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| LETTER TO EDITOR |
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| Ahead of print publication |
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Awake craniotomy for massive intracranial space-occupying lesion: Series of two cases
Vidhu Bhatnagar, Randhir Singh Rajput, Sudhansu Shekhar, S Santhosh Kumar
Department of Anaesthesiology and Critical Care, INHS Asvini, Mumbai, Maharashtra, India
| Date of Submission | 21-Oct-2022 |
| Date of Decision | 16-Nov-2022 |
| Date of Acceptance | 14-Dec-2022 |
| Date of Web Publication | 18-Feb-2023 |
Correspondence Address:
Sudhansu Shekhar,
Department of Anaesthesiology and Critical Care, INHS Asvini, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jmms.jmms_162_22
Sir,
Brain tumor surgery poses an inherent risk of permanent neurological deficit, especially for tumor resection in the eloquent cortex. Awake craniotomy with a goal of maximum tumor resection allows for intraoperative speech, motor, and memory testing while avoiding peri- and postoperative neurological morbidity.[1] Mapping of the eloquent cortex during surgery requires the patient to be conscious and able to communicate. The anesthesiologist needs to titrate adequate sedation, analgesia, and respiratory plus hemodynamic control while keeping an awake, conscious patient for neurological testing.[2] We present two awake craniotomy cases (huge tumors approximately 9 cm3) which were conducted in a lateral position, making lying for good 5–6 h extremely difficult for the patient.
The first patient was a 52 year old male, 70 kg in weight, case of left temporo occipital high grade oligodendroglioma, was scheduled for left fronto parieto temporal craniotomy. There was history of (h/o) non-comprehension of written words and difficulty in forming fresh memories. Noncontrast computed tomography (NCCT) brain established an ill-defined heterogeneous mass lesion in the left temporo-parieto-occipital region 90 mm × 45 mm × 50 mm, 8.9 mm midline shift to right [Figure 1]a. | Figure 1: (a) Case 1 NCCT head, (b) Case 2 NCCT head, (c) tent created under drape. NCCT: Noncontrast computed tomography
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Second case was 33 year old male patient, 96 kg weight, case of left temporo-parietal space occupying lesion. He had h/o delayed recall, decrease in recent memory, mental balance, visual perception, attention and concentration, increase in verbal output and presence of the right hemianopia. NCCT established a well-defined heterogeneous lesion in the left inferior parietal lobule, superior and middle lateral temporal lobe measuring 64 × 67 × 53 mm, 9.1 mm midline shift to right [Figure 1]b. Magnetic resonance imaging and positron emission tomography-CT confirmed the findings in both cases. On preanesthesia checkup, general physical examination, airway examination, systemic examination, biochemical parameters, chest X-ray, and electrocardiography (ECG) were within normal limits. The patient was accepted in the American Society of Anesthesiologists classification Grade II. Patient counseling was done; initial rapport was created. Anesthesia plan was Scalp block with monitored anesthesia care. Difficult airway cart was kept standby. Standard monitoring placed, Heart rate, ECG, pulse oximetry, capnography, arterial blood pressure and urine output monitoring. Two wide-bore intravenous accesses were taken. Scalp nerves block administered with 40 ml Local Anaesthetic solution (0.5% ropivacaine [18 ml], 2% lignocaine [12 ml], and normal saline [10 ml]). Patients were positioned in the right lateral position; pressure points were supported. A tent was created under the drapes for visualization and communication [Figure 1]c. Oxygen supplementation through the nasal cannula started. Intravenous infusion of dexmedetomidine 0.3–0.4 mcg/kg/h administered for sedation. Infusion stopped after dural opening and before neurological testing. If the patient starts snoring, hypoventilation leads to brain bulge, so titration of dexmedetomidine infusion is extremely essential. Dexamethasone 8 mg, mannitol 300 mg, paracetamol 1 g, and levetiracetam 1 g were administered intravenously. Intraoperative monitoring was uneventful. Intraoperative neurological testing (power and movements of hand and feet, speech comprehension, and memory) was conducted. Patients remained alert and oriented throughout surgical resection, without speech impairment or any loss in memory, recent or remote. After tumor resection, dexmedetomidine infusion restarted till the cranium was closed. Postoperatively, the patient was alert, oriented, and able to move all limbs.
Although awake craniotomy is an attractive option for tumor resection involving the eloquent cortex, the patients need to be selected properly. The challenges faced by anesthesiologist are limited access to the patient due to positioning and pinning of the head, chances of losing the unprotected airway, intraoperative seizures, retching, or nausea, hypotension and excessive blood loss. Patients find it extremely difficult to stay in a lateral position for a prolonged period.[3],[4],[5] The key to our success was a well charted plan [Table 1], preparedness for any kind of complications, good rapport building with patients, engaging patients in meaningful conversations, music, chanting hymns and extreme vigilant monitoring.[4]. Judicious use of dexmedetomidine, an alpha-2 agonist, which does not cause respiratory depression also aided in our management.
Acknowledgment
Our acknowledgment to a team of neurosurgeons: Gp Capt MD Sudan, Surg Cdr RK Singh, and team.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Gupta DK, Chandra PS, Ojha BK, Sharma BS, Mahapatra AK, Mehta VS. Awake craniotomy versus surgery under general anesthesia for resection of intrinsic lesions of eloquent cortex – A prospective randomised study. Clin Neurol Neurosurg 2007;109:335-43.  |
| 2. | See JJ, Lew TW, Kwek TK, Chin KJ, Wong MF, Liew QY, et al. Anaesthetic management of awake craniotomy for tumour resection. Ann Acad Med Singap 2007;36:319-25. |
| 3. | Wolff DL, Naruse R, Gold M. Nonopioid anesthesia for awake craniotomy: A case report. AANA J 2010;78:29-32. |
| 4. | Attari M, Salimi S. Awake craniotomy for tumor resection. Adv Biomed Res 2013;2:63. [ PUBMED] [Full text] |
| 5. | Low D, Ng I, Ng WH. Awake craniotomy under local anaesthesia and monitored conscious sedation for resection of brain tumours in eloquent cortex – Outcomes in 20 patients. Ann Acad Med Singap 2007;36:326-31. |
[Figure 1]
[Table 1]
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