Awake craniotomy

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Awake craniotomy
Specialty neurology

Awake craniotomy is a neurosurgical technique and type of craniotomy that allows a surgeon to remove a brain tumor while the patient is awake to avoid brain damage. During the surgery, the neurosurgeon performs cortical mapping to identify vital areas, called the "eloquent brain", that should not be disturbed while removing the tumor.

Contents

Uses

A particular use for awake craniotomy is mapping the cortex to avoid causing language or movement deficits with the surgery. It is more effective than surgeries performed under general anesthesia in avoiding complications. Awake craniotomy can be used in a variety of brain tumors, including glioblastomas, gliomas, and brain metastases. [1] [2] [3] [4] It can also be used for epilepsy surgery to remove a larger amount of the section of tissue causing the seizures without damaging function, for deep brain stimulation placement, or for pallidotomy. [2] [4] Awake craniotomy has increased the scope of tumors that are considered resectable (treatable by surgery) and in general, reduces recovery time. [2] [5] Awake craniotomy is also associated with reduced iatrogenic brain damage after surgery. [6]

Technique

Before an awake craniotomy begins for tumor or epilepsy surgery, the patient is given anxiolytic medications. The patient is then positioned in a neurosurgical head restraint that holds the head completely still and given general anesthesia. The anesthesiologist will then use local anesthetics like lidocaine or bupivacaine to numb the skin and bone of the head and neck. The craniotomy begins with a surgeon removing an area of the skull over the tumor and cutting into the meninges, the membranes that protect the brain. Before removing any brain tissue, the patient is awakened and the neurosurgeon creates a cortical map, using a small electrical stimulation device to observe the changes in the patient's condition when an area is stimulated. If an area is stimulated and the patient moves or loses some ability, like speech, the surgeon knows that the area is vital and cannot be removed or cut through to access a tumor. [1] During the procedure, the surgeon, anesthesiologist, and other surgical personnel speak to the patient, and there is a technician constantly assessing the patient's ability to name objects, for example, or report any abnormal sensations. [4] There are two variations on the technique: asleep-awake-asleep (AAA), and monitored anesthetic care (MAC), also called conscious sedation. In an AAA surgery, the patient is only awake during the cortical mapping; whereas in an MAC surgery the patient is awake the entire time. [5]

The procedure for deep brain stimulation placement is similar, though instead of skull being removed, a burr hole is drilled for the electrodes instead and the MAC surgery is more common. [5]

Complications

The complications of awake craniotomy are similar to complications from brain surgery done under general anesthesia – seizures during the operation, nausea, vomiting, loss of motor or speech function, hemodynamic instability (hypertension, hypotension, or tachycardia), cerebral edema, hemorrhage, stroke or air embolism, and death. [1] [5] Seizures are the most common complication. [4]

Contraindications

There are patients for whom an awake craniotomy is not appropriate. Those with anxiety disorders, claustrophobia, schizophrenia, or low pain tolerance are poor candidates for an awake surgery because any treatment of a psychological crisis would harm the procedure and could harm the patient. [5] Additionally, patients with obstructive sleep apnea are usually considered poor candidates due to problems with oxygenation, ventilation, and a potentially difficult airway. [7]

Related Research Articles

<span class="mw-page-title-main">Neurosurgery</span> Medical specialty of disorders which affect any portion of the nervous system

Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the medical specialty concerned with the surgical treatment of disorders which affect any portion of the nervous system including the brain, spinal cord and peripheral nervous system.

<span class="mw-page-title-main">Anesthesia</span> State of medically-controlled temporary loss of sensation or awareness

Anesthesia or anaesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia, paralysis, amnesia, and unconsciousness. An individual under the effects of anesthetic drugs is referred to as being anesthetized.

<span class="mw-page-title-main">General anaesthesia</span> Medically induced loss of consciousness

General anaesthesia (UK) or general anesthesia (US) is a method of medically inducing loss of consciousness that renders a patient unarousable even with painful stimuli. This effect is achieved by administering either intravenous or inhalational general anaesthetic medications, which often act in combination with an analgesic and neuromuscular blocking agent. Spontaneous ventilation is often inadequate during the procedure and intervention is often necessary to protect the airway. General anaesthesia is generally performed in an operating theater to allow surgical procedures that would otherwise be intolerably painful for a patient, or in an intensive care unit or emergency department to facilitate endotracheal intubation and mechanical ventilation in critically ill patients. Regardless of whether a patient may prefer to be unconscious or not, certain pain stimuli could result in involuntary responses from the patient that may make an operation extremely difficult. Thus, for many procedures, general anaesthesia is required from a practical perspective.

<span class="mw-page-title-main">Anesthesiology</span> Medical specialty concerned with anesthesia and perioperative care

Anesthesiology, anaesthesiology, or anaesthesia is the medical specialty concerned with the total perioperative care of patients before, during and after surgery. It encompasses anesthesia, intensive care medicine, critical emergency medicine, and pain medicine. A physician specialized in anesthesiology is called an anesthesiologist, anaesthesiologist, or anaesthetist, depending on the country. In some countries the terms are synonymous, while in other countries they refer to different positions and anesthetist is only used for non-physicians, such as nurse anesthetists.

Awareness under anesthesia, also referred to as intraoperative awareness or accidental awareness during general anesthesia (AAGA), is a rare complication of general anesthesia where patients regain varying levels of consciousness during their surgical procedures. While anesthesia awareness is possible without resulting in any long-term memory of the experience, it is also possible for victims to have awareness with explicit recall, where they can remember the events related to their surgery.

<span class="mw-page-title-main">Craniotomy</span> Surgical operation on skull

A craniotomy is a surgical operation in which a bone flap is temporarily removed from the skull to access the brain. Craniotomies are often critical operations, performed on patients who are suffering from brain lesions, such as tumors, blood clots, removal of foreign bodies such as bullets, or traumatic brain injury (TBI), and can also allow doctors to surgically implant devices, such as deep brain stimulators for the treatment of Parkinson's disease, epilepsy, and cerebellar tremor. The procedure is also used in epilepsy surgery to remove the parts of the brain that are causing epilepsy.

Corpus callosotomy is a palliative surgical procedure for the treatment of medically refractory epilepsy. In this procedure the corpus callosum is cut through in an effort to limit the spread of epileptic activity between the two halves of the brain.

Intraoperative neurophysiological monitoring (IONM) or intraoperative neuromonitoring is the use of electrophysiological methods such as electroencephalography (EEG), electromyography (EMG), and evoked potentials to monitor the functional integrity of certain neural structures during surgery. The purpose of IONM is to reduce the risk to the patient of iatrogenic damage to the nervous system, and/or to provide functional guidance to the surgeon and anesthesiologist.

Frontal lobe epilepsy (FLE) is a neurological disorder that is characterized by brief, recurring seizures arising in the frontal lobes of the brain, that often occur during sleep. It is the second most common type of epilepsy after temporal lobe epilepsy (TLE), and is related to the temporal form in that both forms are characterized by partial (focal) seizures.

<span class="mw-page-title-main">Electrocorticography</span>

Electrocorticography (ECoG), a type of intracranial electroencephalography (iEEG), is a type of electrophysiological monitoring that uses electrodes placed directly on the exposed surface of the brain to record electrical activity from the cerebral cortex. In contrast, conventional electroencephalography (EEG) electrodes monitor this activity from outside the skull. ECoG may be performed either in the operating room during surgery or outside of surgery. Because a craniotomy is required to implant the electrode grid, ECoG is an invasive procedure.

Epilepsy surgery involves a neurosurgical procedure where an area of the brain involved in seizures is either resected, ablated, disconnected or stimulated. The goal is to eliminate seizures or significantly reduce seizure burden. Approximately 60% of all people with epilepsy have focal epilepsy syndromes. In 15% to 20% of these patients, the condition is not adequately controlled with anticonvulsive drugs. Such patients are potential candidates for surgical epilepsy treatment.

The ASA physical status classification system is a system for assessing the fitness of patients before surgery. In 1963 the American Society of Anesthesiologists (ASA) adopted the five-category physical status classification system; a sixth category was later added. These are:

  1. Healthy person.
  2. Mild systemic disease.
  3. Severe systemic disease.
  4. Severe systemic disease that is a constant threat to life.
  5. A moribund person who is not expected to survive without the operation.
  6. A declared brain-dead person whose organs are being removed for donor purposes.
<span class="mw-page-title-main">Sabuncuoğlu Şerafeddin</span> Ottoman surgeon and physician (1385–1468)

Şerafeddin Sabuncuoğlu (1385–1468) was a medieval Ottoman surgeon and physician. Şerafeddin Sabuncuoğlu started his medical interests at the age of 17. He would continue with this medical interest and practice in Amasya Dar-es Sifa Hospital until he died. Şerafeddin Sabuncuoğlu was the director of the Amasya Dar-es Sifa Hospital for almost 14 years.

Neuro-oncology is the study of brain and spinal cord neoplasms, many of which are very dangerous and life-threatening. Among the malignant brain cancers, gliomas of the brainstem and pons, glioblastoma multiforme, and high-grade astrocytoma/oligodendroglioma are among the worst. In these cases, untreated survival usually amounts to only a few months, and survival with current radiation and chemotherapy treatments may extend that time from around a year to a year and a half, possibly two or more, depending on the patient's condition, immune function, treatments used, and the specific type of malignant brain neoplasm. Surgery may in some cases be curative, but, as a general rule, malignant brain cancers tend to regenerate and emerge from remission easily, especially highly malignant cases. In such cases, the goal is to excise as much of the mass and as much of the tumor margin as possible without endangering vital functions or other important cognitive abilities. The Journal of Neuro-Oncology is the longest continuously published journal in the field and serves as a leading reference to those practicing in the area of neuro-oncology.

Neurosurgical anesthesiology, neuroanesthesiology, or neurological anesthesiology is a subspecialty of anesthesiology devoted to the total perioperative care of patients before, during, and after neurological surgeries, including surgeries of the central (CNS) and peripheral nervous systems (PNS). The field has undergone extensive development since the 1960s correlating with the ability to measure intracranial pressure (ICP), cerebral blood flow (CBF), and cerebral metabolic rate (CMR).

Cortical stimulation mapping (CSM) is a type of electrocorticography that involves a physically invasive procedure and aims to localize the function of specific brain regions through direct electrical stimulation of the cerebral cortex. It remains one of the earliest methods of analyzing the brain and has allowed researchers to study the relationship between cortical structure and systemic function. Cortical stimulation mapping is used for a number of clinical and therapeutic applications, and remains the preferred method for the pre-surgical mapping of the motor cortex and language areas to prevent unnecessary functional damage. There are also some clinical applications for cortical stimulation mapping, such as the treatment of epilepsy.

<span class="mw-page-title-main">Brachial plexus block</span>

Brachial plexus block is a regional anesthesia technique that is sometimes employed as an alternative or as an adjunct to general anesthesia for surgery of the upper extremity. This technique involves the injection of local anesthetic agents in close proximity to the brachial plexus, temporarily blocking the sensation and ability to move the upper extremity. The subject can remain awake during the ensuing surgical procedure, or they can be sedated or even fully anesthetized if necessary.

<span class="mw-page-title-main">James Rutka</span> Canadian neurosurgeon

James Rutka is a Canadian neurosurgeon from Toronto, Canada. Rutka served as RS McLaughlin Professor and Chair of the Department of Surgery in the Faculty of Medicine at the University of Toronto from 2011 – 2022. He subspecializes in pediatric neurosurgery at The Hospital for Sick Children (SickKids), and is a Senior Scientist in the Research Institute at SickKids. His main clinical interests include the neurosurgical treatment of children with brain tumours and epilepsy. His research interests lie in the molecular biology of human brain tumours – specifically in the determination of the mechanisms by which brain tumours grow and invade. He is the Director of the Arthur and Sonia Labatt Brain Tumour Research Centre at SickKids, and Editor-in-Chief of the Journal of Neurosurgery.

Günther C. Feigl is an Austrian neurosurgeon. Feigl is an internationally renowned expert in minimally invasive neurosurgery. His main areas of expertise are skull base surgery and neurooncology. He specializes in the surgery of gliomas, minimally invasive endoscopy-assisted microvascular decompression in trigeminal neuralgia and facial hemispasm as well as the surgery of acoustic neuromas, tumors of the pineal gland and meningiomas of the skull base. Furthermore, his specialties comprise treatment of pituitary adenomas, spinal cord tumours and metastases as well as the area of pediatric neurosurgery.

<span class="mw-page-title-main">Alex Bekker</span> Physician, author and academic

Alex Bekker is a physician, author and academic. He is a professor and chair at the Department of Anesthesiology, Rutgers New Jersey Medical School. He is also professor at the Department of Physiology, Pharmacology & Neurosciences. He serves as the Chief of Anesthesiology Service at the University Hospital in Newark.

References

  1. 1 2 3 Shinoura, Nobusada; Yamada, Ryoji; Tabei, Yusuke; Saito, Kuniaki; Suzuki, Yuichi; Yagi, Kazuo (2011-04-01). "Advantages and disadvantages of awake surgery for brain tumours in the primary motor cortex: institutional experience and review of literature". British Journal of Neurosurgery. 25 (2): 218–224. doi:10.3109/02688697.2010.505671. ISSN   1360-046X. PMID   20854057. S2CID   35732214.
  2. 1 2 3 Ibrahim, George M.; Bernstein, Mark (2012-09-01). "Awake craniotomy for supratentorial gliomas: why, when and how?". CNS Oncology. 1 (1): 71–83. doi:10.2217/cns.12.1. ISSN   2045-0915. PMC   6176819 . PMID   25054301.
  3. ↑ Paldor, Iddo; Drummond, Katharine J.; Awad, Mohammed; Sufaro, Yuval Z.; Kaye, Andrew H. (2016-01-01). "Is a wake-up call in order? Review of the evidence for awake craniotomy". Journal of Clinical Neuroscience. 23: 1–7. doi:10.1016/j.jocn.2015.11.004. ISSN   1532-2653. PMID   26675622. S2CID   6318120.
  4. 1 2 3 4 Dziedzic, Tomasz; Bernstein, Mark (2014-12-01). "Awake craniotomy for brain tumor: indications, technique and benefits". Expert Review of Neurotherapeutics. 14 (12): 1405–1415. doi:10.1586/14737175.2014.979793. ISSN   1744-8360. PMID   25413123. S2CID   207193843.
  5. 1 2 3 4 5 Erickson, Kirstin M.; Cole, Daniel J. (2012-06-01). "Anesthetic considerations for awake craniotomy for epilepsy and functional neurosurgery". Anesthesiology Clinics. 30 (2): 241–268. doi:10.1016/j.anclin.2012.05.002. ISSN   1932-2275. PMID   22901609.
  6. ↑ Brown, Tyler; Shah, Ashish H.; Bregy, Amade; Shah, Nirav H.; Thambuswamy, Michael; Barbarite, Eric; Fuhrman, Thomas; Komotar, Ricardo J. (2013-07-01). "Awake craniotomy for brain tumor resection: the rule rather than the exception?". Journal of Neurosurgical Anesthesiology. 25 (3): 240–247. doi:10.1097/ANA.0b013e318290c230. ISSN   1537-1921. PMID   23603885. S2CID   25386825.
  7. ↑ Wong, Jaclyn, Kong, Amy, Lam, Sau, Woo, Peter. High-Flow Nasal Oxygen in Patient With Obstructive Sleep Apnea Undergoing Awake Craniotomy: A Case Report. A&A Case Reports. 2017;9(12):353-356. doi:10.1213/XAA.0000000000000615.
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