or neuronavigational brain mapping aims to help with surgical resection of
brain tumors, reducing the risk of functional sequelae. Retrospective
randomised studies on large populations have shown that this technique can
optimize surgical approach while reducing postoperative morbidity . The resection of tumors within or near eloquent
motor areas, in particular the precentral convolution, always implies a
compromise between the extension of the resection and the preservation of the
motor function. Especially in gliomas, surgical reduction of the tumor
significantly affects survival and therefore should be as wide as possible .
the dilemmas of brain tumor surgery in the eloquent cortex, is the way to
obtain benefits for the patient in terms of prolonged survival, maintenance or
even improvement of function, quality of life and at the same time not to run
the risk of new neurological deficits [3,4]. The
craniotomy with the awake patient is a functional-focus neurosurgery where the
anesthesiologist should keep the patient conscious and collaborator to allow
his specific neurological evaluation, offering him a conscious sedation and
analgesia for his comfort without altering neurological monitoring and
maintaining control of hemodynamics, brain physiology, ventilation and airway . As the
debate continues on the advantages of regional anesthesia versus general
anesthesia for many forms of surgery, there is an increasing number of
indications in intracranial surgery for the patient to be awake during part or
all of the operation [6-8]. The traditional
indication for craniotomy with awake patient has been the surgery of the
epilepsy since the seventeenth century  and in
particular the temporal lobectomy where the excision can invade the cortical
areas eloquent (motor areas and of the language). Arteriovenous tumors or
malformations are surgeries where the lesion may compromise speech, motor
function, sensory or visual cortex, which requires intraoperative functional
tests or cortical mapping and therefore the need for the patient to be awake .
The most common anesthesiological approach has been
local anesthesia .This approach allows
patients to be kept in an awake and cooperative state in order to decrease
false negative results during stimulation of language areas. Anesthesia is then
usually provided using a combination of local anesthesia (local infiltration and
regional blockade) and Intravenously (IV) with medications to provide sedation,
anxiolysis, and supplemental analgesia during long procedures . Propofol allows a rapid induction and has little
effect on the respiratory function of the patient with spontaneous respiration.
Pain control can be achieved by blocking the scalp for trepanation or local
infiltration for the implantation of deep brain electrodes. In addition, low
doses of remifentanil are recommended for trepanation (i.e., Tumor or Epilepsy Surgery).
The airway can be secured by a tube placed in a trans nasal way. Adequate
antiemetic prophylaxis is required to protect the patient from vomiting .
25-year-old male patient, who consulted for presenting sudden box of frontal
pulsatile headache followed by generalized clonic tonic convulsion with
postictal recovery within expected, when physical examination patient was alert,
conscious, with 15/15 in Glasgow scale, without motor or sensory deficit.
Patient with no major pathological background.Patient with no major pathological background. Is brought to the ER, a
month later presents new convulsive episode of the same characteristics to the
previous one, in the image of simple brain tomography is evident a tumor lesion
of glioma type of large extension in motor area (Figure
1), with low degree of malignancy of 37 x 28 mm and slight local
compressive effect. It is valued in neurosurgical joint where it is considered
that before the extension and localization of the lesion, the patient benefits
from surgery by neuronavigation with anesthesia with patient awake due to the
risk of post-operative motor sequelae.
Description of anesthetic
and surgical Technique
titration was performed by finding a male patient of approximately 25 years of
age and without comorbidity so it is classified as ASA 1. Anesthetic technique
is performed with a fully awake patient with the help of local anesthetics and
continuous infusion by means of a remifentanil and dexmedetomidine pump. At his
entrance he was supplied with ringer lactate. He is monitored with
electrocardiographic shunt DII, left radial arterial line, bladder probe,
thermometer in the sternal region and is administered oxygen by cannula at 3
Prophylaxis of Ranitidine 50 MGs, Ondansetron 8 MGS,
dexamethasone 8 MGS, diclofenac 75 mgs, Phenytoin 750 mgs in infusion for 30
minutes, Desmopressin 15 MCGs, 30 minutes before incision and prophylactic
antibiotic is applied. It starts continuous infusion of dexmedetomidine at the
rate of 0.5 mcg/kg for 15 minutes after 0.1 to 0.2 mcg/kg/hour accompanied by
remifentanil to 0.05 mcg/kg/min by adjusting the infusion by pump to need. Once
the proper sedation has been achieved, Ramsay 2, blockade of the escalpe is
made in the previous region involving the supraorbital nerves, supratrochlear,
zygomatic-temporal and auricular-temporal.atrial-temporal (Figure 2).
In the posterior region the major occipital nerves,
minor occipital and retroauricularwere involved.
For this infiltration is used a mixture of lidocaine
at 2% with epinephrine 15 ml plus bupivacaine to 0.5% with epinephrine 25
milliliters (ml) plus normal saline 5 ml plus bicarbonate 5 ml for a total
mixture of 50 mls. Once the scalpel's anesthesia has been checked, the Mayfield
head is placed. For patient comfort, thermal blanket, intravenous fluid heater
is placed and it’s allowed the patient listen to the music of his choice using
a custom audio system (Figure 3).
By using the neuronavigator, margins of intraaxial
tumor lesion are delineated (Figure 3). Bipolar
cortical stimulation of the posterior margin of the lesion is practiced without
obtaining motor response that indicates immediate relationship with primary
motor cortex. Under microsurgical technique, dissection and resection of the
tumor lesion is practiced (Figure 4). During the
procedure, the patient is asked to perform upper and lower limb movements, as
well as reading, speaking, and language tests without finding alterations in
the stimulation of the tumoural edges (Figure 4). 6 x 3.5 cm tumour lesion is extracted (Figure 5).
Intraoperative evolution is satisfactory. The
procedure is completed without complications. The surgical procedure lasts
approximately 6 hours during which the patient does not have an anesthetic
and/or surgical complication, so at the end of the surgery, 3 mg of morphine is
applied, continuous infusion of medication is suspended and patient is
transferred to the intensive care unit fully awake for post-operative
surveillance. Patient refers complete satisfaction with the anesthesia technique
employed and there is no evidence of postoperative pain, stable and normal
vital signs to his admission in ICU.
After three years of the procedure the patient
presents normal intellect, postoperative magnetic resonance that evidences
resection of the tumor above 95% without relapse (Figure
6), without neurological deficit, labors without
restriction, presented chronic convulsive symptoms that was controlled with
valproic acid 250 mg 1/ 8 hours, and phenytoin 100 Mg1/ 8 hours. He shows
isolated episodes of recent memory loss. In his post-surgical controls and
after three years, the Global Deterioration Scale (GDS-FAST) is 2 with a very
mild cognitive deficit. His superior executive functions are conserved with
slight affectation of recent memory. No behavioral disturbances are presented.
No motor deficits of any kind.
resection of brain tumours by craniotomy in awake patients, with cortical
stimulation and neuronavigation, are surgical alternatives that significantly
improve the prognosis of the patient, because they allow the resection of
tumors of great extension located in eloquent areas of the brain with a neurological
valuation in real time . According to the
literature this technique favors a higher rate of total gross resection vs
patients undergoing general anesthesia (37vs.14% respectively), fewer permanent
neurological deficits (4.6% vs. 16%) and fewer new onset postoperative
neurological deficits (3.3%Vs. 58%); as Sacko or and collaborators evidence [15-17]. In our case, the patient, in the
post-surgical, does not show any type of motor deficit, sensory, or language, however,
if he presented chronic convulsive symptoms currently controlled with mild
compromise of recent memory, despite this he is completely independent in the
activities of the daily life. No recurrences are found in the tomographic
This experience supports the importance of
implementing advanced neurosurgery techniques that offer to the patient safe
management alternatives, which are based on the improvement of their quality of
The advancement in anesthetic care has made an
important contribution to the growing popularity of craniotomy with awake
patient. However, there is not enough comparative evidence yet to make
technical recommendations with an adequate degree of evidence and Recommendation .
In this context, it is of the utmost importance to have a multidisciplinary functional neurosurgery program that allows
the identification of patients with adequate technological support which has a
direct impact on the results . Investment in
these programs is feasible and cost-effective, even in developing countries
like in Latin America, as they reduce hospital stay, stay in Intensive Care
Unit, rehabilitation costs and allow the patient a faster recovery with a
better prognosis [22,23].
of neuronavigation with anesthetic techniques with fully awake patient becomes
the first therapeutic alternative in the approach of patients with tumors that
compromise the eloquent areas. The evolution of these two medical disciplines
have allowed the reduction of post-surgical sequelae as well as recurrences in
this type of tumours.
the Group of Neurosurgery and Anesthesiology at the Rafael Uribe University
Clinic in Cali Valle Colombia.