Kulikov Alexander, Lubnin Andrey
Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia.
Curr Opin Anaesthesiol. 2018 Oct;31(5):506-510. doi: 10.1097/ACO.0000000000000625.
The current review reports on current trends in the anesthetic management of awake craniotomy, including preoperative preparation, sedation schemes, pain management, and prevention of intraoperative complications.
Both approaches for anesthesia for awake craniotomy, asleep-awake-asleep and monitored anesthesia care (MAC), have shown equal efficacy for performing intraoperative brain mapping. Choice of the appropriate scheme is currently based mainly on the preferences of the particular anesthesiologist. Dexmedetomidine has demonstrated high efficacy and safety in MAC for awake craniotomy and has become a rational alternative to propofol. Despite the high efficacy of scalp block and opioids, pain remains a common compliant in awake craniotomy. Appropriate surgical tactics can reduce pain and even prevent postoperative neurological complications. Although the efficacy of prophylaxis of intraoperative seizures with anticonvulsants remains doubtful, levetiracetam can be superior to other drugs for this purpose.
Following a great deal of progress in anesthetic management, awake craniotomy, which had been a relatively rare approach, is now a commonly performed procedure for neurosurgical intervention. Modern anesthesia techniques can provide for successful brain mapping in almost any patient. Management of awake craniotomy in high-risk patients is a central task for future research.
本综述报告清醒开颅手术麻醉管理的当前趋势，包括术前准备、镇静方案、疼痛管理和术中并发症的预防。
清醒开颅手术的两种麻醉方法，即先睡后醒再睡和监护麻醉管理（MAC），在进行术中脑图谱绘制方面显示出同等疗效。目前，合适方案的选择主要基于特定麻醉医生的偏好。右美托咪定在清醒开颅手术的MAC中已显示出高效性和安全性，已成为丙泊酚的合理替代药物。尽管头皮阻滞和阿片类药物效果良好，但疼痛仍是清醒开颅手术中常见的主诉。合适的手术策略可减轻疼痛甚至预防术后神经并发症。尽管使用抗惊厥药物预防术中癫痫发作的疗效仍存疑问，但左乙拉西坦在此方面可能优于其他药物。
在麻醉管理取得重大进展之后，曾经相对少见的清醒开颅手术如今已成为神经外科干预中常用的手术方式。现代麻醉技术几乎可为任何患者成功进行脑图谱绘制。高危患者清醒开颅手术的管理是未来研究的核心任务。
