Awake craniotomy in a patient with ejection fraction of 10%: considerations of cerebrovascular and cardiovascular physiology

Frailty is Not Associated With Awake Craniotomy Outcome: A Single Institution Experience

BACKGROUND AND OBJECTIVES

Patient frailty has been shown to be a powerful predictor of poor surgical outcome across specialties and may guide patient selection. In awake craniotomy, patient selection is particularly important for completion of intraoperative mapping and to reduce conversion to general anesthesia. We evaluated whether frailty is associated with unsuccessful awake craniotomy or poor outcome.

METHODS

We performed a single-center retrospective study of adult patients with tumor, epilepsy, and vascular pathologies that underwent first-time awake craniotomy between 2018 and 2024. The Modified Frailty Index-11 (mFI-11) was calculated for each patient, and frailty was defined as a mFI-11 ≥2. We evaluated the association of frailty with unsuccessful awake craniotomy and postoperative complications.

RESULTS

In total, 143 patients met inclusion criteria. There were 39 (27%) frail patients (mFI-11 ≥ 2) and 104 (73%) nonfrail patients (mFI-11 <2). Frail patients were significantly older ( P < .001), had a higher American Society of Anesthesia classification ( P = .015), higher rates of obstructive sleep apnea ( P = .001), higher body mass index ( P = .035), and glioblastoma ( P < .001) compared with the nonfrail group. Frail patients had longer length of stay ( P = .008) and had more than 2 times increased odds of discharge to skilled nursing facility or inpatient rehab facility ( P = .01). Frail patients had no significant increased risk of conversion to general anesthesia or incomplete mapping, intraoperative deficit, 24-hour postoperative deficit, 30-day readmission, or residual neurologic deficit at follow-up.

CONCLUSION

In our cohort, frailty was associated with higher anesthetic risk and longer length of stay but was not significantly associated with unsuccessful awake craniotomy, postoperative complications, or neurologic outcome.

Wide Dissection Trans-Sulcal Approach for Resection of Deep Intra-Axial Lesions in Eloquent Brain Areas

Introduction: Resection of intra-axial tumors (IaT) in eloquent brain regions risks major postoperative neurological deficits. Awake craniotomy is often used to navigate these areas; however, some patients are ineligible for awake procedures. The trans-sulcal approach (TScal) was introduced to reduce parenchymal trauma during tumor resection. We report our experiences utilizing TScal for resection of deep IaT located in eloquent areas. Materials and Methods: This is a single-center retrospective analysis of patients who underwent IaT resection in eloquent areas via TScal from January 2013 to April 2021. Seventeen cases were reviewed, and relevant data was collected. Fluorescence-guided surgery with 5-aminolevulinic acid (ALA) and intraoperative ultrasound was performed in some cases. Results: Seventeen patients (10 males, 7 females) averaging 61.2 years-old (range, 21-76) were included in this study. Average length of stay was 4.8 days, and only 2 patients (11.8%) required hospital readmission within 30 days. Gross total resection (GTR) was achieved in 15 patients (88.2%), while subtotal resection occurred in 2 patients (11.8%). Eleven patients (64.7%) reported full resolution of symptoms, 4 patients (23.5%) reported deficit improvement, and 2 patients (11.8%) experienced no change from their preoperative deficits. No patient developed new permanent deficits postoperatively. Discussion: GTR, preoperative deficit reduction, and complications were comparable to awake craniotomy and other TScal studies. Ancillary intraoperative techniques, such as brain mapping, 5-ALA and intraoperative ultrasound, are afforded by TScal to improve resection rates and overall outcomes. Conclusions: TScal can be an option for patients with deep lesions in eloquent areas who are not candidates for awake surgeries.

Neuroanesthesia Practice During the COVID-19 Pandemic: Recommendations From Society for Neuroscience in Anesthesiology and Critical Care (SNACC)

The pandemic of coronavirus disease 2019 (COVID-19) has several implications relevant to neuroanesthesiologists, including neurological manifestations of the disease, impact of anesthesia provision for specific neurosurgical procedures and electroconvulsive therapy, and health care provider wellness. The Society for Neuroscience in Anesthesiology and Critical Care appointed a task force to provide timely, consensus-based expert guidance for neuroanesthesiologists during the COVID-19 pandemic. The aim of this document is to provide a focused overview of COVID-19 disease relevant to neuroanesthesia practice. This consensus statement provides information on the neurological manifestations of COVID-19, advice for neuroanesthesia clinical practice during emergent neurosurgery, interventional radiology (excluding endovascular treatment of acute ischemic stroke), transnasal neurosurgery, awake craniotomy and electroconvulsive therapy, as well as information about health care provider wellness. Institutions and health care providers are encouraged to adapt these recommendations to best suit local needs, considering existing practice standards and resource availability to ensure safety of patients and providers.

Recent trends in the anesthetic management of craniotomy for supratentorial tumor resection

PURPOSE OF REVIEW

The article reviews the recent evidence on the anesthetic management of patients undergoing craniotomy for supratentorial tumor resection.

RECENT FINDINGS

A rapid recovery of neurological function after craniotomy for supratentorial tumor allows for the prompt diagnosis of intracranial complications and possibly an early hospital discharge. Intraoperative esmolol infusion was shown to reduce the anesthetic requirements, and may facilitate a more rapid recovery of neurological function. Outpatient craniotomy for supratentorial tumor resection has been associated with several clinical and economic benefits, but has not gained widespread use because of skepticism and medical-legal concerns. Awake craniotomy is associated with advantageous outcomes compared with surgery under general anesthesia, and is regarded as the standard of care for tumors that reside in or in close proximity to the eloquent brain. Recent studies have demonstrated that intraoperative electroacupuncture, dexmedetomidine, pregabalin, and lidocaine may facilitate postcraniotomy pain management. The use of volatile anesthetic agents in cancer surgery is associated with a worse survival compared with intravenous anesthetics, possibly by hindering immunologic defenses against cancer cells.

SUMMARY

Recent evidence has yielded valuable information regarding anesthetic management of patients undergoing supratentorial tumor craniotomy. Despite a plethora of studies that compare short-term outcomes using different anesthetic and analgesic regimens, randomized controlled trials that examine the long-term outcomes (i.e., neurocognitive function, quality of life, tumor recurrence, and survival) that are of particular interest to patients are needed.

Case Report: Emergency awake craniotomy for cerebral abscess in a patient with unrepaired cyanotic congenital heart disease

We report the case of a 39-year-old male with complex cyanotic congenital heart disease undergoing emergency craniotomy for a cerebral abscess. Maintenance of intraoperative hemodynamic stability and adequate tissue oxygenation during anesthesia may be challenging in patients with cyanotic congenital heart disease. In this case, we decided to perform the surgery as an awake craniotomy after interdisciplinary consensus. We discuss general aspects of anesthetic management during awake craniotomy and specific concerns in the perioperative care of patients with congenital heart disease.