Comparing two airway management strategies for moderately sedated patients undergoing awake craniotomy: A single-blinded randomized controlled trial

Practical guidance for monitored anesthesia care during awake craniotomy

Monitored anesthesia care is a feasible option for anesthetic management during awake craniotomy. Patients selected for surgery are thoroughly evaluated by anesthesiologists, primarily focusing on their risk for airway emergencies, such as respiratory depression and obstruction, throughout the procedure. For patients with relative contraindications, a tailored approach is used to assess their suitability. Neuropsychiatric counseling is also helpful for enhancing the patient's ability to participate in and perform the necessary tasks during brain mapping. Building good rapport with the patient is essential for the success of awake craniotomy, as it helps foster trust and cooperation. Analgesia during awake craniotomy is primarily achieved through scalp nerve blocks or infiltration. Among the six scalp nerve blocks, I have described the zygotemporal nerve block in detail. Proper positioning is crucial for both the surgical approach and the safety and comfort of the patient. Even when local anesthetics are effectively administered, many patients may still experience mild to moderate pain during the procedure. This pain is common and transient, typically occurring around the temporal region. In some cases, sedatives or additional analgesics may be necessary. Serious adverse events can arise, including those that require urgent life-saving interventions or those that interfere with brain mapping and the patient's ability to perform tasks. However, MAC in neurosurgery offers the potential for an improved quality of life for individuals with brain tumors or epileptic seizures, as well as for those with disabilities, such as the deaf or visually impaired, in the future.

The application of intravenous general anesthesia under nasopharyngeal airway assisted ventilation undergoing ureteroscopic holmium laser lithotripsy: A prospective, single-center, controlled trial

To observe the effect of intravenous general anesthesia under nasopharyngeal airway-assisted ventilation on patients undergoing ureteroscopic holmium laser lithotripsy. One hundred and twenty patients who underwent ureteroscopic holmium laser lithotripsy in our hospital were selected and randomly divided into nasopharyngeal airway group (research group) and laryngeal mask group (control group). These patients, respectively, received intravenous anesthesia under nasopharyngeal airway and laryngeal mask-assisted ventilation. The following evaluation indexes were compared and analyzed between the two groups, including anesthetic effect, hemodynamics, stress response, postoperative recovery, adverse reactions, etc. There were no significant differences in Visual Analog Scale, hemodynamics, and stress response between the two groups at each time point (P > 0.05). There were no significant differences in residence time and postoperative recovery time between the two groups (P > 0.05). The difference in airway establishment time between the two groups was statistically significant (P < 0.05), and cases with blood in the research group was significantly lower than those in the control group (P < 0.05). Patient satisfaction in research group was significantly higher than those in the control group (P < 0.05). The clinical effect of intravenous general anesthesia under nasopharyngeal airway-assisted ventilation in ureteroscopic holmium laser lithotripsy is significant, which helps to stabilize patients' hemodynamics, reduce their stress response and adverse reactions, and improve the satisfaction rate of patient.

Dexmedetomidine for awake craniotomy: Systematic review and meta-analysis

INTRODUCTION

For awake craniotomy, monitored anaesthesia care (MAC) had shown relatively lower failure rates. Nevertheless, the conclusion of the appropriate anaesthetic agents, and complications, has not been proposed. Therefore, the systematic review and meta-analysis was done to compare the clinical profile, surgical outcomes, and anesthesia-related complications between dexmedetomidine-based and non-dexmedetomidine regimens during monitored anesthesia care (MAC) for this procedure.

EVIDENCE ACQUISITION

Published clinical trials described MAC, including the amount of anaesthetic drugs, or the number of patients for awake craniotomy between January 1st, 2009 and March 31st, 2022 were reviewed through PubMed, Scopus, Google Scholar, and grey literature index. The standard methodological procedures were following the PRISMA statement with the PROSPERO registration. Twenty-two articles with 2,137 awake craniotomy patients identified as epilepsy surgery, deep brain stimulation procedure, and intracranial surgery closed to an eloquent area with intraoperative awakening for neuro-evaluation were included. The relative risk (RR) regarding surgical outcomes, and anaesthesia-related complications were compared.

EVIDENCE SYNTHESIS

Dexmedetomidine-based versus non-dexmedetomidine anaesthetic regimen revealed no statistically significant differences in surgical outcomes (RR 1.08, 95 %CI 0.94-1.24), conversion to general anaesthesia (RR 0.45, 95 %CI 0.05-3.83), respiratory complications (RR 0.4, 95 %CI 0.12-1.27), and intraoperative nausea and vomiting (RR 0.30, 95 %CI 0.08-1.14). However, the intraoperative seizure was higher in non-dexmedetomidine group (RR 4.26, 95 %CI 1.49-12.16).

CONCLUSION

MAC for awake craniotomy with dexmedetomidine seems to be effective and safe. Randomized controlled trials with standard protocol in specific group of patients and surgical interventions would further demonstrate a clear benefit of dexmedetomidine in awake craniotomy under MAC.

How I do it? A multimodality-guided awake hybrid operation for a language-area brain arteriovenous malformation and multiple intracranial aneurysms

Background

The cure of an eloquent brain arteriovenous malformation (BAVM) and multiple intracranial aneurysms with preservation of neurological function and the minimal procedures is challenging.

Method

A 53-year-old male was admitted to treat a left frontal language-area BAVM and concomitant five bilateral intracranial aneurysms. After repairing the ruptured right middle cerebral artery (MCA) bifurcation aneurysms and the other two unruptured ones, at the second-stage multimodality-guided awake hybrid operation, we successfully obliterated the left frontal BAVM and two other left MCA aneurysms.

Conclusion

The multimodality-guided awake hybrid operation may be a promising technique to treat complicated cerebrovascular disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-05093-7.