Review Article

Awake Craniotomy
Introduction
Anesthetic care of neurological patients
increasingly involves management issues not only
to “asleep patients” ,but also to “awake and
waking-up patients”
Introduction
The challenge for the anesthetist is to provide
1.adequate analgesia and sedation
2.a safe airway
3.awake patient
4.cooperate patient for neurological testing
Why awake craniotomy?

• 1.Intraoperative functional cortical mapping

– epileptogenic lesion ,tomor,AVM
– steriotactic surgery
– importance of alert,cooperative patient
Why awake craniotomy?

• 2.Intraoperative electrocorticography
– epileptogenic lesion
– importance of avoidance of confounding drugs
Preoperative Evaluation

The preoperative visit represent the most important

factor contributing to a successful perioperative
period
Preoperative Evaluation

• Patient selection
– chronic refractory epilepsy
– candidate for GA
– uncomplicated airway
Preoperative Evaluation

• Patient assessment
– anxiety
– psychological profile
– seizure pattern( preictal ,ictal and post-
ictal,including behavioural concerns)
Preoperative Preparation

• Detailed verbal description of procidure

– noise ,sensation and environment
– PCA ,neurological testing
Preoperative Preparation

• Videotape session
– conduct of anesthetic
– conduct of the surgery
Preoperative Preparation

• Premedication
– anticonvulsant
– sedative drugs
Intraoperative Management
Intraoperative Management

• Positioning
– temporal lobe surgery:lateral position
– patient comfort and safety
Patient Comfort

• Extra thick mattress

• warming blanket or warm room
• padded horse-shoe
• rigid back support
Patient Comfort

• Pillow between legs

• no urinary catheter
• a hand to hold
• eye to eye contact
Intraoperative Monitoring

• NIBP
• EKG
• Pulse oximetry
• Endtidal CO2
Intraoperative Monitoring

• Additional monitoring added as appropriate for

the patient
– arterial or central venous monitoring depending on
cardiovascular status
 Intraoperative Conduct
The Asleep-Awake-Asleep technique
Intraoperative Conduct

• Oxygen supplement:via nasal canular with

capnography sampling
• Sedation and Analgesia
• Antiemesis
• Antiepileptic
Intraoperative Conduct

• Sedation and Analgesia

– administration of sedative is usually begun
following placement of monitors and positioning
of the patient
Intraoperative Conduct

• Sedation and Analgesia

– neuroleptic analgesia:droperidol and fentanyl
– propofol sedation
Intraoperative Conduct

• During the early intraoperative period,light

sedation is the goal
• If local anesthetic blockade of the scalp and dura
mater is adaquate,the procedure is comfortable
during the period
Intraoperative Conduct

• Sedation and Analgesia

– the objective is to ensure a cooperative patient
when cortical mapping is performed and to
minimized sedation prior to ECoG recording
Intraoperative Conduct

• To avoid anxiety,patient should be forewarned

of these activities
– lound noise levels when burr holes are drilled
– stimulation during ECoG recording
Intraoperative Conduct

• Pain is related to traction and distortion of dura

and blood vessles
• This discomfort can be allevaited with injection
of local anesthetic into the dura or deeper level
of sedation
Intraoperative Conduct

• The surgeon must exercise patient and use of

gentle technique, and inform ithe patient
regularly of the progress of the operation
Intraoperative Conduct

• The anesthesiologist must attend to the patient

– to ensure the patient
– to provide supplemental analgesia
– to manage nausia, emesis and convulsion if they
occur
Postoperative Care

• Monitoring for evidence of neurologic

deterioration
• The early postoperative period may be
complicated by cerebral edema,intracranial
hemorrhage and seizure
Postoperative Care

• Neurological assessment include

– the level of consciousness
– language
– orientation and motor function
Regional Scalp Block

• Greater Occipital Nerve :2-4 cm lat. To

inion,just below sup.nuchal line
• Lesser Occipital Nerve ($Gr. Auricular n.):1.5
cm posterior to ear at the level of tragus over
2cm
Regional Scalp Block
• Auriculotemporal Nerve : 1 cm anterior to tragus
above zygoma, direct posteriorly then anteriorly
• Supraorbital Nerve ($Supratrochlear n.):palpation of
supraorbital notch,1 cm fan
• Up to 20 ml 0.5%bupivacaine with 1:200000 adr for
regional scalp block 1-2 hrs pre-op
Field Block

• Up to 60 ml 0.33% bupivacaine with 1:200,000

adrenaline
– along incision line
– into deep portion of temporalis from supraorbital
ridge to posterior margin of zygoma
Field Block

• Dural leaflets:lidocaine 1% plain via insulin

syringe
 Laryngeal Mask Airway in anesthesia for awake
craniotomy
• A. Sarang and J. Dismore (British Journal of
Anesthesia,2003.90,163-165)
• There were 99 procedures carried out between
1989 and 2002
 Laryngeal Mask Airway in anesthesia for awake
craniotomy
• Patient in Gr 1were sedated throuhout the procedure
• Patient in Gr 2 were anesthetized with a propofol
infusion and fentanyl,and breathed spontaneeously
through LMA
• Patient in Gr 3 had total iv. Anesthesia with propofol and
remifentanil and ventilation was controlled using LMA
 Non -invasive positive pressure ventilation in
anesthesia for awake craniotomy
• F.Yamamoto, R. Kato,J Sato and T. Nishino( British
Journal of Anesthesia 2003;90:381-385)
• Reported 2 casses of anesthesia for awake craniotomy
using non-invasive pressure ventilation
• This technique provided adequate lung ventilation,smooth
transition between anesthesia and arousal
 Endotracheal Intubation in anesthesia for awake
craniotomy
• Kate Huncke et al: Neurosurgery 1998
• This technique, induce general anesthesia with
endotracheal intubation and then to awaken and
extubate the patient for speech mapping
• After the latter, endotracheal reintubation and
general anesthesia were planed
 Endotracheal intubation in anesthesia for awake
craniotomy
• Topically anesthetized the airway with lidocaine
that was delivered through a spraying catheter
• Use fiberoptic endotracheal intubation
 Selection and Use of Drugs

• Appropriate dosing and careful titration to the

patient’s need
• The success of any sedative technique is based
on the effectiveness of local anesthetic blockade
 Selection and Use of Drugs

• Propofol
• Opioids
• Droperidol
• Dexmeditomidine
 Selection and Use of Drugs

• Propofol
• Drug of choice:titratable,anxiolytic,antiemitic
• Administration in repeated small boluses or a
continuous infusion
• Dose-dependent changes in the EEG
 Porpofol
• Many reports suggest that propofol has potent
anticonvulsant effects and may depress
epileptiform activity
• Because of the short duration of action,propofol
administration could be suspended in advance in
ECoG recording
 Sedation and Use of Drugs
• Opioids
• The rapid onset ,short-acting potent synthetic
opioids: fentanyl ,sufentanil and alfentanyl
– Can all be given by either bolus or infusion
– Comparative study show no difference(Can J.
Anesth/40:5)
 Selection and Use of Drugs
• Droperidol
– Sedative and antiemetic
– Long duration of action(onset 6 to 8 minutes
duration 6 to 12 hours)
– Side effects:adrenergic blockade, extrapyramidal
symptoms,and anticholinergic effects
 Sedative and Use of Drugs
• Dexmedetomidine:infusion for awake craniotomy
– A higly specific alpha2-agonist
– Sadative and analgesia
– It does not suppress ventilation
– Small dose infusion provided sedation that could be
easily reversed with verbal stimuli(Anesth
Analg;92(5).May2001.1251-1253)
 Patient-Controlled Intraoperative Sedation
• PCS is safe ,effective and associated with a high
degree of patient satisfaction
• Technique use PCS propofol combined with a
basal propofol infusion
• Supplemental by fentanyl
• (Anesth Analg.1997;84:11285-91)
 Intraoperative Problems

• Potential intraoperative problems are as follows

– Inadequate analgesia
– Excessive sedation
– Airway obstruction
– Restless,uncooperate patient
 Intraoperative Problems

• Potential intraoperative problems are as follows

– Nausia and vomitting
– Excessive blood loss
– “Tight” brain
– Seizure
 Nausia and Vomitting

• Incidence of nausia and vomitting range from

8% to 50%
• Antiemitics:including droperidol (15-50mcg/kg)
dimenhydrinate (0.5-1.0mg/kg) and
propofol(10-20mg)