Awake Craniotomy for Speech Mapping of Temporal Lobe Astrocytoma

Jeremy T. Rainey, D.O.1, Lakshmi N Kurnutala, M.D. 1, Robert Rey-Dios, M.D2.

1 Department of Anesthesiology and 2 Department of Neurosurgery, University of Mississippi Medical Center, Jackson, MS

ABSTRACT The motor cortex and temporal areas were identified

DISCUSSION
using electrocorticography and mapping accomplished
by noting where speech arrest was observed, and
A 27 year old male patient with recent onset of seizures with The awake anesthetic technique for elective craniotomy is usually
anomia and phonetic paraphasias induced. All areas of
left temporal mass was scheduled for craniotomy. An awake selected based on surgical indications, such as supratentorial
tumor were stimulated with no electrical response. and
craniotomy utilizing stereotatic navigation with cortical cortical tumors, but specifically temporal lobectomy where
then debulked successfully.
stimulation for motor and speech mapping with TIVA electrocorticography is utilized to map eloquent areas (1,10).
At the conclusion of surgery he was taken to the
(propofol and remifentanil) was planned. Standard ASA The performance of an awake craniotomy requires a patient to lie
neurosurgical intensive care unit for monitoring.
monitors and capnography were utilized. Two large bore IVs, relatively immobile for long time periods, and systemic and
The length of surgery was approximately 8.5hrs, with
an arterial line, and bilateral scalp blocks of 1:1 mixture of physiological obstructions such as joint pain, back pain,
~300cc blood loss, urine output of ~1L, 2L normal
1% lidocaine with epinephrine and 0.5% bupivacaine with obstructive sleep apnea, and orthopnea may adversely affect the
saline, and 50g Mannitol. Postoperative imaging
3% bicarbonate were placed. The patient was placed supine success of the anesthetic and compromise the procedure (2).
showed expected post surgical changes without acute
with rightward rotation. His head was then turned, exposing All patients should undergo preoperative evaluation by both the
bleeding or midline shifts.
the left temporal area. Mayfield pins were placed. The neurosurgeon and anesthesiologist whereby full details and risks
He was successfully discharged four days
craniotomy proceeded without incident. and benefits of both the surgery and anesthetic are discussed
postoperatively and is currently undergoing
(3,7,9).
chemoradiation treatments. His seizures have
Sedation or asleep-awake-asleep approaches can be performed,
decreased and he continues to have progressive
but both benefit from the use of scalp blocks performed once the
improvement in his speech and memory
CASE REPORT patient is in the operating room (1,2,5,7). Typical local
anesthetics utilized for this are bupivacaine, levobupivacaine, and
A 27 year old male patient with recent onset of seizures ropivacaine with or without the addition of epinephrine, typically
and aggressive behavior with left temporal mass for surgical of 1:200,000 concentration (3,10)
resection of tumor with cortical mapping (speech and Postoperatively patients are typically monitored in a neurosurgical
motor). He had no other significant medical or surgical intensive care unit for twenty-four to seventy-two hours to
history. On the day of his surgery his review of systems was monitor for signs of deterioration (6). Hematomas can occur
negative, except for difficulties with memory and word- within six hours of the operation which may warrant emergent
finding. surgical evacuation (3,6).
An awake craniotomy utilizing sterotatic navigation and Awake craniotomy is a well-tolerated procedure with low
direct cortical stimulation for motor and speech mapping morbidity and mortality, as well as a 2-6% conversion rate to
with TIVA, utilizing propofol and remifentanil infusions general anesthesia (1,8).
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