Skip to main content
SpringerLink
Log in

Anesthesia for Awake Neurosurgery

  • Chapter
  • First Online:
Monitoring the Nervous System for Anesthesiologists and Other Health Care Professionals

Abstract

Neurosurgical operations performed in awake patients are increasingly being used. Procedures employing this technique include resection of tumors and epileptic foci in and around the eloquent areas of the brain, localization of the proper nucleus for deep brain stimulation, testing for spinal cord stimulator placement and other pain procedures, carotid endarterectomy, and surgery on the spine and peripheral nervous system. Proponents cite easy neurological evaluation, short recovery, fewer complications, and early discharge from the hospital. In this chapter, we discuss the anesthetic management as well as monitoring the neurologic function during these procedures.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 109.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Notes

  1. 1.

    Key references marked with asterisk.

References

Key references marked with asterisk.

  1. Bilotta F, Rosa G. ‘Anesthesia’ for awake neurosurgery. Curr Opin Anaesthesiol. 2009;22:560–5.

    Article  PubMed  Google Scholar 

  2. *Bonhomme V, Franssen C, Hans P. Awake craniotomy. Eur J Anaesthesiol. 2009;26:906–12.

    Google Scholar 

  3. Klimek M, Verbrugge SJ, Roubos S, van der Most E, Vincent AJ, Klein J. Awake craniotomy for glioblastoma in a 9-year-old child. Anaesthesia. 2004;59:607–9.

    Article  CAS  PubMed  Google Scholar 

  4. Howe KL, Zhou G, July J, Totimeh T, Dakurah T, Malomo AO, et al. Teaching and sustainably implementing awake craniotomy in resource-poor settings. World Neurosurg. 2013;80:e171–4.

    Article  PubMed  Google Scholar 

  5. Chacko AG, Thomas SG, Babu KS, Daniel RT, Chacko G, Prabhu K, et al. Awake craniotomy and electrophysiological mapping for eloquent area tumours. Clin Neurol Neurosurg. 2013;115:329–34.

    Article  PubMed  Google Scholar 

  6. *Sacko O, Lauwers-Cances V, Brauge D, Sesay M, Brenner A, Roux FE. Awake craniotomy vs surgery under general anesthesia for resection of supratentorial lesions. Neurosurgery. 2011;68:1192–8. discussion 8–9.

    Google Scholar 

  7. *Blanshard HJ, Chung F, Manninen PH, Taylor MD, Bernstein M. Awake craniotomy for removal of intracranial tumor: considerations for early discharge. Anesth Analg. 2001;92:89–94.

    Google Scholar 

  8. Kim SS, McCutcheon IE, Suki D, Weinberg JS, Sawaya R, Lang FF, et al. Awake craniotomy for brain tumors near eloquent cortex: correlation of intraoperative cortical mapping with neurological outcomes in 309 consecutive patients. Neurosurgery. 2009;64:836–45; discussion 345–6.

    Article  PubMed  Google Scholar 

  9. Hol JW, Klimek M, van der Heide-Mulder M, Stronks D, Vincent AJ, Klein J, et al. Awake craniotomy induces fewer changes in the plasma amino acid profile than craniotomy under general anesthesia. J Neurosurg Anesthesiol. 2009;21:98–107.

    Article  PubMed  Google Scholar 

  10. *Costello TG, Cormack JR. Anaesthesia for awake craniotomy: a modern approach. J Clin Neurosci. 2004;11:16–9.

    Google Scholar 

  11. *Hansen E, Seemann M, Zech N, Doenitz C, Luerding R, Brawanski A. Awake craniotomies without any sedation: the awake-awake-awake technique. Acta Neurochir (Wien). 2013;155:1417–24.

    Google Scholar 

  12. Frost EA, Booij LH. Anesthesia in the patient for awake craniotomy. Curr Opin Anaesthesiol. 2007;20:331–5.

    Article  PubMed  Google Scholar 

  13. Erickson KM, Cole DJ. Anesthetic considerations for awake craniotomy for epilepsy. Anesthesiol Clin. 2007;25:535–55.

    Article  CAS  PubMed  Google Scholar 

  14. Dinsmore J. Anaesthesia for elective neurosurgery. Br J Anaesth. 2007;99:68–74.

    Article  CAS  PubMed  Google Scholar 

  15. Sarang A, Dinsmore J. Anaesthesia for awake craniotomy: evolution of a technique that facilitates awake neurological testing. Br J Anaesth. 2003;90:161–5.

    Article  CAS  PubMed  Google Scholar 

  16. Hans P, Bonhomme V, Born JD, Maertens de Noordhoudt A, Brichant JF, Dewandre PY. Target-controlled infusion of propofol and remifentanil combined with bispectral index monitoring for awake craniotomy. Anaesthesia. 2000;55:255–9.

    Article  CAS  PubMed  Google Scholar 

  17. Lobo F, Beiras A. Propofol and remifentanil effect-site concentrations estimated by pharmacokinetic simulation and bispectral index monitoring during craniotomy with intraoperative awakening for brain tumor resection. J Neurosurg Anesthesiol. 2007;19:183–9.

    Article  PubMed  Google Scholar 

  18. Soriano SG, Eldredge EA, Wang FK, Kull L, Madsen JR, Black PM, et al. The effect of propofol on intraoperative electrocorticography and cortical stimulation during awake craniotomies in children. Paediatr Anaesth. 2000;10:29–34.

    Article  CAS  PubMed  Google Scholar 

  19. Schelling G, Hauer D, Azad SC, Schmoelz M, Chouker A, Schmidt M, et al. Effects of general anesthesia on anandamide blood levels in humans. Anesthesiology. 2006;104:273–7.

    Article  CAS  PubMed  Google Scholar 

  20. Beers R, Camporesi E. Remifentanil update: clinical science and utility. CNS Drugs. 2004;18:1085–104.

    Article  CAS  PubMed  Google Scholar 

  21. *Rozet I. Anesthesia for functional neurosurgery: the role of dexmedetomidine. Curr Opin Anaesthesiol. 2008;21:537–43.

    Google Scholar 

  22. Bekker AY, Kaufman B, Samir H, Doyle W. The use of dexmedetomidine infusion for awake craniotomy. Anesth Analg. 2001;92:1251–3.

    Article  CAS  PubMed  Google Scholar 

  23. Souter MJ, Rozet I, Ojemann JG, Souter KJ, Holmes MD, Lee L, et al. Dexmedetomidine sedation during awake craniotomy for seizure resection: effects on electrocorticography. J Neurosurg Anesthesiol. 2007;19:38–44.

    Article  PubMed  Google Scholar 

  24. Moore 2nd TA, Markert JM, Knowlton RC. Dexmedetomidine as rescue drug during awake craniotomy for cortical motor mapping and tumor resection. Anesth Analg. 2006;102:1556–8.

    Article  CAS  PubMed  Google Scholar 

  25. Hall JE, Uhrich TD, Barney JA, Arain SR, Ebert TJ. Sedative, amnestic, and analgesic properties of small-dose dexmedetomidine infusions. Anesth Analg. 2000;90:699–705.

    Article  CAS  PubMed  Google Scholar 

  26. *Pinosky ML, Fishman RL, Reeves ST, Harvey SC, Patel S, Palesch Y, et al. The effect of bupivacaine skull block on the hemodynamic response to craniotomy. Anesth Analg. 1996;83:1256–61.

    Google Scholar 

  27. Watson R, Leslie K. Nerve blocks versus subcutaneous infiltration for stereotactic frame placement. Anesth Analg. 2001;92:424–7.

    Article  CAS  PubMed  Google Scholar 

  28. Nguyen A, Girard F, Boudreault D, Fugere F, Ruel M, Moumdjian R, et al. Scalp nerve blocks decrease the severity of pain after craniotomy. Anesth Analg. 2001;93:1272–6.

    Article  CAS  PubMed  Google Scholar 

  29. *Geze S, Yilmaz AA, Tuzuner F. The effect of scalp block and local infiltration on the haemodynamic and stress response to skull-pin placement for craniotomy. Eur J Anaesthesiol. 2009;26:298–303.

    Google Scholar 

  30. Osborn I, Sebeo J. “Scalp block” during craniotomy: a classic technique revisited. J Neurosurg Anesthesiol. 2010;22:187–94.

    Article  PubMed  Google Scholar 

  31. Piccioni F, Fanzio M. Management of anesthesia in awake craniotomy. Minerva Anestesiol. 2008;74(7–8):393–408.

    CAS  PubMed  Google Scholar 

  32. Bebawy JF, Bilotta F, Koht A. A modified technique for auriculotemporal nerve blockade when performing selective scalp nerve block for craniotomy. J Neurosurg Anesthesiol. 2014;26:271–2.

    Article  PubMed  Google Scholar 

  33. *Lobo FA, Amorim P. Anesthesia for craniotomy with intraoperative awakening: how to avoid respiratory depression and hypertension? Anesth Analg. 2006;102:1593–4. author reply 4.

    Google Scholar 

  34. Baldinelli F, Pedrazzoli R, Ebner H, Auricchio F. Asleep-awake-asleep technique during carotid endarterectomy: a case series. J Cardiothorac Vasc Anesth. 2010;24:550–4.

    Article  PubMed  Google Scholar 

  35. Audu PB, Loomba N. Use of cuffed oropharyngeal airway (COPA) for awake intracranial surgery. J Neurosurg Anesthesiol. 2004;16:144–6.

    Article  PubMed  Google Scholar 

  36. Olsen KS. The asleep-awake technique using propofol-remifentanil anaesthesia for awake craniotomy for cerebral tumours. Eur J Anaesthesiol. 2008;25:662–9.

    Article  CAS  PubMed  Google Scholar 

  37. Ojemann G, Ojemann J, Lettich E, Berger M. Cortical language localization in left, dominant hemisphere: an electrical stimulation mapping investigation in 117 patients. J Neurosurg. 1989;71:316–26.

    Article  CAS  PubMed  Google Scholar 

  38. Berger MS, Kincaid J, Ojemann GA, Lettich E. Brain mapping techniques to maximize resection, safety, and seizure control in children with brain tumors. Neurosurgery. 1989;25:786–92.

    Article  CAS  PubMed  Google Scholar 

  39. Duffau H. Contribution of cortical and subcortical electrostimulation in brain glioma surgery: methodological and functional considerations. Neurophysiol Clin. 2007;37:373–82.

    Article  CAS  PubMed  Google Scholar 

  40. Szelenyi A, Bello L, Duffau H, Fava E, Feigl GC, Galanda M, et al. Intraoperative electrical stimulation in awake craniotomy: methodological aspects of current practice. Neurosurg Focus. 2010;28:E7.

    Article  PubMed  Google Scholar 

  41. Yingling CD, Ojemann S, Dodson B, Harrington MJ, Berger MS. Identification of motor pathways during tumor surgery facilitated by multichannel electromyographic recording. J Neurosurg. 1999;91:922–7.

    Article  CAS  PubMed  Google Scholar 

  42. Sartorius CJ, Berger MS. Rapid termination of intraoperative stimulation-evoked seizures with application of cold Ringer’s lactate to the cortex. Technical note. J Neurosurg. 1998;88:349–51.

    Article  CAS  PubMed  Google Scholar 

  43. McNicholas E, Bilotta F, Titi L, Chandler J, Rosa G, Koht A. Transient facial nerve palsy after auriculotemporal nerve block in awake craniotomy patients. A A Case Rep. 2014;2:40–3.

    Article  PubMed  Google Scholar 

  44. *Gabarros A, Young WL, McDermott MW, Lawton MT. Language and motor mapping during resection of brain arteriovenous malformations: indications, feasibility, and utility. Neurosurgery. 2011;68:744–52.

    Google Scholar 

  45. Abla AA, Lawton MT. Awake motor examination during intracranial aneurysm surgery. World Neurosurg. 2014;82:e683–4.

    Article  PubMed  Google Scholar 

  46. Passacantilli E, Anichini G, Cannizzaro D, Fusco F, Pedace F, Lenzi J, et al. Awake craniotomy for trapping a giant fusiform aneurysm of the middle cerebral artery. Surg Neurol Int. 2013;4:39.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Halpern CH, Wolf JA, Bale TL, Stunkard AJ, Danish SF, Grossman M, et al. Deep brain stimulation in the treatment of obesity. J Neurosurg. 2008;109:625–34.

    Article  PubMed  Google Scholar 

  48. Awan NR, Lozano A, Hamani C. Deep brain stimulation: current and future perspectives. Neurosurg Focus. 2009;27:E2.

    Article  PubMed  Google Scholar 

  49. Deuschl G, Schade-Brittinger C, Krack P, Volkmann J, Schafer H, Botzel K, et al. A randomized trial of deep-brain stimulation for Parkinson’s disease. N Engl J Med. 2006;355:896–908.

    Article  CAS  PubMed  Google Scholar 

  50. Weaver FM, Follett K, Stern M, Hur K, Harris C, Marks Jr WJ, et al. Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial. JAMA. 2009;301:63–73.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Benabid AL, Chabardes S, Mitrofanis J, Pollak P. Deep brain stimulation of the subthalamic nucleus for the treatment of Parkinson’s disease. Lancet Neurol. 2009;8:67–81.

    Article  PubMed  Google Scholar 

  52. Chakrabarti R, Ghazanwy M, Tewari A. Anesthetic challenges for deep brain stimulation: a systematic approach. N Am J Med Sci. 2014;6:359–69.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Khatib R, Ebrahim Z, Rezai A, Cata JP, Boulis NM, John Doyle D, et al. Perioperative events during deep brain stimulation: the experience at Cleveland Clinic. J Neurosurg Anesthesiol. 2008;20:36–40.

    Article  PubMed  Google Scholar 

  54. Krauss JK, Akeyson EW, Giam P, Jankovic J. Propofol-induced dyskinesias in Parkinson’s disease. Anesth Analg. 1996;83:420–2.

    CAS  PubMed  Google Scholar 

  55. Nicholson G, Pereira AC, Hall GM. Parkinson’s disease and anaesthesia. Br J Anaesth. 2002;89:904–16.

    Article  CAS  PubMed  Google Scholar 

  56. Poon CC, Irwin MG. Anaesthesia for deep brain stimulation and in patients with implanted neurostimulator devices. Br J Anaesth. 2009;103:152–65.

    Article  CAS  PubMed  Google Scholar 

  57. Venkatraghavan L, Manninen P, Mak P, Lukitto K, Hodaie M, Lozano A. Anesthesia for functional neurosurgery: review of complications. J Neurosurg Anesthesiol. 2006;18:64–7.

    Article  PubMed  Google Scholar 

  58. Kral T, Kurthen M, Schramm J, Urbach H, Meyer B. Stimulation mapping via implanted grid electrodes prior to surgery for gliomas in highly eloquent cortex. Neurosurgery. 2006;58(1 Suppl):ONS36–43; discussion ONS36–43.

    Google Scholar 

  59. Rerkasem K, Rothwell PM. Routine or selective carotid artery shunting for carotid endarterectomy and different methods of monitoring in selective shunting. Stroke. 2009;40:e564–72.

    Article  PubMed  Google Scholar 

  60. Hans SS, Jareunpoon O. Prospective evaluation of electroencephalography, carotid artery stump pressure, and neurologic changes during 314 consecutive carotid endarterectomies performed in awake patients. J Vasc Surg. 2007;45:511–5.

    Article  PubMed  Google Scholar 

  61. Moritz S, Kasprzak P, Woertgen C, Taeger K, Metz C. The accuracy of jugular bulb venous monitoring in detecting cerebral ischemia in awake patients undergoing carotid endarterectomy. J Neurosurg Anesthesiol. 2008;20:8–14.

    Article  PubMed  Google Scholar 

  62. Stoneham MD, Knighton JD. Regional anaesthesia for carotid endarterectomy. Br J Anaesth. 1999;82:910–9.

    Article  CAS  PubMed  Google Scholar 

  63. Guay J. Regional or general anesthesia for carotid endarterectomy? Evidence from published prospective and retrospective studies. J Cardiothorac Vasc Anesth. 2007;21:127–32.

    Article  PubMed  Google Scholar 

  64. Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, Torgerson D, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008;372(9656):2132–42.

    Article  CAS  PubMed  Google Scholar 

  65. Bekker AY, Basile J, Gold M, Riles T, Adelman M, Cuff G, et al. Dexmedetomidine for awake carotid endarterectomy: efficacy, hemodynamic profile, and side effects. J Neurosurg Anesthesiol. 2004;16:126–35.

    Article  PubMed  Google Scholar 

  66. Stoneham MD, Lodi O, de Beer TC, Sear JW. Increased oxygen administration improves cerebral oxygenation in patients undergoing awake carotid surgery. Anesth Analg. 2008;107:1670–5.

    Article  CAS  PubMed  Google Scholar 

  67. Winnie AP, Ramamurthy S, Durrani Z, Radonjic R. Interscalene cervical plexus block: a single-injection technic. Anesth Analg. 1975;54:370–5.

    CAS  PubMed  Google Scholar 

  68. Moore DC. Regional block: a handbook for use in the clinical practice of medicine and surgery. Springfield: Charles C. Thomas; 1978.

    Google Scholar 

  69. Moritz S, Kasprzak P, Arlt M, Taeger K, Metz C. Accuracy of cerebral monitoring in detecting cerebral ischemia during carotid endarterectomy: a comparison of transcranial Doppler sonography, near-infrared spectroscopy, stump pressure, and somatosensory evoked potentials. Anesthesiology. 2007;107:563–9.

    Article  PubMed  Google Scholar 

  70. Calligaro KD, Dougherty MJ. Correlation of carotid artery stump pressure and neurologic changes during 474 carotid endarterectomies performed in awake patients. J Vasc Surg. 2005;42:684–9.

    Article  PubMed  Google Scholar 

  71. Kwaan JH, Peterson GJ, Connolly JE. Stump pressure: an unreliable guide for shunting during carotid endarterectomy. Arch Surg. 1980;115:1083–6.

    Article  CAS  PubMed  Google Scholar 

  72. Rigamonti A, Scandroglio M, Minicucci F, Magrin S, Carozzo A, Casati A. A clinical evaluation of near-infrared cerebral oximetry in the awake patient to monitor cerebral perfusion during carotid endarterectomy. J Clin Anesth. 2005;17:426–30.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Departments of Anesthesiology, Neurological Surgery and Neurology, Northwestern University Feinberg School of Medicine, 251 East Huron Street, F-5-704, Chicago, IL, 60611, USA

    Antoun Koht M.D.

  2. Department of Neurosurgery, University of Aachen, Aachen, Germany

    Georg Neuloh M.D.

  3. Department of Neurological Surgery, Northwestern Memorial Hospital, 676 North Saint Clair Street, Suite 2210, Chicago, IL, 60611, USA

    Matthew C. Tate M.D., Ph.D.

Authors
  1. Antoun Koht M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Georg Neuloh M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Matthew C. Tate M.D., Ph.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Antoun Koht M.D. .

Editor information

Editors and Affiliations

  1. Departments of Anesthesiology, Neurological Surgery and Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

    Antoun Koht

  2. Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA

    Tod B. Sloan

  3. Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA

    J. Richard Toleikis

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Blocking the supra trochlear nerve is done by inserting the needle perpendicular to the supratrochlear notch utilizing 25-gauge short needle to reach to the notch. After negative aspiration, 1 mL of local anesthetics is injected (MOV 2599 kb)

Blocking the supraorbital nerve is done by inserting the needle perpendicular to the supraorbital notch utilizing 25-gauge short needle to reach to the notch. After negative aspiration 1 mL of local anesthetics is injected (MOV 1372 kb)

The 25-gauge 38-mm-long needle is inserted just above the zygomatic arch two-thirds between the edge of orbit and the tragus. The needle is inserted to touch the temporal skull bone then to slide toward the orbit. Three milliliter of local anesthetics is injected closer to the orbit, 1 mL injected 1 cm lateral to the first inject followed by one more milliliter injected 1 cm more distal. (The 5 mL is injected only on the side of surgery; other side will be injected with 3-mL only) (MOV 5112 kb)

This is a home-modified block [32]. Three milliliters of local anesthetics is injected 1 cm above the tragus just behind the superfacial temporal artery (MOV 2938 kb)

The lesser occipital nerve is blocked behind the ear at a straight line from the tragus to the edge of the earlobe, in the groove behind the mastoid. Two milliliters injected at the groove and 1 mL superficial and anterior to the groove (MOV 2337 kb)

First the occipital artery is palpated and the needle inserted medial to the artery to block the greater occipital nerve with 3 mL of local anesthetics (MOV 1734 kb)

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing AG

About this chapter

Cite this chapter

Koht, A., Neuloh, G., Tate, M.C. (2017). Anesthesia for Awake Neurosurgery. In: Koht, A., Sloan, T., Toleikis, J. (eds) Monitoring the Nervous System for Anesthesiologists and Other Health Care Professionals. Springer, Cham. https://doi.org/10.1007/978-3-319-46542-5_18

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-46542-5_18

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-46540-1

  • Online ISBN: 978-3-319-46542-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation