Section of Neurosurgery, Department of Neurosciences, University of Verona, Verona, Italy.
J Neurosurg Anesthesiol. 2012 Jul;24(3):209-16. doi: 10.1097/ANA.0b013e3182464aec.
Although generally well tolerated, awake craniotomy is burdened by non-negligible failure rates. The aim of this pilot study was to verify the feasibility of a wider research scope to define objective criteria for patient exclusion and the risk of intraoperative mapping failures.
Twenty-one patients with brain tumors were subjected to a procedure in 3 steps: neuropsychological criteria for both cognition and language; psychological questionnaires for anxiety, attitude to pain and depression, and psychophysiological monitoring for the candidate's capacity for self-control; and an intraoperative interview for the patient's perception during awake procedure. Outcome measures were as follows: (1) patient compliance, defined as patient response to the intraoperative procedure and measured by psychological scale scores for fear and pain, and (2) failure, defined as the impossibility to complete brain mapping (minor) or conversion to general anesthesia (major). Data analysis included the description of preoperative and intraoperative assessments and their evaluation (Spearman ρ test), and the prognostic factors for intraoperative compliance and procedure failure (Mann-Whitney test).
Three patients were considered ineligible after the first step. In the remaining 18, the responses of 10 patients fell within the normal range and 8 showed some degree of impairment on at least 1 preoperative evaluation, but not enough to be excluded from awake surgery. The data analysis also showed that fear of pain correlated with pain felt during the operation and preoperatively with depression and psychophysiological changes, the latter of which was associated with fear felt during craniotomy. Minor failures occurred in 2 patients.
From these preliminary results, we observed that warning signs for minor failure were fear of pain and anxiety, as revealed by psychological questionnaire responses, and the incapability of self-control at psychophysiological monitoring. This assessment may serve to fit mapping modality to the single patient and to avoid complications.
尽管清醒开颅术通常耐受性良好，但仍存在不可忽视的失败率。本研究旨在验证扩大研究范围的可行性，以确定客观的患者排除标准和术中定位失败的风险。
21 例脑肿瘤患者分三步进行：认知和语言的神经心理学标准；焦虑、疼痛态度和抑郁的心理问卷，以及候选者自我控制能力的心理生理监测；以及患者在清醒手术过程中的感知的术中访谈。主要观察指标为：（1）患者依从性，定义为患者对术中程序的反应，通过恐惧和疼痛的心理量表评分进行衡量；（2）失败，定义为无法完成脑图（轻微）或转为全身麻醉（严重）。数据分析包括术前和术中评估及其评估的描述（Spearman ρ 检验），以及术中依从性和手术失败的预后因素（Mann-Whitney 检验）。
第一步后有 3 例患者被认为不适合手术。在剩余的 18 例患者中，10 例患者的反应处于正常范围内，8 例患者在至少一项术前评估中表现出一定程度的损伤，但不足以排除清醒手术。数据分析还表明，对疼痛的恐惧与手术过程中和术前的疼痛以及抑郁和心理生理变化有关，后者与开颅术中的恐惧有关。2 例患者发生轻微失败。
从这些初步结果来看，我们观察到轻微失败的警告信号是对疼痛和焦虑的恐惧，这是通过心理问卷的反应以及心理生理监测中的自我控制能力丧失来揭示的。这种评估可以根据患者的个体情况调整定位模式，避免并发症。
