Wednesday, August 11, 2010

WE07 – Neuro

A Novel Approach . . . Awake Craniotomy

Garry J. Brydges, CRNA, MSN, ACNP-BC

Awake craniotomy originally existed as a form of trephination and the oldest known form of surgery dating back
10,000 years. Human fossils provide evidence of trephination originating in the European Neolithic era, Canary
Islands, North Africa, Russia, and the New World. Modern awake craniotomies originated with the Peruvian and
Bolivian American Indians. Patients during this era demonstrated rudimentary forms of postsurgical healing. It has
been postulated that coca leaves gave rise to cocaine-induced local anesthesia, which enabled the advancement
of trephination.

In 1953, Wilder Penfield and Andre Pasquet, further developed the concept of awake craniotomies at the
Montreal Neurological Institute. They described the management of epilepsy through cortical exploration and
craniotomies. Their techniques, still in use today, incorporated regional anesthesia, intermittent sedation, and
analgesia for cortical mapping procedures. Direct brain stimulation enabled the ability to map language, motor,
and sensory regions of the cerebral cortex, giving rise to the motor and sensory homunculus.

As shorter acting anesthetic agents become available, the trend toward awake craniotomies increased in
neurosurgical intervention. Intracranial tumor resection is technically challenging. Surgical intracranial tumor
resection in an anesthetized patient forces a reliance on indirect measurement instruments, which are impacted
by various anesthetic agents. As a result, interrupting normal cerebral integrity and pathways is likely in an
anesthetized patient. Awake craniotomies are quickly becoming the “gold standard” for certain intracranial tumor
resections. The M. D. Anderson Cancer Center has adopted various anesthetic techniques in achieving awake
craniotomies for tumor resections on the motor strip, Broca area, Wernicke area, arcuate fasciculus, and the
insula. More recently, the M. D. Anderson Cancer Center has progressed to performing awake craniotomies in an
intraoperative magnetic resonance imaging suite. Nurse anesthetists provide a critical role in providing
appropriate anesthesia techniques, such as sedation, analgesia, hemodynamic optimization, and airway
management. Transdisciplinary collaboration within the neurosurgical team is critical to optimal patient outcomes
and patient safety.

Bibliography

Hentschel SJ, Lang FF. Surgical resection of intrinsic insular tumors. Neurosurgery. 2005;57(1 suppl):176-183.

Miller RD. Miller's Anesthesia. 7th ed. Philadelphia, PA: Churchill Livingstone/Elsevier; 2010.

Penfield W. Combined regional and general anesthesia for craniotomy and cortical exploration, part I:
neurosurgical considerations. Int Anesthesiol Clin. 1986;24(3):1-11.

Penfield W, Roberts L. Speech and Brain-Mechanisms. Princeton, NJ: Princeton University Press; 1959.

Sarang A, Dinsmore J. Anaesthesia for awake craniotomy: evolution of a technique that facilitates awake
neurological testing. Br J Anaesth. 2003;90(2):161-165.