Awake Mini-Craniotomy for Edematous Brain Lesions

Purpose: Introduction: Awake craniotomy has been proven to be safe and effective in several conditions including low grade gliomas, epilepsy surgeries and some vascular conditions.1–3 It provides several advantages over craniotomy in general anesthesia. Firstly, it provides the ability to use intraoperative monitoring of eloquent regions including speech, motor, and visual areas. Secondly, pulmonary complications due to intubation, ventilation etc., that can occur with general anesthesia can be avoided. Thirdly, positional complications like ulcers, spinal torsions etc. can also be prevented.

The use of newer drugs like Dexmedetomidine is an alpha-2 adrenergic agonist, have properties of sedative and analgesic effect, reduced delirium and agitation, sympatholysis, cardiovascular stabilizing effect, without respiratory depression and has proved to be safe and effective in perioperative and ICU situations.4

Awake craniotomy has been generally used in non-edematous conditions, possibly due to apprehension of intraoperative brain bulge. If done in edematous conditions, large craniotomies have been advised.5 We have reported minicraniotomy and endoscopic assisted excision of edematous lesions in the past.6 In this article we report the combined use of techniques of awake and minicraniotomy for dealing with edematous brain lesions.

References:

1.         Gamble AJ, Schaffer SG, Nardi DJ, Chalif DJ, Katz J, Dehdashti AR. Awake Craniotomy in Arteriovenous Malformation Surgery: The Usefulness of Cortical and Subcortical Mapping of Language Function in Selected Patients. World Neurosurg. 2015;84(5):1394-1401. doi:10.1016/j.wneu.2015.06.059

2.         Sitnikov AR, Grigoryan YA, Mishnyakova LP. Awake craniotomy without sedation in treatment of patients with lesional epilepsy. Surg Neurol Int. 2018;9:177. doi:10.4103/sni.sni_24_18

3.         Taylor MD, Bernstein M. Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: a prospective trial of 200 cases. J Neurosurg. 1999;90(1):35-41. doi:10.3171/jns.1999.90.1.0035

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5.         Khu KJ, Ng WH. Intraoperative swelling leading to neurological deterioration: an argument for large craniotomy in awake surgery for glioma resection. J Clin Neurosci Off J Neurosurg Soc Australas. 2009;16(7):886-888. doi:10.1016/j.jocn.2008.10.002

6.         Ratre S, Yadav YR, Parihar VS, Kher Y. Microendoscopic Removal of Deep-Seated Brain Tumors Using Tubular Retraction System. J Neurol Surg Part Cent Eur Neurosurg. 2016;77(04):312-320. doi:10.1055/s-0036-1580595