Awake craniotomy

Awake craniotomy

Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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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. 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.

Preoperative management

Patient evaluation

System	Considerations
Neurologic	Neuro exam to establish baseline function and deficits. Consider signs and symptoms of: Increased ICP Impingement of motor areas Intracranial bleeding.
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.
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: History of nausea or vomiting (especially if present on the day of surgery) History of uncontrolled GERD If in Mayfield pins, active GERD may trigger coughing, resulting in potential for injury to head and neck
Renal	Inform patient that a Foley catheter will be inserted under sedation and that when awakened, they will have the sensation of the catheter in their lower urinary tract and may feel as if their bladder is full
Endocrine	In patients with a history of diabetes, intraoperative glucose should be closely monitored. Hypoglycemia and extreme hyperglycemia may result in altered mental status that could interfere with neurological monitoring, disinhibition, and airway compromise.

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

• The patient should counseled extensively on the process of awake craniotomy in great detail to avoid surprises that may result in untoward anxiety intraoperatively.
• Premedication with a short-acting benzodiazepines such as midazolam (in an incremental titrated dose administration to 1-10 mg IV)
• Dexmedetomidine (0.2-0.7 mcg/kg/hr) may be helpful for preoperative line placement

Regional and neuraxial techniques

Video demonstration of a scalp block

• Scalp blocks are placed using 0.5% bupivacaine with epinephrine

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications