Difference between revisions of "Awake craniotomy"
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}}An '''awake craniotomy''' is a surgical procedure that is sometimes employed for patients undergoing tumor excision or clipping of arteriovenous malformation in regions of the brain that involve speech or motor function. Patients are sedated during line placement and cranial opening, and then awakened once the dura is opened. Due to the unconventional nature of the surgery, this technique is generally reserved for patients who have undergone careful preoperative selection, with considerations for temperament, overall health status, and adequate education. | }}An '''awake craniotomy''' is a surgical procedure that is sometimes employed for patients undergoing tumor excision or clipping of arteriovenous malformation in regions of the brain that involve speech or motor function. Patients are typically sedated during line placement and cranial opening, and then awakened once the dura is opened. Due to the unconventional nature of the surgery, this technique is generally reserved for patients who have undergone careful preoperative selection, with considerations for temperament, overall health status, and adequate education. | ||
The procedure can be performed using either monitored anesthesia care (MAC) or using an asleep-awake-asleep (SAS) technique. A recent meta-analysis suggests that MAC was associated with lower likelihood of failure and shorter procedure time, while SAS was associated with lower incidence of intraoperative seizure.<ref>{{Cite journal|last=Natalini|first=Daniele|last2=Ganau|first2=Mario|last3=Rosenkranz|first3=Ruben|last4=Petrinic|first4=Tatjana|last5=Fitzgibbon|first5=Karina|last6=Antonelli|first6=Massimo|last7=Prisco|first7=Lara|date=2020-01-16|title=Comparison of the Asleep-Awake-Asleep Technique and Monitored Anesthesia Care During Awake Craniotomy: A Systematic Review and Meta-analysis|url=https://pubmed.ncbi.nlm.nih.gov/31972627|journal=Journal of Neurosurgical Anesthesiology|doi=10.1097/ANA.0000000000000675|issn=1537-1921|pmid=31972627}}</ref> The use of non-pharmacological anxiolytic techniques (e.g. hypnosis) to achieve success with an awake-awake-awake technique has also been reported.<ref>{{Cite journal|last=Zemmoura|first=Ilyess|last2=Fournier|first2=Eric|last3=El-Hage|first3=Wissam|last4=Jolly|first4=Virginie|last5=Destrieux|first5=Christophe|last6=Velut|first6=Stéphane|date=2016-01|title=Hypnosis for Awake Surgery of Low-grade Gliomas: Description of the Method and Psychological Assessment|url=https://pubmed.ncbi.nlm.nih.gov/26313220|journal=Neurosurgery|volume=78|issue=1|pages=53–61|doi=10.1227/NEU.0000000000000993|issn=1524-4040|pmid=26313220}}</ref> | |||
==Preoperative management== | ==Preoperative management== | ||
===Patient | ===Patient consultation=== | ||
Detailed consultation to psychologically prepare the patient is essential to set expectations and address questions to minimize anxiety intraoperatively<ref>{{Cite journal|last=Kulikov|first=Alexander|last2=Lubnin|first2=Andrey|date=2018-10|title=Anesthesia for awake craniotomy|url=https://pubmed.ncbi.nlm.nih.gov/29994938|journal=Current Opinion in Anaesthesiology|volume=31|issue=5|pages=506–510|doi=10.1097/ACO.0000000000000625|issn=1473-6500|pmid=29994938}}</ref> | |||
*Perform prior to the day of surgery | |||
*Should include the neuropsychology team that will be performing intraoperative testing | |||
* Discuss non-medical modalities of intraoperative anxiety management (as feasible) | |||
**Music, hypnosis, phone calls, etc. | |||
The patient experience of the surgical procedure should also be discussed in detail: | |||
*Lines and foley catheter will be placed under sedation | *Lines and foley catheter will be placed under sedation | ||
**May | **May experience the feeling of a full bladder when awakened | ||
* | *Patient's head will be unable to move | ||
*Patient will be asked to perform tasks and/or answer questions | **Will likely feel pressure | ||
**Pain is possible, but can be addressed | |||
**May experience dry mouth | |||
*Patient will be able to communicate with the OR staff at all times while awake | |||
*Patient will be asked to perform tasks and/or answer questions throughout the procedure | |||
=== Patient evaluation === | |||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
!System | ! System | ||
!Considerations | !Considerations | ||
|- | |- | ||
|Neurologic | | Neurologic | ||
| | | | ||
Neuro exam to establish baseline function and deficits. Consider signs and symptoms of:<ref>{{Cite journal|last=Buckner|first=JC|date=2007|title=Central nervous system tumors|url=|journal=Mayo Clin Proc|volume=82(10)|pages=1271-86|via=}}</ref> | Neuro exam to establish baseline function and deficits. Consider signs and symptoms of:<ref>{{Cite journal|last=Buckner|first=JC|date=2007|title=Central nervous system tumors|url=|journal=Mayo Clin Proc|volume=82(10)|pages=1271-86|via=}}</ref> | ||
*Increased ICP | *Increased ICP | ||
| Line 44: | Line 56: | ||
Due to the lack of a protected airway and risk of aspiration, relative contraindications to this procedure include: | Due to the lack of a protected airway and risk of aspiration, relative contraindications to this procedure include: | ||
*History of nausea or vomiting (especially if present on the day of surgery) | *History of nausea or vomiting (especially if present on the day of surgery) | ||
*History of uncontrolled [[GERD]] | * History of uncontrolled [[GERD]] | ||
**If in Mayfield pins, active GERD may trigger coughing, resulting in potential for injury to head and neck | **If in Mayfield pins, active GERD may trigger coughing, resulting in potential for injury to head and neck | ||
|- | |- | ||
| Line 55: | Line 67: | ||
===Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. -->=== | ===Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. -->=== | ||
*Complete blood count | *Complete blood count | ||
*Metabolic panel | * Metabolic panel | ||
*Coagulation panel | *Coagulation panel | ||
*Type and screen | *Type and screen | ||
| Line 66: | Line 78: | ||
*For patients who are used to a morning cup of coffee, consider caffeine 200 mg PO before surgery to reduce the risk of withdrawal headache<ref>{{Cite journal|last=Potters|first=Jan-Willem|last2=Klimek|first2=Markus|date=2015|title=Awake craniotomy: improving the patient's experience|url=https://pubmed.ncbi.nlm.nih.gov/26263121/|journal=Current Opinion in Anaesthesiology|volume=28|issue=5|pages=511–516|doi=10.1097/ACO.0000000000000231|issn=1473-6500|pmid=26263121|via=}}</ref> | *For patients who are used to a morning cup of coffee, consider caffeine 200 mg PO before surgery to reduce the risk of withdrawal headache<ref>{{Cite journal|last=Potters|first=Jan-Willem|last2=Klimek|first2=Markus|date=2015|title=Awake craniotomy: improving the patient's experience|url=https://pubmed.ncbi.nlm.nih.gov/26263121/|journal=Current Opinion in Anaesthesiology|volume=28|issue=5|pages=511–516|doi=10.1097/ACO.0000000000000231|issn=1473-6500|pmid=26263121|via=}}</ref> | ||
===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->=== | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->=== | ||
{{#ev:youtube|https://www.youtube.com/watch?v=5mTEa7ZdM_g|480|right|Video demonstration of a scalp block}} | {{#ev:youtube|https://www.youtube.com/watch?v=5mTEa7ZdM_g|480|right|Video demonstration of a scalp block}} | ||
*Scalp blocks are placed using 0.5% bupivacaine with epinephrine | *Scalp blocks are placed using 0.5% bupivacaine with epinephrine | ||
| Line 72: | Line 84: | ||
==Intraoperative management== | ==Intraoperative management== | ||
===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->=== | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->=== | ||
*Provide sedation and anxiolysis during line placement<ref name=":0" /> | *Provide sedation and anxiolysis during line placement<ref name=":0" /> | ||
| Line 79: | Line 91: | ||
*Place lines with field blocks using buffered lidocaine for patient comfort | *Place lines with field blocks using buffered lidocaine for patient comfort | ||
**Arterial line | **Arterial line | ||
** CVC vs PICC | **CVC vs PICC | ||
*Large bore IV(s) | *Large bore IV(s) | ||
*Microphone for patient to communicate | *Microphone for patient to communicate | ||
| Line 86: | Line 98: | ||
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ||
===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | ||
===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ||
===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ==== Intraoperative seizures ==== | ||
The incidence of intraoperative seizures varies widely, with one analysis reporting a range of 2.5-54%.<ref>{{Cite journal|last=Spena|first=Giannantonio|last2=Schucht|first2=Philippe|last3=Seidel|first3=Kathleen|last4=Rutten|first4=Geert-Jan|last5=Freyschlag|first5=Christian Franz|last6=D'Agata|first6=Federico|last7=Costi|first7=Emanule|last8=Zappa|first8=Francesca|last9=Fontanella|first9=Marco|last10=Fontaine|first10=Denys|last11=Almairac|first11=Fabien|date=2017|title=Brain tumors in eloquent areas: A European multicenter survey of intraoperative mapping techniques, intraoperative seizures occurrence, and antiepileptic drug prophylaxis|url=https://pubmed.ncbi.nlm.nih.gov/27481498|journal=Neurosurgical Review|volume=40|issue=2|pages=287–298|doi=10.1007/s10143-016-0771-2|issn=1437-2320|pmid=27481498|via=}}</ref> | |||
Seizures can be treated using:<ref>{{Cite journal|last=Meng|first=Lingzhong|last2=McDonagh|first2=David L.|last3=Berger|first3=Mitchel S.|last4=Gelb|first4=Adrian W.|date=2017|title=Anesthesia for awake craniotomy: a how-to guide for the occasional practitioner|url=https://pubmed.ncbi.nlm.nih.gov/28181184/|journal=Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie|volume=64|issue=5|pages=517–529|doi=10.1007/s12630-017-0840-1|issn=1496-8975|pmid=28181184|via=}}</ref> | |||
* Cold water irrigation of the surgical field | |||
* Low doses of propofol (30-50 mg) | |||
There is limited evidence to support the use of levetiracetam for seizure prophylaxis.<ref>{{Cite journal|last=Pourzitaki|first=Chryssa|last2=Tsaousi|first2=Georgia|last3=Apostolidou|first3=Eirini|last4=Karakoulas|first4=Konstantinos|last5=Kouvelas|first5=Dimitrios|last6=Amaniti|first6=Ekaterini|date=2016|title=Efficacy and safety of prophylactic levetiracetam in supratentorial brain tumour surgery: a systematic review and meta-analysis|url=https://pubmed.ncbi.nlm.nih.gov/26945547/|journal=British Journal of Clinical Pharmacology|volume=82|issue=1|pages=315–325|doi=10.1111/bcp.12926|issn=1365-2125|pmc=4917799|pmid=26945547|via=}}</ref> | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | |||
==Postoperative management== | ==Postoperative management== | ||
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->=== | ===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ||
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | ===Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ||
Revision as of 18:34, 11 July 2021
Awake craniotomy
| Anesthesia type | |
|---|---|
| Airway | |
| Lines and access | |
| Monitors | |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative | |
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 0 |
An awake craniotomy is a surgical procedure that is sometimes employed for patients undergoing tumor excision or clipping of arteriovenous malformation in regions of the brain that involve speech or motor function. Patients are typically sedated during line placement and cranial opening, and then awakened once the dura is opened. Due to the unconventional nature of the surgery, this technique is generally reserved for patients who have undergone careful preoperative selection, with considerations for temperament, overall health status, and adequate education.
The procedure can be performed using either monitored anesthesia care (MAC) or using an asleep-awake-asleep (SAS) technique. A recent meta-analysis suggests that MAC was associated with lower likelihood of failure and shorter procedure time, while SAS was associated with lower incidence of intraoperative seizure.[1] The use of non-pharmacological anxiolytic techniques (e.g. hypnosis) to achieve success with an awake-awake-awake technique has also been reported.[2]
Preoperative management
Patient consultation
Detailed consultation to psychologically prepare the patient is essential to set expectations and address questions to minimize anxiety intraoperatively[3]
- Perform prior to the day of surgery
- Should include the neuropsychology team that will be performing intraoperative testing
- Discuss non-medical modalities of intraoperative anxiety management (as feasible)
- Music, hypnosis, phone calls, etc.
The patient experience of the surgical procedure should also be discussed in detail:
- Lines and foley catheter will be placed under sedation
- May experience the feeling of a full bladder when awakened
- Patient's head will be unable to move
- Will likely feel pressure
- Pain is possible, but can be addressed
- May experience dry mouth
- Patient will be able to communicate with the OR staff at all times while awake
- Patient will be asked to perform tasks and/or answer questions throughout the procedure
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic |
Neuro exam to establish baseline function and deficits. Consider signs and symptoms of:[4]
|
| Cardiovascular |
Evaluate for comorbidities which may be exacerbated by intraoperative stress during the procedure (i.e. being under drapes, head clamped in Mayfield pins, surgical sounds, etc.) Increased ICP may result in Cushing's triad of HTN, bradycardia, and irregular respiratory pattern.[5] |
| Respiratory |
Significant comorbidities (e.g. advanced COPD requiring supplemental oxygen or history of exacerbation, asthma with history of exacerbations requiring rescue inhaler use, etc.) should be assessed in advance to determine suitability for this procedure. |
| Gastrointestinal |
Due to the lack of a protected airway and risk of aspiration, relative contraindications to this procedure include:
|
| Endocrine |
In patients with a history of diabetes, intraoperative glucose should be closely monitored.
|
Labs and studies
- Complete blood count
- Metabolic panel
- Coagulation panel
- Type and screen
Operating room setup
- Be aware of type of table and head support to be employed to adjust anesthesia technique accordingly
Patient preparation and premedication
- For patients who are used to a morning cup of coffee, consider caffeine 200 mg PO before surgery to reduce the risk of withdrawal headache[6]
Regional and neuraxial techniques
- Scalp blocks are placed using 0.5% bupivacaine with epinephrine
Intraoperative management
Monitoring and access
- Provide sedation and anxiolysis during line placement[5]
- Midazolam 1-10 mg IV (titrated incremental doses)
- Dexmedetomidine 0.2-0.7 mcg/kg/hr
- Place lines with field blocks using buffered lidocaine for patient comfort
- Arterial line
- CVC vs PICC
- Large bore IV(s)
- Microphone for patient to communicate
- ± Precordial doppler
Induction and airway management
Positioning
Maintenance and surgical considerations
Intraoperative seizures
The incidence of intraoperative seizures varies widely, with one analysis reporting a range of 2.5-54%.[7]
Seizures can be treated using:[8]
- Cold water irrigation of the surgical field
- Low doses of propofol (30-50 mg)
There is limited evidence to support the use of levetiracetam for seizure prophylaxis.[9]
Emergence
Postoperative management
Disposition
Pain management
Potential complications
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ Natalini, Daniele; Ganau, Mario; Rosenkranz, Ruben; Petrinic, Tatjana; Fitzgibbon, Karina; Antonelli, Massimo; Prisco, Lara (2020-01-16). "Comparison of the Asleep-Awake-Asleep Technique and Monitored Anesthesia Care During Awake Craniotomy: A Systematic Review and Meta-analysis". Journal of Neurosurgical Anesthesiology. doi:10.1097/ANA.0000000000000675. ISSN 1537-1921. PMID 31972627.
- ↑ Zemmoura, Ilyess; Fournier, Eric; El-Hage, Wissam; Jolly, Virginie; Destrieux, Christophe; Velut, Stéphane (2016-01). "Hypnosis for Awake Surgery of Low-grade Gliomas: Description of the Method and Psychological Assessment". Neurosurgery. 78 (1): 53–61. doi:10.1227/NEU.0000000000000993. ISSN 1524-4040. PMID 26313220. Check date values in:
|date=(help) - ↑ Kulikov, Alexander; Lubnin, Andrey (2018-10). "Anesthesia for awake craniotomy". Current Opinion in Anaesthesiology. 31 (5): 506–510. doi:10.1097/ACO.0000000000000625. ISSN 1473-6500. PMID 29994938. Check date values in:
|date=(help) - ↑ Buckner, JC (2007). "Central nervous system tumors". Mayo Clin Proc. 82(10): 1271–86.
- ↑ 5.0 5.1 Jaffe, Richard A. (2014). Anesthesiologist's Manual of Surgical Procedures. New York: Wolters Kluwer. pp. 31–36. ISBN 978-1-4511-7660-5.
- ↑ Potters, Jan-Willem; Klimek, Markus (2015). "Awake craniotomy: improving the patient's experience". Current Opinion in Anaesthesiology. 28 (5): 511–516. doi:10.1097/ACO.0000000000000231. ISSN 1473-6500. PMID 26263121.
- ↑ Spena, Giannantonio; Schucht, Philippe; Seidel, Kathleen; Rutten, Geert-Jan; Freyschlag, Christian Franz; D'Agata, Federico; Costi, Emanule; Zappa, Francesca; Fontanella, Marco; Fontaine, Denys; Almairac, Fabien (2017). "Brain tumors in eloquent areas: A European multicenter survey of intraoperative mapping techniques, intraoperative seizures occurrence, and antiepileptic drug prophylaxis". Neurosurgical Review. 40 (2): 287–298. doi:10.1007/s10143-016-0771-2. ISSN 1437-2320. PMID 27481498.
- ↑ Meng, Lingzhong; McDonagh, David L.; Berger, Mitchel S.; Gelb, Adrian W. (2017). "Anesthesia for awake craniotomy: a how-to guide for the occasional practitioner". Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie. 64 (5): 517–529. doi:10.1007/s12630-017-0840-1. ISSN 1496-8975. PMID 28181184.
- ↑ Pourzitaki, Chryssa; Tsaousi, Georgia; Apostolidou, Eirini; Karakoulas, Konstantinos; Kouvelas, Dimitrios; Amaniti, Ekaterini (2016). "Efficacy and safety of prophylactic levetiracetam in supratentorial brain tumour surgery: a systematic review and meta-analysis". British Journal of Clinical Pharmacology. 82 (1): 315–325. doi:10.1111/bcp.12926. ISSN 1365-2125. PMC 4917799. PMID 26945547.