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Chapter 102. Awake Craniotomy

Nicolai Goettel, MD, DESA

Indications for Awake Craniotomy

See table on following page.

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Indications for awake craniotomy
Brain tumor (located either in or close to areas of eloquent brain function, such as speech, motor, and sensory pathways)
  • Surgical advantages: optimal tumor resection, minimization of the risk of neurologic injury
  • Brain mapping (electrocorticography) for accurate localization of eloquent brain function before tumor resection
Epilepsy surgery
  • Resection of epileptogenic foci (intractable lesional epilepsy)
  • Brain mapping (electrocorticography) for accurate localization of eloquent brain function before resection of epileptogenic foci
Functional stereotaxy of the brain
  • Implantation of deep brain stimulation (DBS) electrodes: classically Parkinson’s disease, but other simple or complex central movement disorders, Alzheimer’s disease, psychiatric disease, pharmacoresistant depression, and eating disorders are increasingly considered for DBS insertion
Minor craniotomy
  • Drainage of acute/chronic subdural hematoma
  • Intracranial catheter placement
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Poor candidates for awake craniotomy
Poor understanding or cooperation
  • Children
  • Mental retardation
  • Psychiatric conditions
  • Extreme anxiety
  • Claustrophobia
  • History of poorly tolerated sedation
  • Severe dystonia
  • Language barrier
Difficult airway
  • Anticipated or documented difficult airway
  • Morbid obesity
  • Obstructive sleep apnea (OSA)
  • Intractable epilepsy: watch for rare syndromes associated with airway abnormalities
Hemorrhagic risk
  • Coagulopathy or anticoagulation agents
  • Thrombocytopenia, thrombopathy, or antiplatelet agents

Preoperative Considerations

  • Routine assessment and preparation as for any patient undergoing a craniotomy (cf. Chapter 101)
  • Patient preparation: give detailed explanation of procedure, inquire about expectations and fears
  • Premedication: minimal/no preoperative sedation, nausea prophylaxis
  • Continuation of all preoperative medications including anti-epileptics and steroids (Exception: For DBS insertion anti-Parkinsonian drugs may need to be stopped for better intraoperative evaluation of electrode placement)
  • Establishment of good collaborative rapport with the patient

Intraoperative Considerations

  • The goal is to provide a comfortable environment to the patient, who is able to stay immobile on an operating room table for the duration of the procedure, and yet be alert and cooperative with cortical mapping

Installation and Monitoring

  • Limited access to airway: GA setup ready, fiberoptic available, treatment of complications available
  • Patients position themselves in such a way as to have some freedom of movement of the extremities to allow for intraoperative mapping
  • Provide comfortable environment (padding, quiet, and warm OR)
  • Neuronavigation is usually used, necessitating rigid fixation of the head (pins are inserted under local anesthesia with sedation)
  • Maintain continuous communication and visual contact with patient and surgical team
  • Standard monitoring, capnography, supplemental O2, large-bore IV
  • Fluids should be kept to a minimum, a urinary catheter is not routinely needed, but to be considered if procedure exceeding 4 hours
  • Invasive monitoring (arterial line) not routinely used

Anesthetic Technique

  • The decision for the choice of the technique of anesthesia will depend on the preferences of the institutional team including surgeon and anesthesiologist
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