primary outcome measure was postoperative TN pain quantified on the Barrow Neurological Institute (BNI) Pain Severity Scale. RESULTS The median patient age was 65.5 years, with a female:male ratio of 6:4. All 10 patients tolerated the procedure well and did not require GEA intraoperatively or postoperatively. Nine patients had a successful surgical outcome (BNI score I, n = 5; BNI score II, n = 4). One patient did not have pain relief (BNI score IV). This same patient also developed a pseudomeningocele, which was the sole surgical complication observed in this series. One patient experienced recurrence of pain at 11 months, with BNI score increasing from I to II. The median duration of follow-up was 16.5 months. Two patients did not experienced resolution of evoked pain during intraoperative awake testing following decompression. Further intraoperative exploration revealed secondary offending vessels that were subsequently decompressed, leading to resolution of pain. CONCLUSIONS Intraoperative awake testing for treatment efficacy may increase the success rate of MVD by rapidly identifying and mitigating insufficient cranial nerve V decompression.
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Affiliation(s)
- Saleem I Abdulrauf
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA.
| | - Jorge F Urquiaga
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Ritesh Patel
- Department of Anesthesiology and Critical Care, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - J Andrew Albers
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Varun B Sampat
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Meghan Baumer
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Eric Marvin
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Matthew Pierson
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Raquel Kragel
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Jodi Walsh
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
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Tanabe J, Ishikawa T, Moroi J. Safe time duration for temporary middle cerebral artery occlusion in aneurysm surgery based on motor-evoked potential monitoring. Surg Neurol Int 2017; 8:79. [PMID: 28584682 PMCID: PMC5445649 DOI: 10.4103/sni.sni_410_16] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 03/20/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Temporary vessel occlusion of the parent artery is an essential technique for aneurysm surgery. Our aim was to clarify the safe time for temporary occlusion for aneurysm surgery, that is the "safe time duration" (STD), in which brain tissue exposed to ischemia will almost never fall into even the ischemic penumbra during temporary occlusion of the middle cerebral artery (MCA), and even transient postoperative motor impairment will be rare using intraoperative motor-evoked potentials (MEP). METHODS Twenty-four patients underwent MCA aneurysm clipping surgery with MEP monitoring for 13 ruptured aneurysms and 11 unruptured aneurysms. The duration of vessel occlusion in patients without MEP changes was measured as the STD. Average STD was calculated as 95% confidence interval for the population mean using sample data from patients with MEP changes and patients without changes. RESULTS All 24 patients received proximal flow control only. Five patients (20.8%) developed significant intraoperative MEP changes. Time to MEP change (i.e., STD) in these patients was 4.6 ± 2.1 min. In patients without MEP changes, STD was 2.7 ± 1.4 min. Average STD was thus 3.1 ± 0.7 min. CONCLUSIONS The 95% lower confidence limit for average STD was 2.4 min when applying temporary occlusion on the proximal side of the MCA. This STD resembled that previously reported for temporary proximal occlusion of the internal carotid artery.
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Affiliation(s)
- Jun Tanabe
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan
| | - Tatsuya Ishikawa
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan
| | - Junta Moroi
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan
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Shafiq F, Khan S, Nathani K, Enam S. Awake craniotomy in developing countries: review of hurdles. ACTA ACUST UNITED AC 2017. [DOI: 10.4103/2468-7332.200557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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