Anaes · Neuroanaesthesia
Awake craniotomy: asleep-awake-asleep technique, mapping, and airway strategy
Also known as Asleep-awake-asleep · Asleep awake asleep · Eloquent cortex anaesthesia
Asleep-awake-asleep and monitored anaesthesia care for eloquent cortex surgery, propofol-remifentanil and dexmedetomidine regimens, airway options, seizure control, and conversion triggers.
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Red flags
- Uncooperative patient or poorly controlled seizures undermine mapping safety.
- Airway obstruction during sedation is the classic preventable crisis.
- Intraoperative seizure — cold saline and anticonvulsants before defaulting to GA.
- Urgent conversion to GA needs a rehearsed airway plan (LMA or ETT).
- Hypercarbia and venous congestion worsen brain bulk during mapping.
Meet the patient
A 45-year-old man with a left temporal glioma near Wernicke area is scheduled for awake craniotomy with language mapping. He is anxious but cooperative, speaks fluent English, has a BMI of 28, and no sleep apnoea. The neurosurgeon needs him naming objects and following commands during resection. Your job is to keep him comfortable enough to lie still in pins, deep enough for the craniotomy, then awake and cooperative for mapping — all without losing the airway or the brain.[1]
The question that owns this case: can you simultaneously protect the airway and the brain map? The candidate who only recites propofol infusion rates without a conversion plan or cold-saline seizure ladder is not yet at pass standard for a high-stakes neuro theatre.[1]
References9ShowHide
- [1]Goettel N, Bharadwaj S, Venkatraghavan L, et al. Dexmedetomidine vs propofol-remifentanil conscious sedation for awake craniotomy: a prospective randomized controlled trial. Br J Anaesth, 2016.PMID 27099154
- [2]Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth, 2015.PMID 26556848
- [3]Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet, 2016.PMID 26507180
- [4]Kulikov A, Lubnin A. Anesthesia for awake craniotomy. Curr Opin Anaesthesiol, 2018.PMID 29994938
- [5]Natalini D, Ganau M, Rosenkranz R, et al. Comparison of the Asleep-Awake-Asleep Technique and Monitored Anesthesia Care During Awake Craniotomy: A Systematic Review and Meta-analysis. J Neurosurg Anesthesiol, 2022.PMID 31972627
- [6]Seo H, Kim E, Jung H, et al. A prospective randomized trial of the optimal dose of mannitol for intraoperative brain relaxation in patients undergoing craniotomy for supratentorial brain tumor resection. J Neurosurg, 2017.PMID 27540904
- [7]Shen SL, Zheng JY, Zhang J, et al. Comparison of dexmedetomidine and propofol for conscious sedation in awake craniotomy: a prospective, double-blind, randomized, and controlled clinical trial. Ann Pharmacother, 2013.PMID 24259599
- [8]Mamani R, Jacobo JA, Mejia S, et al. Analysis of Intraoperative Seizures During Bipolar Brain Mapping in Eloquent Areas: Intraoperative Seizures in brain mapping. Clin Neurol Neurosurg, 2020.PMID 33096426
- [9]Zhao Y, Li P, Li DW, et al. Severe gastric insufflation and consequent atelectasis caused by gas leakage using AIR-Q laryngeal mask airway: A case report. World J Clin Cases, 2022.PMID 35582056