Awake craniotomy

• Advancements in Imaging and Neurosurgical Techniques for Brain Tumor Resection: A Comprehensive Review
• Investigating unilateral and bilateral motor imagery control using electrocorticography and fMRI in awake craniotomy
• Comparative efficacy of awake and asleep motor mapping in glioma surgery: A meta-analysis of 3011 patients
• The impact of intraoperative mapping during re-resection in recurrent gliomas: a systematic review
• Detection of face motor activation in the precentral gyrus with functional thermography following inconclusive direct electrical stimulation mapping: illustrative case
• Bilingual awake craniotomy with English and Polish language mapping in a 15-year-old patient provides evidence for the role of the left superior temporal gyrus in language switching
• Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Lateral Supraorbital Approach with Expanded Indications
• Awake Craniotomy in Epilepsy Surgery: A Case Series and Proposal for Three Different Scenarios

Usually employed for brain mapping, especially for speech areas. Numerous techniques and protocols have been described. Typically, the patient is temporarily anesthetized with short-acting agents (inhalational and/or injectable). This is supplemented with local anesthesia. The craniotomy is then performed and the patient is allowed to wake up while the brain is exposed to permit neurophysiologic testing during surgery. If (short-acting) paralytics are used, it is critical to reverse these agents 15–30 minutes prior to applying the electrostimulation and that a train-of-four muscle twitch can be elicited.

An awake craniotomy is a safe neurosurgical procedure that minimizes the risk of brain injury. During the course of this surgery, the patient is asked to perform motor or cognitive tasks, but some patients exhibit severe sleepiness.

For neurosurgery with an awake craniotomy, the critical issue is to set aside enough time to identify eloquent cortices by electrocortical stimulation (ECS). High gamma activity (HGA) ranging between 80 and 120 Hz on electrocorticogram (ECoG) is assumed to reflect localized cortical processing.

In recent years, there have been a number of reports on interventions in conscious patients with other neurosurgical pathologies, which may be regarded as a new emerging tendency in neurosurgery and neuroanesthesiology. Neurosurgery in conscious patients provides a special advantage because it enables highly functional neuromonitoring without use of complex devices ¹⁾.

Awake craniotomy (AC) was first performed by Sir Victor Horsley in 1886 to localise the epileptic focus with cortical electrostimulation ²⁾.

Wilder Penfield, made mappings in conscious patients with severe epilepsy under local anaesthesia (LA) by directly observing the brain and assessing the responses to electrical stimuli. He prepared detailed reports on brain physiology, speech cortex, interpreting cortex and brain regions controlling body movements ³⁾.

Awake craniotomy indications.

Retrospective analysis of a cohort of 17 patients with perirolandic gliomas who underwent an AC with DCS were case-control matched with 23 patients with perirolandic gliomas who underwent surgery under GA with neuromonitoring (ie, motor-evoked potentials, somatosensory-evoked potentials, phase reversal). Inpatient costs, quality-adjusted life years (QALY), extent of resection, and neurological outcome were compared between the groups.

Total inpatient expense per patient was ${\$}$ 34 804 in the AC group and ${\$}$ 46 798 in the GA group ( P = .046). QALY score for the AC group was 0.97 and 0.47 for the GA group ( P = .041). The incremental cost per QALY for the AC group was ${\$}$ 82 720 less than the GA group. Postoperative Karnofsky performance status was 91.8 in the AC group and 81.3 in the GA group (P = .047). Length of hospitalization was 4.12 days in the AC group and 7.61 days in the GA group ( P = .049).

The total inpatient costs for awake craniotomies were lower than surgery under GA. This study suggests better cost effectiveness and neurological outcome with awake craniotomies for perirolandic gliomas ⁴⁾.

Awake craniotomy anesthesia.

see Awake surgery case series.

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