Anesthetic management of awake craniotomy for resection of the language and motor cortex vascular malformations

Annie Ting Wang, Promod Pillai, Elyse Guran, Harmony Carter, Tanya Minasian, John Lenart, Rashmi Vandse
World Neurosurgery 2020 July 28

BACKGROUND: Although the safety and feasibility of awake craniotomy is well-established for epilepsy and brain tumor surgery, its application for resection of vascular lesions, including arteriovenous malformations (AVMs) and cavernomas, is still limited. Apart from the usual challenges of awake craniotomy, vascular lesions pose several additional problems. Our goal is to determine the safety and practicality of awake craniotomy in patients with cerebral vascular malformations located near the eloquent areas, using a refined anesthetic protocol.

METHODS: A retrospective case series was performed on seven patients who underwent awake craniotomy for resection of AVMs or cavernomas located in the eloquent language and motor areas. Our protocol consisted of achieving deep sedation, without a definitive airway, using a combination of propofol, dexmedetomidine, and remifentanil/fentanyl during scalp block placement and surgical exposure, then transitioning to a wakeful state during the resection.

RESULTS: Six patients had intracranial AVMs, and one patient had a cavernoma. Six patients had complete resection; however, one patient underwent repeat awake craniotomy for residual AVM nidus. The patients tolerated the resection under continuous "awake" neurological and neurophysiological testing without significant perioperative complications or the need to convert to general anesthesia.

CONCLUSION: Awake craniotomy for excision of intracranial vascular malformations located near the eloquent areas, in carefully selected patients, can facilitate resection by allowing close neuromonitoring and direct functional assessment. A balanced combination of sedative and analgesic medications can provide both adequate sedation and rapid wakeup, facilitating the necessary patient interaction and tolerance of the procedure.

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