Page 10 - CASA Bulletin of Anesthesiologisy 2022 9(6)-1 (3)

CASA Bulletin of Anesthesiology

本期专题

Anesthetic consideration and management of awake craniotomy

Hui Yang, MD PhD
Clinical Assistant Professor
Cleveland Clinic Lerner College of Medicine (CCLCM) of Case Western Reserve University
Cleveland Clinic, Cleveland, OH 44195, USA

Awake craniotomy refers to an intracranial surgery performed while the patient is in a state
of awareness allowing for cooperation with functional testing of the cortex. This technique is a
gold standard of care for neurosurgical interventions requiring tissue resection within or close to
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the eloquent brain areas involved in motor, visual, language function or short-term memory .
The cortical mapping during awake craniotomy enables the identification of cortical and
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maximal removal of lesions while preserving neurological and cognitive function . Awake
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craniotomy has been originally adopted for the surgical treatment of intractable epilepsy, and in
recent decades has been widely carried out for both low-grade and high-grade gliomas resection
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and for other lesions close to eloquent brain areas (e.g., cerebral aneurysm , vestibular
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schwannomas ). Compared with craniotomy under general anesthesia (GA), awake craniotomy
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is associated with greater extent of tumor resection, lower incidence of postoperative
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neurological deficit , shorter hospital stays, and longer survival after brain tumor resection .
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Aside from the surgical benefits, awake craniotomy is also associated with less exposure to GA,
less hemodynamic and physiological disturbances, less postoperative nausea and vomiting and
lower postoperative pain scores despite reduced narcotic use . Recently, awake craniotomy has
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been studied as a potential outpatient procedure and some reports showed it is a feasible option
in carefully selected patients undergoing supratentorial tumor surgery on an outpatient basis 9, 10 .

Preoperative patient selection and preparation
Appropriate patient selection and preparation are crucial to procedural success. The absolute
contraindications for awake craniotomy are patient refusal and inability to cooperate (e.g.,
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decreased level of consciousness) . Some medical conditions may make this surgery
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challenging, including obesity, OSA, difficult airway, seizure history, psychiatric disorders,
chronic cough, severe GERD, pregnancy, hearing or language barrier, pediatric population, and
challenging tumor pathology (e.g., large and deep-seated tumors, highly vascular lesions).
Strategic anesthetic planning tailored to each individual patient and a skilled multidisciplinary
team are essential for the procedural success.

Awake craniotomy requires a highly motivated and cooperative patient. Preoperative
preparation is of utmost importance. Approximately one quarter of patients report significant
anxiety prior to awake brain surgery. This can be mitigated by providing comprehensive
perioperative information and support, which should begin as soon as the patient is scheduled for
awake craniotomy . During the preanesthetic visit, an anesthesiologist should take this
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opportunity to establish good rapport with the patient, outline the procedure in detail
(positioning, scalp nerve block, airway management, and motor and language testing), counsel

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