Departments of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA.
Departments of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, California, USA.
World Neurosurg. 2020 Nov;143:e136-e148. doi: 10.1016/j.wneu.2020.07.050. Epub 2020 Jul 28.
Although the safety and feasibility of awake craniotomy are well established for epilepsy and brain tumor surgery, its application for resection of vascular lesions, including arteriovenous malformations (AVMs) and cavernomas, is still limited. Apart from the usual challenges of awake craniotomy, vascular lesions pose several additional problems. Our goal is to determine the safety and practicality of awake craniotomy in patients with cerebral vascular malformations located near the eloquent areas, using a refined anesthetic protocol.
A retrospective case series was performed on 7 patients who underwent awake craniotomy for resection of AVMs or cavernomas located in the eloquent language and motor areas. Our protocol consisted of achieving deep sedation, without a definitive airway, using a combination of propofol, dexmedetomidine, and remifentanil/fentanyl during scalp block placement and surgical exposure, then transitioning to a wakeful state during the resection.
Six patients had intracranial AVMs, and 1 patient had a cavernoma. Six patients had complete resection; however, 1 patient underwent repeat awake craniotomy for residual AVM nidus. The patients tolerated the resection under continuous awake neurologic and neurophysiologic testing without significant perioperative complications or the need to convert to general anesthesia with a definitive airway.
Awake craniotomy for excision of intracranial vascular malformations located near the eloquent areas, in carefully selected patients, can facilitate resection by allowing close neuromonitoring and direct functional assessment. A balanced combination of sedative and analgesic medications can provide both adequate sedation and rapid wakeup, facilitating the necessary patient interaction and tolerance of the procedure.
尽管对于癫痫和脑肿瘤手术来说，清醒开颅术的安全性和可行性已经得到充分证实，但它在血管病变（包括动静脉畸形和海绵状血管瘤）切除中的应用仍然有限。除了清醒开颅术的常见挑战外，血管病变还带来了一些额外的问题。我们的目标是使用改良的麻醉方案，确定位于语言和运动功能区附近的脑血管病变患者接受清醒开颅术的安全性和实用性。
对 7 例因位于语言和运动功能区附近的动静脉畸形或海绵状血管瘤而行清醒开颅切除术的患者进行了回顾性病例系列研究。我们的方案包括在头皮阻滞和手术暴露期间使用异丙酚、右美托咪定和瑞芬太尼/芬太尼的组合实现深度镇静，而不建立明确的气道，然后在切除过程中过渡到清醒状态。
6 例患者颅内有动静脉畸形，1 例患者有海绵状血管瘤。6 例患者达到完全切除；然而，1 例患者因残留的动静脉畸形核需要再次进行清醒开颅切除术。患者在持续进行的清醒神经功能和神经生理测试下耐受了切除，没有出现明显的围手术期并发症，也不需要转换为有明确气道的全身麻醉。
在精心选择的患者中，对于位于语言和运动功能区附近的颅内血管病变，采用清醒开颅切除术可以通过允许进行密切的神经监测和直接的功能评估来促进切除。镇静和镇痛药物的平衡组合可以提供足够的镇静和快速苏醒，从而促进必要的患者互动和对手术的耐受。
