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PubMed2006

Risk factors for developing epilepsy after craniotomy in children.

INTRODUCTION: We performed a retrospective analysis of children undergoing supratentorial craniotomy, attempting to identify possible risk factors for postoperative epilepsy and the need for prophylactic anticonvulsant therapy. MATERIALS AND METHODS: We analysed 107 consecutive patients (55% males) who had supratentorial craniotomy for a variety of diagnoses (tumours, trauma, infection, vascular malformations and others) during 1995-1999. Mean age at operation was 89 months (range: 1-180 months). Patients who presented with epilepsy were excluded. Postoperative epilepsy was considered present if patients required systematic pharmacological treatment, at a minimum follow-up of 6 months. Linear regression was used to analyse the effect of sex, anticonvulsant prophylaxis, duration of operation, closure of dura, postoperative infection, the diagnosis, anatomical region of brain affected, operation type (craniotomy/craniectomy) and the need for brain resection. RESULTS: Prophylactic anticonvulsants were given to 52% of the patients; 97% had craniotomy; in five patients, the dura was left open; in 33%, some kind of brain tissue resection had been performed; two patients (1.8%) developed postoperative infection; one patient died. Only 13 patients (12%) developed postoperative epilepsy. The only two factors with statistical significance were female sex (p=0.045) and the absence of dural closure (p=0.001). All other factors were not significant (p>0.258). CONCLUSIONS: Postoperative epilepsy after supratentorial craniotomy is uncommon in children, incidence being 12%. The administration of prophylactic anticonvulsants does not appear to influence the risk of epilepsy. Surprisingly, females have statistically higher risk. Lack of dural closure has higher risk of epilepsy, but this may reflect the type of pathology.

Adolescent↗

PubMed2003

The effect of craniotomy location on postoperative pain and nausea.

PURPOSE: At least one retrospective study has suggested that the need for postoperative control of pain and nausea depends on the location of the cranial surgery. This prospective study was performed to examine the hypothesis that patients who have had infratentorial craniotomy experience more severe pain and more frequent nausea than those with supratentorial procedures. METHODS: We compared postoperative outcomes in 28 patients with infratentorial craniotomy, 53 with supratentorial craniotomy, and 47 with complex spinal cord surgery (the control group). Anesthesia was standardized for all three groups and the concentration of isoflurane was titrated to keep mean arterial pressure within 30% of preoperative values. Severity of pain and frequency of nausea and vomiting were recorded for 24 h after surgery. Pain was assessed with a verbal pain score scale of 0-10, with 10 being the worst pain imaginable. Data were collected for 24 h postoperatively. RESULTS: Because nausea and pain diminish drastically 2 h after surgery, pairwise differences were assessed at each point within the first 2 h. Within 30 min of extubation, median pain scores in the supratentorial and spine groups rose to 2 and in the infratentorial group to 5. The statistical differences between groups were not significant ( P > 0.06) by logistic regression. Also, the incidence of nausea was not significantly different (57% supratentorial, 57% spine, 67% infratentorial; P = 0.62) by Dunn's procedure. CONCLUSION: There were no significant differences in the severity of pain or the frequency of nausea based on the craniotomy site.

Craniotomy↗

PubMed2004

Craniotomies without burr holes using an oscillating saw.

OBJECTIVE: The object of this study is to describe a new method for performing craniotomies which obviates the need for burr holes, improves bony reconstruction, and reduces post-operative cosmetic deformities. Moreover, this technique provides excellent exposure of skull base structures and dural venous sinuses. METHODS: Craniotomies in varied locations are created with the use of a micro-oscillating saw and chisel. No burr holes are used and reconstruction with plates and screws is unnecessary. RESULTS: We initially applied our technique to approaches to the anterior skull base with combined craniofacial tumour resections. We have since performed over 2000 craniotomies of any size and shape in all supratentorial locations using the oscillating saw. CONCLUSIONS: We have found that our method creates better cosmetic results than standard techniques and is safer for craniotomies spanning dural venous sinuses. With experience, operating time was significantly reduced and costs were lowered because reconstruction with fixation devices was not needed.

Brain Neoplasms↗

PubMed2005

Multimodal protocol for awake craniotomy in language cortex tumour surgery.

BACKGROUND: Intra-operative neurophysiological language mapping has become an established procedure in patients operated on for tumours in the area of the language cortex. Awake cranial surgery has specific risks and patients are exposed to an increased physical and mental stress. The aim of the study was to establish an algorithm that enables tailoring the neurosurgical and anaesthetic techniques to the individual patient. METHOD: A total of 25 patients underwent awake craniotomy for intra-operative language mapping between 1999 and 2004. Following craniotomy under analgesia and sedation without rigid pin fixation of the head, cortical language mapping was performed in the fully co-operative patient. The results of functional magnetic resonance imaging and of cortical language mapping were incorporated into the 3D dataset for neuronavigation. Depending on the functional data and the individual operative risk tumour resection then proceeded either under conscious sedation with the option of subcortical language monitoring or under general anaesthesia. FINDINGS: After cortical language mapping patients are assigned to one of four groups: BACC (Berlin awake craniotomy criteria) I-IV. BACC I (9 patients): adequate functional data+operative risk not increased-->tumour resection in the awake patient; BACC II (4 patients): limited functional data+operative risk not increased-->tumour resection in the awake patient with the option of language monitoring as needed; BACC III (9 patients): adequate functional data+increased operative risk-->tumour resection under general anaesthesia using functional navigation; BACC IV (3 patients): limited functional data+increased operative risk-->tumour resection in the awake patient with the option of language monitoring as needed. We observed less adverse events in group BACC III. No permanent deterioration of language function occurred in this series. CONCLUSIONS: The multimodal protocol for awake craniotomy provides for tumour resection under general anaesthesia in selected patients using functional neuronavigation. Our experience with the algorithm suggests that it is a useful tool for preserving function in patients undergoing surgery of the language cortex while reducing the operative risk on an individual basis.

Adult↗

PubMed1987

Subdural fluid collection following craniotomy.

The occurrence of subdural fluid collection following craniotomy for intracranial aneurysms was studied with regard to the patient's age, preoperative grade, external decompression, incidence of the craniotomy, external drainage, and ventriculoperitoneal shunt. The following results and conclusions were obtained: Enlargement of the subdural space was observed in 76 of 147 patients (51.7%). The patient's age was the most likely causative factor in producing the lesion. Six patients required surgical management for the collection: three were for subdural hygroma and three were for chronic subdural hematoma. It is estimated that two factors, multiple craniotomy and younger age, accelerated the formation of symptomatic subdural hygromas. When the patient complains of headache or motor weakness 1 or 2 months after undergoing a craniotomy, one should suspect chronic subdural hematoma, especially in an elderly patient with ruptured aneurysm.

Adult↗

PubMed2005

Double concentric craniotomy for a craniocerebral penetrating nail. Case report and technical note.

BACKGROUND: Craniocerebral penetrating injuries from nail-gun accidents are rare and usually are discovered immediately after the trauma. Several surgical procedures have been described to extract a foreign body that is infixed in the skull and has penetrated the surrounding structures; blind extraction, craniectomy, and craniotomy. CASE DESCRIPTION: We report the case of a 25-year-old ex-carpenter who presented with jacksonian seizure at the left limb. Plain radiography of the skull revealed the unexpected presence of a nail hammered in the right parietal bone, penetrating the underlying structures of the frontoparietal area up to a depth of 3 cm. The patient was operated on; a small craniotomy (1 x 1 cm) just around the head of the nail, and a concentric larger frontoparietal bone flap, involving the first craniotomy, were performed. The larger bone flap was elevated first, whereas the small bone flap with the nail infixed was carefully elevated along the axis of the nail, under direct vision of the nail tract. CONCLUSIONS: Double concentric craniotomy is the only technique that permits the removal of a foreign body that has penetrated both the skull and the brain, under direct vision, without transmitting any undue forces to the underlying structures. With this technique, control of bleeding can also be easily achieved.

Accidents, Occupational↗

PubMed1998

Differential induction of immediate early gene mRNAs following cryogenic and impact trauma with/without craniotomy in rats.

Expression of immediate early gene (IEG) mRNAs following traumatic brain injury in 3 different models-cryogenic injury, impact injury with craniotomy and impact injury without craniotomy-was investigated using in situ hybridization. Cryogenic brain injury resulted in c-fos and c-jun mRNA expression throughout the ipsilateral cortex, piriform cortex and dentate gyrus on the injured side, with peak at 30 min to 1 h post-injury. Impact injury with craniotomy was associated with hybridization signals in the same areas and also in the subcortical white matter or ependyma underlying the impact site at 30 min post-injury. The expression was rather more prolonged than with cryogenic injury. Impact injury without craniotomy induced the expression of both mRNAs throughout the ipsilateral cortex, piriform cortex and dentate gyrus at 30 min post-injury, but this was promptly attenuated by 1 h post-injury, except for bilateral elevation in the dentate gyrus. The present study, thus, demonstrated that regional and temporal expression of IEG mRNAs is influenced by the intensity, quality and manner of application of the insult. Differences in the expression of IEGs may alter the late response gene expression and affect the succeeding events.

Animals↗

PubMed2003

Routine use of postoperative ICU care for elective craniotomy: a cost-benefit analysis.

OBJECTIVE: Postoperative monitoring in an intensive care unit (ICU) setting following elective craniotomy is routine at many institutions, as it is believed that this reduces the incidence and potential seriousness of early postoperative complications. This is unproven, however, and ICU resources are scarce and costly. At our institution, one surgeon began to routinely transfer elective craniotomy patients directly to the floor following an uneventful postanesthesia care unit (PACU) recovery. This study was undertaken to see whether that practice was safe and cost-effective. METHODS: A retrospective cohort of 430 consecutive, elective adult craniotomies, from February, 2000 to September, 2001 were analyzed. Variables were divided into 12 major groups: attending surgeon, age, sex, diagnosis, Current Procedural Terminology (CPT) code, length of stay, preoperative deficit, medical co-morbidities, postop floor, medical complications, neurological complications, and total hospitalization cost. RESULTS: Patients admitted to the surgical intensive care unit (SICU) did not have fewer complications than patients transferred directly to the floor. Patients admitted to the SICU did not have more preoperative neurological deficits or medical co-morbidities. Age was not a significant predictor of either medical or neurological complications. In patients without initial postop complications, only length of stay and postop floor assignment correlated with cost (p < 0.001). Immediate transfer to the floor decreased average hospitalization length by 3 days, and provided cost savings of $4,026 per patient. CONCLUSIONS: Selective, rather than routine use of postoperative ICU care in elective craniotomy patients is safe, resulting in no greater incidence of medical or neurological complications, and may provide significant reductions in average hospitalization length and cost.

Adult↗

PubMed1999

Cosmetic osteoplastic craniotomy with a chisel and hammer.

BACKGROUND: Osteoplastic craniotomy has been performed recently with microfixation systems such as miniplates, burr hole buttons, and/or ceramic dust. However, these are costly methods of treatment. Without the use of these devices, we performed cosmetic osteoplastic craniotomy using an inexpensive chisel and hammer. METHODS: Our osteoplastic craniotomy with a chisel and hammer was used on 19 lesions in 15 patients. Using a chisel, the bone flap was cut gently from the calvarium to the skull base, the lamina externa to the diploe (finally the lamina interna), and both ends to the midportion between two holes. The lamina interna in the cranium was trimmed easily after removal of the bone flap. The bone defect was minimal because of the absence of a narrow cutting groove and because craniectomy was not performed. The bone flap was replaced by tapping and was tightly fixed. No special fixation system was needed, except for threads. RESULTS: Follow-up (mean follow-up, 5 months; range, 5 weeks to 9 months) skull X-ray and 3D-CT showed good fusion and inherent normal configuration of the bone flap. There were two minor dural tears and two minor bony fractures. CONCLUSION: A good cosmetic effect without the use of any additional instruments was accomplished with osteoplastic craniotomy using a chisel and hammer.

Craniotomy↗

PubMed2000

The effect of propofol on intraoperative electrocorticography and cortical stimulation during awake craniotomies in children.

Propofol has been proposed as a sedative agent during awake craniotomies. However, there are reports of propofol suppressing spontaneous epileptiform electrocorticography (ECoG) activity during seizure surgery, while others describe propofol-induced epileptiform activity. The purpose of this study was to determine if propofol interferes with ECoG and direct cortical stimulation during awake craniotomies in children. Children scheduled for awake craniotomies for resection of epileptic foci or tumours were studied. An intravenous bolus of 1-2 mg.kg-1 followed by infusion of 100-200 microgram.kg-1.min-1 of propofol was administered to induce unconsciousness. Fentanyl (0.5 microgram.kg-1) was administered incrementally to provide analgesia. After the cortex was exposed, the propofol infusion was stopped and the patient permitted to awaken. Cortical electrodes were applied. ECoG was recorded continuously on a Grass polygraph. Motor, sensory, language, and memory testing were done throughout the procedure. The cortex was stimulated with a hand-held electrode using sequential increases in voltage to map the relevant speech and motor areas. We studied 12 children (aged 11-15 years) with intractable seizures. The raw ECoG did not reveal any prolonged beta-waves associated with propofol effect. Electroencephalogram spikes due to spontaneous activity or cortical stimulation were easily detected. Cognitive, memory and speech testing was also successful. We conclude that propofol did not interfere with intraoperative ECoG during awake craniotomies. Using this technique, we were able to fully assess motor, sensory, cognitive, speech and memory function and simultaneously avoid routine airway manipulation.

Adolescent↗

PubMed1995

The arterial to end-tidal carbon dioxide difference in neurosurgical patients during craniotomy.

PETCO2 is often used as an estimate of PaCO2, with the understanding that PaCO2 usually exceeds PETCO2. During intraoperative craniotomies, because hyperventilation is used to therapeutically lower intracranial pressure, the difference between PaCO2 and PETCO2 (P(a-ET)CO2) has therapeutic implications. The P(a-ET)CO2 was hypothesized to be stable during craniotomies with relatively short-term monitoring and controlled cardiorespiratory variables. Thirty-five patients undergoing elective craniotomies were studied. Arterial blood gases (with PaCO2) were measured after induction of general anesthesia, after cranium opening prior to dural incision, and at start of closure; PETCO2 was simultaneously determined with infrared capnometry. The PaCO2 was 31.9 +/- 3.9 mm Hg (range, 24.8-46.7) (values are mean +/- SD) and PETCO2, 24.7 +/- 3.8 mm Hg (range, 16-34), with a P(a-ET)CO2 of 7.2 +/- 3.3 mm Hg (of 126 comparisons, range was -1.2-17.3). There was no correlation of P(a-ET)CO2 with blood pressure, heart rate, respiratory volumes, airway pressures, or inspired oxygen concentration. There was a significant positive correlation between PaCO2 and PETCO2 (r = 0.632, slope = 0.609) and P(a-ET)CO2 and PaCO2 (r = 0.46, slope = 0.391, P < 0.017, and r2 = 0.22). Although changes in the study population of PaCO2 and PETCO2 correlated statistically (r = 0.818, slope = 0.76, P < 0.001, r2 = 0.669), comparisons in 17 of 35 individuals were not significant. On comparison of subsequent measurements, 18.4% of changes in PaCO2 and PETCO2 (although sometimes small) were in opposite directions. P(a-ET)CO2 did not change with time. The PETCO2 does not provide a stable reflection of PaCO2 in many patients undergoing craniotomies.

Adult↗

PubMed1998

Emergency craniotomy in a rural Level III trauma center.

Patients with closed head injury and expanding epidural (EDH) or subdural (SDH) hematoma require urgent craniotomy for decompression and control of hemorrhage. In remote areas where neurosurgeons are not available, trauma surgeons may occasionally need to intervene to avert progressive neurologic injury and death. In 1990, a young man with rapidly deteriorating neurologic signs underwent emergency burr hole decompression of a combined EDH/SDH at our hospital, with complete recovery. In anticipation of future need, five surgeons at our rural, American College of Surgeons-verified Level III trauma center participated in a neurosurgeon-directed course in emergency craniotomy. Since January 1, 1991, 792 patients have been entered into the trauma registry, including 60 with closed head injury and Glasgow Coma Scale (GCS) score of 13 or less. All but seven were transferred to a regional Level II trauma center, which is a minimum flight time of 1 hour each way. All patients with EDH (5) and 2 of 14 with SDH were deemed too unstable for transport and underwent burr hole decompression followed by immediate transfer. All craniotomies were approved by the consulting neurosurgeon and were done for computed tomography-confirmed lesions combined with neurologic deterioration as demonstrated by (1) GCS score of 8 or less, (2) lateralizing signs (dilated pupil, hemiparesis), or (3) development of combined bradycardia and hypertension. One patient with a GCS score of 3 on arrival died. Seven survivors (mean follow-up, 3.9 years; range, 1-6.5 years), including the index case, function independently, although one survivor has moderate cognitive and motor impairment. We conclude that early craniotomy for expanding epidural and subdural hematomas by properly trained surgeons may save lives and reduce morbidity in properly selected cases when timely access to a neurosurgeon is not possible.

Adolescent↗

PubMed1996

Stereotactic microsurgical craniotomy for the treatment of third ventricular colloid cysts.

The treatment of colloid cysts remains controversial. This article reports on 18 patients with colloid cysts of the third ventricle who presented to the University of Michigan between January 1990 and June 1995. Two patients had conventional transcortical-transventricular approaches; the remaining 16 patients underwent a stereotactic modification of the transcortical approach, using a specially designed cylindrical retractor, for the resection of their colloid cysts. Minor morbidity and no mortality have been associated with this technique. There have been no instances of recurrence during the period of this report. The mean operative time for the two conventional craniotomies was 233 minutes, compared with 129 minutes for the stereotactic craniotomies. Our technique allows for a limited craniotomy and limited cortical disruption. It is not dependent on ventricular size. Localization of the colloid cyst is trivial because of modern stereotactic technology, and all standard microsurgical techniques can be used. The retractor is readily adaptable to any Leksell system. This technique shortens operative time, compared with conventional craniotomy, and allows for definitive treatment of the lesion.

Adolescent↗

PubMed2001

Craniotomy improves outcomes for cranial subdural empyemas: computed tomography-era experience with 699 patients.

OBJECTIVE: Uncertainty regarding the best surgical management for subdural empyemas (SDEs) continues. Our unit has considered craniotomy the preferred method of surgical drainage for all cranial SDEs since 1988. We performed an analysis of our previously published, computed tomography-era, experience with 699 patients. METHODS: Two analyses of the database (1983-1997) were performed. First, analysis of the periods from 1983 to 1987 and from 1988 to 1997 was performed. Second, analysis of the composite database was performed. Outcomes were compared for possible outcome predictors by univariate analysis. Multivariate analysis was used to identify variables that contributed independently to outcomes, using stepwise discriminant analysis. RESULTS: Significant correlations between the analyzed periods with respect to outcome and type of surgery (P = 0.001) were noted. Analysis of the entire database (1983-1997) revealed a significant relationship between outcome and surgery type (P = 0.05). Pairwise comparison of limited procedures such as burr holes or craniectomies with wide-exposure surgical procedures such as primary craniotomies or procedures proceeding to full craniotomies indicated significant correlation with outcomes (P = 0.027). Reoperation and morbidity rates were increased with limited procedures. Stepwise discriminant analyses revealed that the type of surgery was correlated with outcomes (P = 0.0008, partial r(2) = 0.034). CONCLUSION: Craniotomy was determined to be the surgical procedure of choice for treatment of cranial SDEs, allowing complete evacuation of the pus and, more importantly, decompressing the underlying cerebral hemisphere. Limited procedures such as burr holes or craniectomies may be performed for patients in septic shock, for patients with parafalcine empyemas, or for children with SDEs secondary to meningitis.

Craniotomy↗

PubMed1998

Consolidation of craniotomy lines after resorbable polylactide and titanium plating: a comparative experimental study in sheep.

The consolidation process of craniotomy lines in a skeletally immature large mammal was studied. A traditional narrow titanium miniplate was compared with a 0.5-mm-thick, 12-mm-wide absorbable punched self-reinforced poly-L-lactide (SR-PLLA) plate, both fixed with titanium miniscrews over bilateral parietal 2.5-mm-wide stable transosseous craniotomies on nine female sheep (16 to 20 months old). After 6, 12, 20, 52, and 104 weeks, cross-sectional histology, histomorphometry, and oxytetracycline chloride fluorescence studies were done to compare the healing process of the craniotomy lines and to study the biocompatibility and the degradation process of the SR-PLLA plate. The consolidation pattern supported the principle of guided tissue regeneration: under the wide, resorbable plate osseous bridging proceeded evenly throughout the line, whereas titanium plating led to bulky, uneven growth in the bone margins. All SR-PLLA-plated osteotomy lines had healed completely by 20 weeks, whereas none of the titanium-plated lines had consolidated during a follow-up of 1 year. The nonossified gaps were filled with dense connective tissue. Histomorphometric analysis showed that osseous bridging proceeded significantly faster on the resorbable plate side compared with the titanium side (p < 0.001). The osteoid surface fraction over the total trabecular surface was highest at 6 weeks, being 63 percent on the SR-PLLA side and only 36 percent on the titanium side. The oxytetracycline chloride fluorescence studies confirmed these findings. After 52 weeks, there was no osteoid or oxytetracycline chloride fluorescence left as a sign of terminated ossification, even in the nonconsolidated titanium sides. Microscopic cracking of the plate was evident at 12 to 20 weeks, and the first signs of active resorption were present at 52 weeks. After 2 years, the plate had disappeared and tiny polylactide particles were being actively reabsorbed. The biocompatibility of SR-PLLA and titanium was good, and no adverse cellular reactions to these materials were noted, except a clinical foreign body reaction caused by loosened titanium miniscrews. A densely punched, 0.5-mm-thick self-reinforced PLLA plate seems to retain its integrity for a sufficiently long time to complete osseous healing of a 2.5-mm-wide craniotomy line in the sheep calvarial area. A thin, wide fixation plate enables superior healing, especially in osseous defects. The degradation process of the SR-PLLA plate begins within 1 year and is far advanced after 2 years. By using absorbable SR-PLLA fixation plates instead of metallic plates, a subsequent operation for the removal of the implants can be avoided. SR-PLLA devices could thus be a potential additive or even alternative to metallic implants in craniofacial surgery.

Animals↗

PubMed1996

Brain relaxation and cerebrospinal fluid pressure during craniotomy for resection of supratentorial mass lesions.

Neurosurgery can be complicated by the clinical situation commonly referred to as "tight brain," in which the brain presses against the inner table of the skull or protrudes through the craniotomy site. We report here a retrospective study of 32 patients who had undergone elective craniotomy for resection of supratentorial mass lesions. We determined the relationship between lumbar cerebrospinal fluid pressure (CSFP) and brain relaxation and whether brain relaxation varies with anesthetic technique. Patients had received one of four anesthetic techniques: 1 MAC isoflurane (ISO), 1 MAC desflurane (DES), 50% N2O with 0.5 MAC ISO, or 50% N2O with 0.5 MAC DES. Lumbar CSFP had been recorded before the induction of anesthesia (baseline) and immediately prior to dural incision. Charts were retrospectively reviewed for evidence of tight brain, which was considered present if mannitol had been administered, CSF had been drained via the lumbar needle, or the surgical dictation noted the brain was tight at the time of dural incision. Tight brain occurred in 10 of 32 patients. CSFP (mean +/- SD) was significantly greater in the tight than in the nontight group both at baseline (11 +/- 5 vs. 8 +/- 3 mm Hg, p < 0.05) and immediately prior to dural incision (13 +/- 7 vs. 9 +/- 4 mm Hg, p < 0.05). Tight brain did not occur in any patient with CSFP < 6 mm Hg, but it did occur in all patients with CSFP > 17 mm Hg. Within the range of 6-17 mm Hg, CSFP was not predictive of brain relaxation. Tight brain was more common in patients receiving 1 MAC ISO or DES (9 of 20 patients; 45%) than in patients receiving 0.5 MAC ISO or DES with 50% N2O (1 of 12 patients; 8%, p < 0.05). We conclude that in patients undergoing elective craniotomy for resection of a supratentorial mass lesion, brain relaxation is not predictive of CSFP. Although CSFP values at the extremes of the observed distribution ( > 17 mm Hg or < 6 mm Hg) did correlate with brain relaxation, within the range of 6-17 mm Hg, CSFP did not predict brain relaxation. Additionally, the data from this study suggest that in patients undergoing elective craniotomy for resection of a supratentorial mass lesion, tight brain may occur with a lower frequency in patients receiving 0.5 MAC ISO or DES with 50% N2O than in patients receiving 1 MAC ISO or DES.

Aged↗

PubMed2002

Usefulness of monitoring brain tissue oxygen pressure during awake craniotomy for tumor resection: a case report.

Awake craniotomy is indicated for surgical resection of tumors located near eloquent areas of the brain. The anesthetic technique is based on a combination of local anesthesia, sedation, and analgesia. Usually only clinical parameters are assessed and no other cerebral oxygenation monitoring techniques are applied. The authors report the use of brain tissue oxygen pressure monitoring during awake craniotomy. A 48-year-old right-handed man with a left temporoparietal mass was scheduled for awake craniotomy, cortical stimulation, and selective tumor removal. Monitoring included electrocardiography, pulse oximetry, end-tidal CO2, bladder temperature, invasive and noninvasive arterial pressure, and brain tissue oxygen pressure (PtiO2). The anesthetic technique consisted of continuous perfusions of 0.02 to 0.05 microg/kg/min remifentanil, propofol (target concentration, 0.5 to 1.2 microg/mL), and 25 to 50 microg/kg/min esmolol, and local anesthetic blockade of the head pin insertion sites and surgical incision area (a mixture of 0.2% ropivacaine, 1% lidocaine, and epinephrine, 1:200 000). Intraoperative cortical stimulation was performed to guide the resection according to the patient's verbal response. A change in PtiO2 was observed, gradually falling from 28 mm Hg at the beginning of the intervention down to 3 mm Hg. At this stage, surgical resection was concluded. On arrival at the intensive care unit, mixed dysphasia and slight weakness of the right arm were noted. Three weeks after surgery, the patient's speech is improving and the motor deficit has disappeared. This case suggests a possible role of PtiO2 in awake craniotomy as an aid in detecting intraoperative adverse events, but further experience with PtiO2 in this setting is needed.

Anesthesia↗

PubMed2004

Dexmedetomidine and neurocognitive testing in awake craniotomy.

Patients are selected for awake craniotomy when the planned procedure involves eloquent areas of the brain, necessitating an awake, cooperative patient capable of undergoing neurocognitive testing. Different anesthetic combinations, including neurolept, propofol with or without opioid infusions, and asleep-awake-asleep techniques, have been reported for awake craniotomy. In all these techniques, respiratory depression has been reported as a complication. In this case series dexmedetomidine, the highly selective alpha-2 adrenoreceptor agonist, was selected for its lack of respiratory depression as well as its sedative and analgesic properties. The charts of 10 consecutive patients who underwent awake craniotomy with dexmedetomidine infusion were reviewed. Five of the patients underwent "asleep-awake" technique with a laryngeal mask airway and volatile agent. Five patients received moderate to conscious sedation. All patients received a dexmedetomidine load of 0.5 to 1.0 microg/kg over 20 minutes followed by an infusion at rates of 0.01 to 1.0 microg/kg per hour. Four patients had extensive sensory and motor testing, and six underwent neurocognitive testing, including naming, reading, counting, and verbal fluency. There were no permanent neurologic deficits, except one patient who had an exacerbation of preoperative language difficulties. Dexmedetomidine appears to be a useful sedative for awake craniotomy when sophisticated neurologic testing is required.

Adrenergic alpha-Agonists↗