Department of Anesthesia, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
Department of Neurophysiology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
Paediatr Anaesth. 2020 Apr;30(4):480-489. doi: 10.1111/pan.13833. Epub 2020 Feb 13.
Awake craniotomy with direct cortical stimulation and mapping is the gold standard for resection of lesions near eloquent brain areas, as it can maximize the extent of resection while minimizing the risk of neurological damage. In contrast to the adult population, only small series of awake craniotomies have been reported in children.
The aim of our study is to establish the feasibility of awake craniotomy in the pediatric population.
We performed a retrospective observational study of children undergoing a supratentorial awake craniotomy between January 2009 and April 2019 in a pediatric tertiary care center. Our primary outcome was feasibility of awake craniotomy, defined as the ability to complete the procedure without conversion to general anesthesia. Our secondary outcomes were the incidence of serious intraoperative complications and the mapping completion rate.
Thirty procedures were performed in 28 children: 12 females and 16 males. The median age was 14 years (range 7-17). The primary diagnosis was tumor (83.3%), epilepsy (13.3%), and arterio-venous malformation (3.3%). The anesthetic techniques were asleep-awake-asleep (96.7%) and conscious sedation (3.3%), all cases supplemented with scalp block and pin-site infiltration. Awake craniotomy was feasible in 29 cases (96.7%), one patient converted to general anesthesia due to agitation. Serious complications occurred in six patients: agitation (6.7%), seizures (3.3%), increased intracranial pressure (3.3%), respiratory depression (3.3%), and bradycardia (3.3%). All complications were quickly resolved and without major consequences. Cortical mapping was completed in 96.6% cases. New neurological deficits occurred in six patients (20%)-moderate in one case and mild in 5-being all absent at 6 months of follow-up.
Awake craniotomy with intraoperative mapping can be successfully performed in children. Adequate patient selection and close cooperation between neurosurgeons, anesthesiologists, neuropsychologists, and neurophysiologists is paramount. Further studies are needed to determine the best anesthetic technique in this population group.
对于语言功能区附近病变的切除，清醒开颅术联合皮层电刺激和脑功能定位是金标准，因为它可以在最大程度上切除肿瘤的同时，将神经损伤的风险降到最低。与成人人群相比，只有少数关于儿童清醒开颅术的小系列报道。
本研究旨在探讨儿童清醒开颅术的可行性。
我们对 2009 年 1 月至 2019 年 4 月在一家儿科三级护理中心接受幕上清醒开颅术的儿童进行了回顾性观察性研究。主要结局是评估清醒开颅术的可行性，定义为能够在不转为全身麻醉的情况下完成手术。次要结局是严重术中并发症的发生率和皮层定位图绘制完成率。
28 例患儿共完成 30 例手术：12 例女性，16 例男性。中位年龄为 14 岁（范围 7-17 岁）。主要诊断为肿瘤（83.3%）、癫痫（13.3%）和动静脉畸形（3.3%）。麻醉技术为睡-醒-睡（96.7%）和清醒镇静（3.3%），所有病例均辅以头皮阻滞和皮钉部位浸润。29 例（96.7%）手术可行，1 例因躁动转为全身麻醉。6 例患儿发生严重并发症：躁动（6.7%）、癫痫发作（3.3%）、颅内压升高（3.3%）、呼吸抑制（3.3%）和心动过缓（3.3%）。所有并发症均迅速得到解决，无严重后果。96.6%的病例完成了皮层定位图绘制。6 例患儿（20%）出现新的神经功能缺损-1 例为中度，5 例为轻度，随访 6 个月时均消失。
儿童清醒开颅术联合术中皮层定位图绘制是可行的。神经外科医生、麻醉师、神经心理学家和神经生理学家之间的充分合作是至关重要的。需要进一步的研究来确定该人群的最佳麻醉技术。
