Anesthetic Management of Awake Craniotomy for Resection of the Language and Motor Cortex Vascular Malformations.
BACKGROUND
Although the safety and feasibility of awake craniotomy are 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 7 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 1 patient had a cavernoma. Six patients had complete resection; however, 1 patient underwent repeat awake craniotomy for residual AVM nidus. The patients tolerated the resection under continuous awake neurologic and neurophysiologic testing without significant perioperative complications or the need to convert to general anesthesia with a definitive airway.


CONCLUSIONS
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.
['Wang|Annie Ting|AT|', 'Pillai|Promod|P|', 'Guran|Elyse|E|', 'Carter|Harmony|H|', 'Minasian|Tanya|T|', 'Lenart|John|J|', 'Vandse|Rashmi|R|']
D000293:Adolescent D000328:Adult D000701:Analgesics, Opioid D018686:Anesthetics, Intravenous D001932:Brain Neoplasms D065711:Broca Area D002533:Cerebral Angiography D000072226:Computed Tomography Angiography D003399:Craniotomy D054810:Deep Sedation D020927:Dexmedetomidine D005260:Female D005283:Fentanyl D020786:Hemangioma, Cavernous, Central Nervous System D006801:Humans D006993:Hypnotics and Sedatives D002538:Intracranial Arteriovenous Malformations D008297:Male D008875:Middle Aged D009044:Motor Cortex D009407:Nerve Block D019635:Neurosurgical Procedures D015742:Propofol D000077208:Remifentanil D014851:Wakefulness D065813:Wernicke Area D055815:Young Adult
Craniotomy Arteriovenous malformations Propofol Dexmedetomidine Remifentanil Brain vascular malformations