Neuroanaesthetic Review

Anaesthesia for awake craniotomy: a modern approach

T.G. Costello MBBS FANZCA MBBS FANZCA, , J.R. Cormack MBBS FANZCA MBBS FANZCA
Consultant Anaesthetist, St. Vincents Hospital, Melbourne, Australia
INTRODUCTION
Awake craniotomy techniques are widely used and offer many
advantages in patients undergoing surgical management of epi-
lepsy and other procedures in eloquent areas of the brain.
The usual indication for the awake approach is to facilitate
intraoperative electrocorticography and cortical mapping to ac-
curately identify those areas of brain which control motor func-
tions and speech. The same anaesthetic techniques can also be
useful for patients with tumour or arteriovenous malformation
near the speech or motor areas, or for patients in whom a general
anaesthetic may be present an unnecessary risk. Indeed, there are
frequent reports of the use of this technique for unusual tumour or
epilepsy surgical cases
13
and to facilitate early discharge in
suitable cases.
46
Some are recommending the technique for all
supratentorial intraaxial tumours regardless of the involvement of
eloquent cortex.
7
Early descriptions indicate that the youngest
suitable patients are 11 or 12 years old
8
and again, there is re-
newed interest in this age group particularly with the use of novel
sedation techniques.
9;10
Many of the early reported anaesthetic protocols involved
awake-asleep-awake techniques (involving general anaesthesia for
part of the craniotomy) or relatively heavy intravenous sedation
with drugs that have a slow offset of action.
11;12
Asleep-awake-
asleep techniques have been successfully employed in some
centres, but often involve elaborate airway manoeuvres intraop-
eratively.
13
For example, Sarang and Dinsmore
14
retrospectively
examined three anaesthetic techniques: sedation with propofol,
fentanyl, droperidol and midazolam; asleep-awake-asleep with
propofol infusion, fentanyl and spontaneous ventilation via a
laryngeal mask airway (LMA) and asleep-awake-asleep with
propofol and remifentanil and intermittent positive pressure ven-
tilation via a LMA. All of these techniques, whilst allowing rea-
sonable patient comfort and satisfaction, complicate intraoperative
testing because they all result in significant sedation.
If general anaesthesia is to be employed, it is generally
agreed that where cortical mapping is required the use of volatile
agents should be avoided
15;16
as a concentration-dependent dis-
tortion of electrocorticography is seen with consequent inaccu-
racy in seizure focus identification. Other agents, such as opioids
and propofol, also have concentration-dependent effects on
electrocorticography.
17
At our institution, general anaesthesia is avoided, as it is
considered unnecessary in most cases, and sedation is kept to a
minimum. Our technique has been refined to ensure good
conditions for patient cooperation during testing and allow op-
timal levels of sedation and analgesia without respiratory or
cardiovascular compromise. A retrospective review of 354 pa-
tients undergoing awake craniotomy for epilepsy surgery high-
lighted many of the possible intraoperative problems of
convulsions (16%), nausea and vomiting (8%), tight brain
(1.4%), local anaesthetic toxicity (2%) and need for emergent
conversion to general anaesthesia (2%).
18
It is likely that the
incidence of all of these complications may be influenced in
some way by the anaesthetic technique used. Girvin,
11
for ex-
ample, reports no known cases of local anaesthetic toxicity in a
large series.
Experience over some years with the art of successful awake
craniotomy demonstrates the main obstacles to achieving a suc-
cessful outcome involve one or more of the following problems:
1. Pain Inadequate analgesia may manifest at the time of rigid
head pin-fixation or during temporalis muscle dissection early
in the craniotomy. Traction on the dura close to the middle
meningeal artery territory and on intracerebral blood vessels
are other possible causes of intraoperative pain.
2. Airway obstruction This is a possibility where overzealous
sedation has been employed, often to overcome pain when an-
algesia is suboptimal.
3. Nausea and vomiting Surgical manipulation at dural strip-
ping, temporal lobe or amygdala manipulation, meningeal ves-
sel handling, inadequate analgesia and hypovolaemia may all
contribute to nausea and vomiting.
4. Seizures Seizures may occur, particularly during cortical
stimulation, as a result of decreased levels of anticonvulsant
in the individual patient, or as a result of local anaesthetic tox-
icity.
18
Our local anaesthetic technique is designed to avoid these
common problems associated with awake craniotomy.
ANAESTHETIC MANAGEMENT OF AWAKE
CRANIOTOMY
Sedation technique
Patients are premedicated with oral clonidine 34 lg per kg
19
60
90 min before surgery. Clonidine is an a-2 agonist and provides
intra- and postoperative blood pressure control and anxiolysis
without cognitive impairment.
20;21
A long line is placed in the antecubital fossa and twin infusions
of propofol and dilute remifentanil (10 lg per ml) are commenced.
These agents are rapidly metabolised when used in low sedative
doses for short periods.
2224
The infusions are timed to commence
some minutes prior to scalp infiltration in order to achieve the
ideal plasma concentration to render the patient comfortable yet
co-operative.
Prior thought must be given to the positioning of the patient, as
this will influence the placement of lines and affect the visibility
and accessibility of the patient. A clear, unobstructed view of the
patient is essential for cortical mapping, particularly of the motor
cortex. Similarly the patient must have a clear view of objects
presented for object naming.
Journal of Clinical Neuroscience (2004) 11(1), 1619
0967-5868/$ - see front matter 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jocn.2003.09.003
Received 16 September 2003
Accepted 24 September 2003
Correspondence to: Dr. T.G. Costello, Consultant Anaesthetist, Unit 7/13
Brunswick St., Fitzroy, Melbourne 3065, Australia. Tel.: +61-03-94173600;
Fax: +61-03-94171295;
E-mail: analg@ozemail.com.au
16
Nerve blocks
Local anaesthetic blocks are then performed to include six nerves
on each side. A small wheal of local anaesthetic is first raised at
each site to anaesthetise the skin and then between 2 and 3 ml of
local anaesthetic is deposited at each point.
Indiscriminate ring blockade of the scalp subcutaneously re-
quires a large volume of concentrated local anaesthetic solution,
placing the patient at risk of toxicity. It also fails to allow for local
anaesthesia deep to the temporalis fascia when that muscle is to be
reflected. We therefore use an anatomical basis for our blocks
(Fig. 1).
Auriculotemporal
The auriculotemporal nerve is located at the junction of the bony
and cartilaginous parts of the anterior wall of the auditory canal.
The nerve extends over the posterior root of the zygoma posterior
to the (palpable) superficial temporal artery.
Zygomaticotemporal
The zygomaticotemporal nerve arises midway between auriculo-
temporal nerve and supraorbital nerve where it emerges above the
zygoma. It may ramify as it pierces temporalis fascia, therefore
injection in deep and superficial plains is recommended.
Supraorbital
The supraorbital nerve emerges from a notch at the upper border
of the orbit which is palpable above the mid point of the eye.
Supratrochlear
The supratrochleaer nerve is found at the medial edge of root of
nose, immediately below the angle between superior and medial
borders of the orbit.
Lesser occipital
The lesser occipital (the first branch of cervical plexus) emerges
from the posterior border of sternomastoid, approximately at its
mid-point, and radiates upwards and backwards.
Greater occipital
The greater occipital nerve (the posterior ramus of cervical nerve)
crosses the superior nuchal line one third of the way between the
external occipital protuberance and the mastoid process. It can
sometimes be located by palpating the occipital artery which lies
adjacent to it.
Satisfactory and safe blocks are achieved using long-acting
local anaesthetic solutions in sufficient volume. We favour the use
of local anaesthetics that have less cardiac and neurotoxicity in
laboratory animal preparations.
25
Accordingly, ropivacaine and
levobupivacaine are recommended ahead of bupivacaine. In a 70
90 kg adult, for example, we use up to 40 ml of ropivacaine in a
concentration of 75 mg per ml. To this we add adrenaline 1 in
200,000 dilution. The use of adrenaline is recommended in well-
vascularised areas such as the scalp to both minimise acute rises in
plasma concentration which may predispose to local anaesthetic
toxicity
26
and to maximise the block duration.
Operating room ergonomics
Appropriate setting up of the operating room equipment is crucial
to a favourable outcome in awake craniotomy. A clear approach
needs to be designed to accommodate the needs of the many
personnel in the room for the procedure, plus the necessary ad-
ditional pieces of equipment.
The ideal operating room set-up needs to broadly address the
anticipated needs of
(i) Visualization
(ii) Communication and
(iii) Incident management.
The ability of the surgical team to see and hear the patient
clearly is paramount but the environment is often challenging in
this respect. The surgeon will usually be denied direct eye contact
with the patient due to sterile draping and other equipment. This
becomes even more evident with the use of frameless stereotactic
systems and image guided surgery with reference arcs, which may
encroach on the patients face. Background noise from suction,
ultrasonic aspirators and diathermy are ever present and patients
vary in their ability or willingness to speak loudly during this
critical time in their lives.
We have devised a closed-circuit monitoring and recording
system for the critical testing phase whereby the surgical team and
any attendant neurology staff can see and hear the same responses
as the anaesthetist with an unsurpassed clarity (Fig. 2). This sys-
Fig. 1 Innervation of the scalp.
Anaesthesia for awake craniotomy 17
2003 Elsevier Ltd. All rights reserved. Journal of Clinical Neuroscience (2004) 11(1), 1619
tem has several advantages over the alternative of relayed mes-
sages via the tester on the patients side of the drapes:
1. All personnel, and in particular the surgeon, can view or hear a
reaction to stimulation instantaneously.
2. Amplification of the verbal responses and improved acoustics
are possible.
3. Responses that are difficult to interpret are replayed (e.g.
speech interruption versus dysarthria versus early facial fit-
ting).
4. A zoomed view of the face during stimulation around that part
of the homunculus aids interpretation.
5. If unexpected postoperative deficit occurs, review of the test-
ing phase to point out possible preventable errors of interpre-
tation is possible.
6. It gives the surgical team a greater awareness of possible pain-
ful areas such as periosteum, deep vascular structures and dura
close to the middle meningeal artery. Manoeuvres such as top-
ical anaesthesia to the dura or trigeminal ganglion are possible
alternatives to deepening sedation.
The management of intra-operative incidents involves plan-
ning for unexpected securing of the airway, and management of
intraoperative seizures, nausea and bradycardia. Adequate plan-
ning and expert execution of the scalp blocks should make in-
traoperative airway intervention extremely unlikely. Adequate
preoperative assessment and communication with the surgical
team will help to define the rare occasions when a pure awake
technique is inadvisable.
CONCLUSION
Expert performance of scalp blocks, improved pharmacological
agents, adequate patient preparation and an appreciation of in-
traoperative difficulties will allow the use and applications of
awake craniotomy to flourish. New technology on the horizon
such as infrared cameras to detect functionally active areas of
cortex intraoperatively
6
as well as established techniques of image
guided surgery will allow complex operations to be performed
faster and with fewer complications, making awake craniotomy an
even more attractive alternative to general anaesthesia.
ACKNOWLEDGEMENTS
Many thanks to Leo Mertens, Medical Artist for his help with
diagrams.
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Fig. 2 View of theatre setup from above. Legend: (A) surgeon; (B) anaesthetist; (C) assistant surgeon; (D) scrub sister; (E) neurologist or EEG technician. (1)
video camera; (2) microphone; (3) light source; (4) anaesthetic machine; (5) television monitor; (6) image guidance camera; (7) microscope recorder; (8) EEG.
18 Costello and Cormack
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Anaesthesia for awake craniotomy 19
2003 Elsevier Ltd. All rights reserved. Journal of Clinical Neuroscience (2004) 11(1), 1619