Anesthesia for awake craniotomy
- Lashmi Venkatraghavan, MD
Lashmi Venkatraghavan, MD
- Assistant Professor, Department of Anesthesia
- University of Toronto
Awake craniotomy (AC) is most commonly used to allow mapping for resection of brain tumors near eloquent regions of the cerebral cortex, and occasionally for epilepsy surgery. In some institutions, supratentorial craniotomies without such indications are increasingly performed with patients awake, in order to reduce length of stay, and intensive care unit admissions, and to avoid the risks of general anesthesia.
The patient is not necessarily awake throughout the entire craniotomy, but is conscious and cooperative during the portions of the procedure that involve testing. The success of awake craniotomy depends on careful patient selection, and coordination between experienced anesthesia and surgical teams.
This topic will discuss anesthetic management for AC (table 1). General concerns for anesthesia for craniotomy, and anesthesia for placement of deep brain stimulators, are discussed separately. (See "Anesthesia for craniotomy" and "Anesthesia for patients having deep brain stimulator implantation".)
The most common surgical indication for awake craniotomy (AC) is to allow functional cortical mapping for brain tumors, and occasionally vascular lesions or epileptogenic foci, close to eloquent cortex. Eloquent cortex refers to those parts of the brain that control motor, sensory, or language function. AC may also be used to facilitate electrocorticography for seizure focus localization, to minimize interference from anesthetic medications. Awake craniotomy may be performed without these indications, in order to facilitate enhanced recovery and reduce resource utilization. In some centers, selected patients are discharged on the day of surgery after awake craniotomy [1,2]. (See 'Postoperative care' below.)
●Functional cortical mapping of eloquent brain function – The primary goal of awake craniotomy for a brain lesion near eloquent cerebral cortex is to enable a tailored resection, to theoretically maximize the extent of the tumor resection and minimize the risk for neurological injury [3,4]. Awake craniotomy is often appropriate for mapping language and sensorimotor function ; in addition to the baseline individual variability in the cortical regions associated with these functions, cerebral topography may be distorted by tumor infiltration, radiotherapy, or previous surgery [6,7].
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- STEPS OF SURGERY
- Cortical mapping
- Electrocorticographic recordings
- PREOPERATIVE EVALUATION
- PREOPERATIVE PATIENT PREPARATION
- ANESTHETIC MANAGEMENT
- Local anesthesia
- Choice of anesthetic technique
- - Conscious sedation
- Choice of medications for conscious sedation
- - Asleep awake asleep
- Choice of anesthetic agents for general anesthesia
- Airway management
- AUTHOR’S STRATEGY FOR AWAKE CRANIOTOMY
- Strategy for conscious sedation
- Strategy for asleep-awake-asleep technique
- POSTOPERATIVE CARE
- PATIENT PERCEPTION AND SATISFACTION
- SUMMARY AND RECOMMENDATIONS