Anesthetic Considerations for Awake Craniotomy

KSNACC - - - - ]. The The ]. 6 , 5 [ Review Review CRANIOTOMY CRANIOTOMY Generally, inhalational anesthetic agents are rarely used rarely are agents anesthetic Generally, inhalational Awake craniotomy has several anesthetic benefits and benefits anesthetic and several has craniotomy Awake ANESTHETIC ADVANTAGES OF AWAKE OF AWAKE ANESTHETIC ADVANTAGES surgical and anesthetic advantages of awake craniotomy craniotomy of awake advantages and anesthetic surgical 1. in Table listed are or intubation endotracheal unless craniotomy, in awake insertion of laryngeal performed, airway mask are and only is used as propofol, such agents, dose of intravenous small achieved is mainly craniotomy during awake [7]. Analgesia surgical advantages. Patients undergoing awake cranioto awake undergoing Patients advantages. surgical such procedures, anesthesia-related general avoid can my ventilation. and mechanical intubation as endotracheal and physiologic hemodynamic General anesthesia-related nausea, pain, postoperative and reduced, are disturbances compared craniotomy awake in reduced are vomiting and anesthesia general under with craniotomy the cation between the surgeons and patients are important an important are between and patients the surgeons cation fac key the surgery, this in are and considerations esthetic craniotomy. awake for successful tors 269 ------]. 4 , 3 [ eISSN 2383-7977 Awake craniotomy; Brain neoplasms; Conscious sedation; Craniotomy. Craniotomy. sedation; Conscious Brain neoplasms; craniotomy; Awake tions for intraoperative brain mapping. Appropriate patient selection, adequate perioperative perioperative adequate selection, patient Appropriate mapping. brain intraoperative for tions in each patients individual for management anesthetic support, proper and psychological satisfaction. success, safety, patient and procedural for crucial are surgery of stage Keywords: Anesthetic considerations for awake craniotomy awake craniotomy for considerations Anesthetic and Seung Ho Choi Seung Hyun Kim Research Medicine, Anesthesia and Pain and Pain Department of Anesthesiology College of Medicine, Seoul, Korea University Institute, Yonsei within or located tumors brain of resection for care of standard a gold is craniotomy Awake anesthesia monitored and technique asleep-awake-asleep Both areas. eloquent the to close anesthetic optimal of choice the and craniotomy awake for used effectively been have care team. surgical and anesthesiologist the of preferences the based on is primarily approach condi reliable the provide block scalp nerve and dexmedetomidine, remifentanil, Propofol, Anesth Pain Med 2020;15:269-274 Med Pain Anesth https://doi.org/10.17085/apm.20050 • pISSN 1975-5171 INTRODUCTION ]. The modern awake craniotomy techniques techniques craniotomy awake modern The ]. 2 , 1 [ June 5, 2020 June Awake craniotomy has been adopted for the surgical treat been adopted the surgical has for craniotomy Awake ment of intractable epilepsy more than 100 years ago, and is and ago, years 100 than more epilepsy intractable of ment of for resection of care as a gold standard considered now within or close located to as primarily such gliomas, tumors, of areas) sensorimotor language or (i.e., areas eloquent the brain the This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits which (http://creativecommons.org/licenses/by-nc/4.0) License Non-Commercial Attribution Commons Creative the of terms the under Access article is an Open This distributed cited. is properly work original the provided in any medium, reproduction and distribution, use, non-commercial unrestricted 2020 Anesthesiologists, Society of Korean © the Copyright Corresponding author author Corresponding M.D., Ph.D. Choi, Ho Seung and Anesthesiology of Department Pain and Anesthesia Medicine, Pain University Yonsei Institute, Research 50-1 Yonsei-ro, Medicine, of College Korea 03772, Seoul Seodaemun-gu, 82-2-2228-2415 Tel: 82-2-2227-7897 Fax: [email protected] E-mail: Received Received 2020 17, June Accepted physiologic monitoring to identify the eloquent areas of the areas the eloquent monitoring identify to physiologic of removal maximal the is resection tumor optimal An brain. as such deficit, neurological significant without any mass tumors. brain for most function damage, or language motor the enables craniotomy during awake cortical mapping The for indi of cortical and subcortical networks identification with cra Compared functions. neurological vidual patients’ can craniotomy awake anesthesia, under general niotomy without postopera removal of tumor wider extent provide pa of survival rates improved and deficits neurologic tive of as the treatment considered it is now Therefore, tients. areas for surgery in the eloquent choice tumor of brain have evolved in combination with intraoperative neuro with intraoperative in combination evolved have Smooth intraoperative emergence and adequate communi and adequate emergence Smooth intraoperative Anesth Pain Med Vol. 15 No. 3 by the scalp nerve block with local anesthetic agents. obstructive sleep apnea is a poor candidate for awake crani- Therefore, hypotension associated with general anesthesia otomy, but only the patient’s refusal is considered as an ab- is uncommon during awake craniotomy and subsequently, solute contraindication for awake craniotomy [6]. vasopressors are used less than that during general anes- Control of preoperative anxiety before awake craniotomy thesia [8]. Hence, patient’s hemodynamic and physiologic is important and can be relieved by proper preoperative status can be more stable in awake craniotomy than that in counseling about the anesthetic and surgical procedures. general anesthesia. Therefore, preoperative consultation by anesthesiologist is Possible adverse effect of general anesthetic agents, in- an important process [14,15]. The anesthesiologist should cluding inhalation anesthetic agents and opioids on cancer outline the overall awake craniotomy procedures including prognosis, such as increased recurrence or metastasis after the positioning, scalp nerve block, the possible discomfort, the surgery, has been reported recently [9,10]. In contrast, and the motor and language test. A good anesthesiolo- local anesthetics can directly inhibit some cancer cells gist-patient relationship is essential and the anesthesiolo- even though this effect seems agent specific [11]. However, gist should attempt to alleviate anxiety and discomfort of the impact of avoiding general anesthesia during awake the patient as much as possible to ensure the success of craniotomy on brain tumor prognosis has not been evalu- awake craniotomy [15]. ated in prospective, randomized, and controlled trials. Awake craniotomy is also associated with shorter hospi- ANESTHETIC APPROACHES FOR AWAKE tal stay compared with the craniotomy under general anes- CRANIOTOMY: OVERVIEW thesia [12], potentially reducing the risks of hospital-ac- quired infection and deep vein thrombosis [13]. Various anesthetic techniques may be useful for awake craniotomy. Among them, there are two commonly used PREOPERATIVE PREPARATION anesthetic methods for awake craniotomy: monitored anesthesia care (MAC) and asleep-awake-asleep (AAA) tech- Awake craniotomy requires a highly cooperative patient nique [4–6]. The anesthesiologists should provide sufficient and an expert surgical team. Appropriate patient selection sedation and analgesia during the initial craniotomy, a and preparation are essential for the success of awake crani- rapid and smooth emergence of patients is required for in- otomy. Preoperative airway evaluation should be performed traoperative neurophysiologic test including motor and in all patients. Although a patient with a difficult airway or language test, and brain mapping. After the tumor resection, sedation is often sufficient until completion of the surgery. The overall stages of awake craniotomy and anes- Table 1. Advantages of Awake Craniotomy thetic techniques are presented in Table 2. The sedation Surgical aspects Better preservation of motor & speech function profile during the first stage of awake craniotomy, from Shorter hospitalization scalp incision to dura opening, plays a pivotal role in the Reduced postoperative neurologic deficits quality of intraoperative consciousness. The anesthesiolo- Improved survival gist should restore the consciousness of patient back to the Anesthetic aspects Less physiological disturbance preoperative state for neurophysiologic tests and brain Avoidance of mechanical ventilation mapping to be performed successfully. Avoidance the adverse impact on immunity associated with general In the MAC technique, adequate depth of sedation and anesthesia

Table 2. The Stages of Awake Craniotomy and Anesthetic Options Stages Pre-awake stage Awake stage Post-awake stage Surgical procedure Craniotomy Neurophysiologic monitoring Closure Brain mapping Tumor resection Anesthetic methods AAA GA (ETT or LMA) Awake GA or MAC MAC MAC Awake MAC AAA: asleep-awake-asleep, GA: general anesthesia, ETT: endotracheal tube, LMA: laryngeal mask airway, MAC: monitored anesthesia care.

270 www.anesth-pain-med.org KSNACC ------271 ]. In a recent study study a recent ]. In 23 [ ]. 22 [ ]. Similarly, a retrospective co a retrospective ]. Similarly, ]. 24 [ 26 [ ], and experienced anesthesiologists ], and experienced anesthesiologists 6 [ ]. The propofol and remifentanil-based MAC MAC and remifentanil-based propofol ]. The 6 ]. Although high dose of dexmedetomidine may cause cause may dosedexmedetomidine of high Although ]. Inhalational anesthetics, such as sevoflurane, are also also are sevoflurane, as such anesthetics, Inhalational Dexmedetomidine an alternative to propofol for the for the propofol to Dexmedetomidine an alternative 25 quired during awake craniotomy. Moreover, it is especially Moreover, craniotomy. during awake quired of duration or when prolonged useful for high-risk patients surgery is anticipated Howev craniotomy. used for the AAA technique in awake intracranial increase to the potential have these agents er, during awake and vomiting and induce nausea pressure MAC technique during awake craniotomy can also be also be can craniotomy technique during awake MAC analge with agonist sedative, selectivea is alpha-2 used.It advanta The properties. anxiolytic, and sympatholytic sic, effect minimal as such dexmedetomidine, of effects geous hemodynamics, stable monitoring, on neurophysiologic for it suitable makes depression, respiratory and minimal craniotomy sedation during awake and dexmedetomidine propofol-remifentanil comparing supraten undergoing in patients craniotomy during awake com dexmedetomidine provided torial resection, tumor terms in quality of of intra environment surgical parable efficacyand with sedation, of less mapping brain operative with the propo compared events adverse respiratory group fol-remifentanil dexme that demonstrated 55 patients hort including study nerve and the scalp detomidine used success were block airway inter urgent without any craniotomy in awake fully anesthesia general to conversion or unplanned vention [ of the variability inter-individual significant bradycardia, sedation af from recovery and a prolonged state, sedative dose is not re a high such of infusion, the cessation ter mapping [ mapping withtechnique is associated respiratory dose-dependent and subse hypercapnia produce can which depression, seda the optimal achieving Therefore, edema. brain quent se light for an individual is crucial.tion level Meanwhile, movement patient accidental the risk of causing has dation but of drowsiness state and anxiety Generally, is likely. in sedation optimal as the is considered responsive readily craniotomy awake set complex in the this balance accomplish to required are electroencephalography-de The craniotomy. of awake ting as the electroencephalogram-derived such rived monitors, of propofol infusion index,bispectral and target-controlled Schnei The be useful can for this setting. and remifentanil infu target-controlled the for recommended is model der pa for maintaining craniotomy in awake of propofol sion ventilation spontaneous tients’ ------Anesthesia for awake craniotomy awake for Anesthesia ]. Therefore, with a with a ]. Therefore, 18 ]. 19 ]. The propofol and remifentan propofol ]. The 20 ]. The main disadvantage of this ap disadvantage main ]. The , 6 21 [ [ ]. In a recent retrospective analysis comparing comparing analysis retrospective a recent ]. In ]. In another retrospective analysis comparing the comparing analysis another retrospective ]. In 16 [ 17 [ A combination of propofol and remifentanil has been been has and remifentanil of propofol A combination Although there are significant differences in these two in these two differences significant are there Although ANESTHETIC APPROACHES FOR AWAKE ANESTHETIC APPROACHES FOR AWAKE www.anesth-pain-med.org physiologic testing testing physiologic risk of delirium is the potential be on emergence proach and brain testing neurophysiologic intraoperative fore use and reliability use and reliability il-based AAA and a smooth emergence technique allows neuro for intraoperative of consciousness recovery rapid considered as the standard protocol for sedation during for sedation during protocol as the standard considered of the ease of because craniotomy of awake stage the first CRANIOTOMY: SEDATIVE COMPONENTS COMPONENTS SEDATIVE CRANIOTOMY: compared to the AAA to technique [ compared good cooperation among anesthesiologists, surgeons, and and surgeons, anesthesiologists, among good cooperation be performed technique can the MAC neurophysiologists, withsuccessfully and comfort safety similar for the patients quired in the AAA group than that in the MAC group during group MAC the in that than AAAthe in group quired [ examination the neurophysiologic incidence of seizures and agitation were higher in the MAC in the MAC higher were and agitation incidence of seizures blood pressure However, in the AAA group. that than group re was treatment antihypertensive and more higher was nique and AAA of the MAC effectiveness techniques in 64 pa the resection, tumor brain supratentorial undergoing tients and safe, and produced comparable perioperative out perioperative comparable and produced and safe, surgeryof tech with MAC shorterthe a in duration comes, be safe be safe in a craniotomy and AAAthe MAC technique for awake equally effective both techniques the were center, single techniques, both the MAC and AAA be both per the MAC techniques can techniques, to found and are craniotomy formed in awake successfully stage of awake craniotomy. This approach is also is advanta approach This craniotomy. of awake stage hyperventilation via swelling brain for controlling geous movements. patient of accidental and prevention MAC technique are better comfort and pain control for the comfortbetter control and pain technique are MAC airway during the first and securing the patient’s patient, nique ranges from deep sedation to general anesthesia us anesthesia deep general to sedation from nique ranges a laryngeal by commonly mask ventilation, mechanical ing the to airway. benefits of this technique as compared The gence and decrease neurophysiologic tests or brain map or brain tests neurophysiologic genceand decrease the AAA technique uses higher contrast, In reliability. ping depth of AAA target The tech agents. doses of sedative spontaneous ventilation are maintained using low doses of low using maintained are ventilation spontaneous asleep from recovery a sudden avoid to agents sedative be a risk could which for delirium factor emer on state, Anesth Pain Med Vol. 15 No. 3 stage. A new inhalational anesthetic, xenon has potential reported to vary between 2.9 and 54% in a multicenter ret- advantages for awake craniotomy because of its neuropro- rospective study of 823 cases of intraoperative brain map- tective properties and rapid emergence [27]. ping [32]. The main risk factors for intraoperative seizure are history of preoperative seizure and frontal lobe tumors, ANESTHETIC APPROACHES FOR and preoperative antiepileptic medication does not reduce AWAKE CRANIOTOMY: ANALGESIC the incidence of seizures [32,33]. Intraoperative seizures COMPONENTS mainly occur due to electrical cortical stimulation during brain mapping, and the seizures can be easily controlled by The mainstay of analgesia for awake craniotomy is a re- cortical surface irrigation with cold saline by the surgeon. gional block, and there are two main approaches: the re- If this is ineffective, low doses of intravenous propofol can gional scalp block along with incision line infiltration, and be administered [6]. The efficacy of antiepileptic drugs for the scalp nerve block for six nerves, which provide sensory intraoperative seizure prevention remains debatable. In a innervation to the scalp [28]. Adequate regional blocks systematic review, antiepileptic drug prophylaxis did not make the patient tolerable for the surgery and enables bet- show benefits of seizures prevention in brain tumor resec- ter patient satisfaction after surgery in terms of pain com- tion [34]. Another systematic review and meta-analysis re- pared with general anesthesia. However, even when reported that the efficacy of levetiracetam is superior to that gional blocks are successfully performed, patients often ex- of phenytoin and valproate in terms of seizure prevention perience and complain of pain during surgery. Usually, [35]. However, evidence encouraging the routine use of an- these sensations are associated with manipulations of the tiepileptic drugs in awake craniotomy remains limited. skull-base structures or traction of pain-sensitive intracra- Airway obstruction is another serious complication en- nial structures [29]. Additional opioids may lead to poor countered in awake craniotomy, but can be solved by sim- cooperation of the patient and reduced reliability of brain ple intervention, such as jaw thrust and supplemental oxy- mapping [6]. Adequate preoperative patient information gen. In anticipation of airway emergencies, a full range of and preparation, expert anesthesiologists, and surgical airway equipment including laryngeal mask airway, video technique to avoid traction of pain-sensitive intracranial laryngoscope, and endotracheal tube should be immedi- structures are the cornerstone to improve intraoperative ately available [6]. Moreover, it should be considered that pain management and ensure postoperative patient’s satis- laryngeal mask airway insertion, or endotracheal intuba- faction. tion are difficult in patients with semi-lateral position whose head is turned with a head frame. COMPLICATIONS OF AWAKE CRANIOTOMY FUTURE CONSIDERATIONS FOR AWAKE CRANIOTOMY Seizures, hypertension, respiratory depression, nausea and vomiting, and mild brain swelling may occur during Awake craniotomy may be considered not only in brain awake craniotomy [17]. Macroglossia [30] and accidental tumor and epilepsy surgery, but also in other neurosurgical intracerebral injection of local anesthetics during scalp procedures, such as cerebral aneurysm clipping and exci- nerve block [31] have also been reported. Although com- sion of arteriovenous malformations [36,37]. plications during awake craniotomy are minor and easily Awake craniotomy has been performed to minimize the manageable, urgent intervention should be performed for risk of motor and language function damage. However, an seizures and airway obstruction. A recent meta-analysis increasing interest is seen in the adoption of awake crani- demonstrated that failure of awake craniotomy, defined as otomy for brain tumors located in the non-dominant failure to achieve complete awake brain mapping occurs in hemisphere area, which is responsible for visuospatial and < 2% cases, and the incidence of adverse events, such as social cognition. Preservation of such functions is import- seizures, conversion to general anesthesia, and new post- ant especially for patients with low-grade glioma to return operative neurologic dysfunction, were similar between to their daily lives quickly after the surgery, and expect lon- the AAA and MAC techniques [2]. ger survival [38]. However, precise brain mapping of The frequency of seizures during awake craniotomy was non-dominant hemisphere functions is particularly diffi-

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273 . Neurosurgery Neurosurgery

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39 [ Anesthesia for awake craniotomy awake for Anesthesia ORCID REFERENCES CONCLUSION CONCLUSION

CONFLICTS OF INTEREST CONFLICTS AUTHOR CONTRIBUTIONS Uff C, Frith D, Harrison C, Powell M, Kitchen N. Sir Victor Victor Sir N. C, Harrison M, Kitchen C,Uff Powell Frith D, Stevanovic A, Rossaint R, Veldeman M, Bilotta F, Coburn M. M. Coburn F, M, Bilotta A, R, Veldeman Stevanovic Rossaint Anaesthesia management for awake craniotomy: systematic systematic craniotomy: awake for management Anaesthesia PLoS One 2016; 11: e0156448. and meta-analysis. review Horsley's 19th century operations at the National Hospital for for Hospital the National at 19th centuryHorsley's operations J Neurosurg Square. Queen and Neurosurgery, Neurology 2011; 114: 534-42. Conceptualization: Seung Hyun Kim, Seung Ho Choi. Choi. Ho Seung Kim, Hyun Seung Conceptualization: No potential conflict of interest relevant to this article this article to relevant conflict of interest potential No Anesthesia for awake craniotomy is one of the most chal one of the most is craniotomy for awake Anesthesia 2. 1. www.anesth-pain-med.org Seung Ho Choi, https://orcid.org/0000-0001-8442-4406 https://orcid.org/0000-0001-8442-4406 Choi, Seung Ho Seung Hyun Kim, https://orcid.org/0000-0003-2127-6324 https://orcid.org/0000-0003-2127-6324 Kim, Seung Hyun vision: Seung Ho Choi. Writing-original draft: Writing-original Choi. Seungvision: Ho Seung Hyun Choi. Seung Ho Kim, Data acquisition: Seung Hyun Kim, Seung Ho Choi. Super Choi. Seung Ho Kim, Seung acquisition: Hyun Data was reported. reported. was management for individual patients in each stage of sur stage in each patients for individual management patient and success, safety, gerycrucial procedural for are satisfaction. is required for effective intraoperative pain control and and control pain intraoperative effective for required is selection, patient Appropriate satisfaction. patient better anesthetic and proper support, psychological perioperative with craniotomy under general anesthesia. Both the MAC Both the MAC anesthesia. under general with craniotomy tech anesthetic and safe feasible AAAand techniquesare block regional and adequate craniotomy, niques for awake tumor resection with less risk of neurological deficits in with risk less resection tumor of neurological compared damage, speech and function motor cluding lenging fields for anesthesiologists. Awake craniotomy is is craniotomy Awake fields for anesthesiologists. lenging perform of it can because range extended advantageous cult due to complexity of its functional anatomy. Therefore, Therefore, anatomy. complexity to due cult its functional of it is necessary methods large assess to adequate develop to surgery brain spectrum of cognition during awake Anesth Pain Med Vol. 15 No. 3

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