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09 04 30 Awake Craniotomy Jordan meeting

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					 Awake Craniotomy
past, present & future
Dr. Jafar H. Faraj
Department of Anesthesia/ICU
Hamad Medical Corporation
Doha, Qatar
2009

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Out of 120 prehistoric skulls found at one burial site in France dated
to 6500 BC, 40 had trepanation holes                      wikipedia




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        Awake craniotomy
First introduced to treat intractable Epilepsy
Sparing important foci such as
   Motor
   Memory
   Speech
   Vision
Electrocorticography ECoG (Brain Mapping)


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           Awake craniotomy
           Functional Neurosurgery
Movement disorders
Parkinson disease
Essential tremor
Dystonia
Myoclonus
Others (chorea, torticollis, spasticity)
Chronic pain
Psychiatric disorders
Chronic depression
Obsessive compulsive
Seizure disorders
Multiple sclerosis
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       Awake craniotomy
Emergency surgery
High risk patients




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         Awake craniotomy

1886, first craniotomy under LA
1929, Dr Harvey Cushing
1934, LA + Sedation
1959, Neurolept technique (for 30 yrs.)




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      Conscious-sedation analgesia during
       craniotomy for intractable epilepsy:
            a review of 354 patients


354 Intractable Epilepsy 1976-1983
Droperidol & Fentanyl ± Methohexitone (325)
7 patients had GA


CJA 1988 , 35: 4 , 338-44




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     Anaesthesia for awake craniotomy
            evolution of a technique
99 procedures 1989-2002
Group A        Group B          Group C
Fent            Fent            Remi
MZ+ Prop       Prop             Prop TCI
NP airway       LMA             LMA
Sp Vent        Sp Vent          Con Vent
MS-tech        AAA-tech         AAA-tech
Complications in Group C is minimal
BJA 90 (2): 161-5 (2003)
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   Awake craniotomy-HMC
Three males, 28 to 39 years
Parietal tumors, four procedures
Body weight 59 to 72 kg. ASA I
Pre-medicated with Glycopyrrolate
Monitoring: ECG, SpO2,IBP, ABG and BIS
Foley catheter
Oxygen provided through nasal prongs
MAC i.e. LA + Sedation/Analgesia.
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   Awake craniotomy-HMC
Complications: oversedation & airway
obstruction (in one case), hypercapnia &
brain swelling (in three procedures)
         Mannitol 20%
Postoperatively: no ICU admission, short
hospital stay




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           Awake craniotomy
             Techniques
MAC Monitored Anesthesia Care
   Moderate sedation
   Spontaneous breathing+ Oxygen, possibly
    airway control
   Responsive to call
AAA Asleep-Awake-Asleep
   Deep sedation &/or GA, possibly spontaneous
    breathing
   Airway control: LMA, ETT to be extubated
    during the procedure
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     Awake craniotomy
     Aims of Anesthesia
1. Maintain patient cooperation
    Adequate sedation and analgesia

    Prevention of N/V and seizures

    Comfortable position

2. Homeostasis
    Safe airway, adequate ventilation

    Hemodynamic stability

    Normal ICP ?

3. Limited interference with ECoG in
      Epilepsy surgery
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        Awake Craniotomy
     Preoperative assessment
Airway assessment
Patient’s understanding and cooperation
SAS, Morbid obesity
Severe anxiety
Psychiatric disorders      patients should not be considered
                           for awake craniotomy.
Large vascular tumors
Occipital lobe surgery
Significant dural invasion
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        Awake Craniotomy
         Pre-medication
Benzodiazepine
Clonidine
Anticholinergic
Antiemetic




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            Awake Craniotomy
            Scalp (Skull) Block
Adrenaline + Lignocaine/ Bupivacaine   (+NaHCO3)

Vigilance within 15 min. of block
Nerves to be blocked:
   1. Auriculotemporal
   2. Zygomaticotemporal
                                   Trigeminal Nerve
   3. Supraorbital
   4. Supratrochlear
   5. Greater occipital
                                        C2 – C3
   6. Lesser occipital
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         Awake Craniotomy
          MAC-Technique
Midazolam
Propofol: TCI 1-2 µg/ml
Fentanyl
Remifentanil: 0.05-0.1 µg/kg/min,
             TCI 1-3 ng/ml
NB: discontinue 15 min. before mapping &
resume at Dura closure
Oxygen: NP or nasal cann., Face mask
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                  Awake Craniotomy
                  Dexmedetomidine
α2- adrenergic agonist (Bekker AY et al The use of dexmedetomidine
infusion for awake craniotomy. Anesth Analg 2001;92: 1251–3.)

Excitation inhibition
Natural sleep without respiratory depression
Eight times greater affinity than Clonidine
Shorter half life: 2 hrs. vs.12 hrs Clonidine
Does not interfere with electrophysiological
monitoring
Has sedative, analgesic and anesthetic sparing
effects. (BJA August 2006)
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        Awake Craniotomy
         AAA- Technique
ETT
LMA either spontaneous or controlled
….better Proseal
BiPAP
NT above glottis




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        Awake Craniotomy
           Monitoring
Standard: BP, SpO2, ECG
Preferable or necessary: IBP & Foley cath.
CVC not commonly used
ETCO2 when applicable
BIS




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        Awake craniotomy
          In pediatrics
All reported cases above 10 years
Limited number
Often needs a “mature child” !




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          Awake craniotomy
           Complications


1.   Desaturation/ airway obstruction
2.   Seizures
3.   N/V
4.   Brain swelling
5.   Shivering
6.   Aspiration??

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           Awake Craniotomy
                Future
A shorter hospital stay
Low cost, bed occupancy HDU > ICU
Less complications, better results
Day-case procedures?
Suitable for all supratentorial tumor resection?




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    Awake craniotomy for intra-axial tumors
       a prospective trial of 200 cases
Reduction in OR time
Lack of ICU admission
Minimal or none invasive monitoring
Tumors in eloquent brain area became resectable
Late admission and early discharge
Recommend AC to all supratentorial tumor
Exclusion criteria case-by-case

J Neurosurg 90:35–41, 1999


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    Awake Craniotomy for Removal of
           Intracranial Tumor:
    Considerations for Early Discharge

241 patients
15 patients (6%) discharged after 6 hrs
76 patients (31%) discharged after 24 hrs
Median hospital stay 5 days


Anesth Analg 2001;92:89 –94


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           Awake Craniotomy
            CONCLUSION
Reduces postoperative morbidity;
  Early discharge from ICU or PACU and

  A shorter hospital stay

Cost-effective
No protocol
MAC is the favorable technique
Propofol and Remifentanil
A good rapport between the patient, the
anesthesiologist and the neurosurgeon is essential.

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“Man's mind, once stretched by
 a new idea, never regains its
 original dimensions.”
Oliver Wendell Holmes
US author & physician (1809 - 1894)




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THANK YOU




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