Wednesday, August 11, 2010 WE07 – Neuro A Novel Approach . . . Awake Craniotomy Garry J. Brydges, CRNA, MSN, ACNP-BC Awake craniotomy originally existed as a form of trephination and the oldest known form of surgery dating back 10,000 years. Human fossils provide evidence of trephination originating in the European Neolithic era, Canary Islands, North Africa, Russia, and the New World. Modern awake craniotomies originated with the Peruvian and Bolivian American Indians. Patients during this era demonstrated rudimentary forms of postsurgical healing. It has been postulated that coca leaves gave rise to cocaine-induced local anesthesia, which enabled the advancement of trephination. In 1953, Wilder Penfield and Andre Pasquet, further developed the concept of awake craniotomies at the Montreal Neurological Institute. They described the management of epilepsy through cortical exploration and craniotomies. Their techniques, still in use today, incorporated regional anesthesia, intermittent sedation, and analgesia for cortical mapping procedures. Direct brain stimulation enabled the ability to map language, motor, and sensory regions of the cerebral cortex, giving rise to the motor and sensory homunculus. As shorter acting anesthetic agents become available, the trend toward awake craniotomies increased in neurosurgical intervention. Intracranial tumor resection is technically challenging. Surgical intracranial tumor resection in an anesthetized patient forces a reliance on indirect measurement instruments, which are impacted by various anesthetic agents. As a result, interrupting normal cerebral integrity and pathways is likely in an anesthetized patient. Awake craniotomies are quickly becoming the “gold standard” for certain intracranial tumor resections. The M. D. Anderson Cancer Center has adopted various anesthetic techniques in achieving awake craniotomies for tumor resections on the motor strip, Broca area, Wernicke area, arcuate fasciculus, and the insula. More recently, the M. D. Anderson Cancer Center has progressed to performing awake craniotomies in an intraoperative magnetic resonance imaging suite. Nurse anesthetists provide a critical role in providing appropriate anesthesia techniques, such as sedation, analgesia, hemodynamic optimization, and airway management. Transdisciplinary collaboration within the neurosurgical team is critical to optimal patient outcomes and patient safety. Bibliography Hentschel SJ, Lang FF. Surgical resection of intrinsic insular tumors. Neurosurgery. 2005;57(1 suppl):176-183. Miller RD. Miller's Anesthesia. 7th ed. Philadelphia, PA: Churchill Livingstone/Elsevier; 2010. Penfield W. Combined regional and general anesthesia for craniotomy and cortical exploration, part I: neurosurgical considerations. Int Anesthesiol Clin. 1986;24(3):1-11. Penfield W, Roberts L. Speech and Brain-Mechanisms . Princeton, NJ: Princeton University Press; 1959. Sarang A, Dinsmore J. Anaesthesia for awake craniotomy: evolution of a technique that facilitates awake neurological testing. Br J Anaesth. 2003;90(2):161-165.

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Wednesday, August 11, 2010

WE07 – Neuro

A Novel Approach . . . Awake Craniotomy

Garry J. Brydges, CRNA, MSN, ACNP-BC

Awake craniotomy originally existed as a form of trephination and the oldest known form of surgery dating back10,000 years. Human fossils provide evidence of trephination originating in the European Neolithic era, CanaryIslands, North Africa, Russia, and the New World. Modern awake craniotomies originated with the Peruvian andBolivian American Indians. Patients during this era demonstrated rudimentary forms of postsurgical healing. It hasbeen postulated that coca leaves gave rise to cocaine-induced local anesthesia, which enabled the advancementof trephination.

In 1953, Wilder Penfield and Andre Pasquet, further developed the concept of awake craniotomies at theMontreal Neurological Institute. They described the management of epilepsy through cortical exploration andcraniotomies. Their techniques, still in use today, incorporated regional anesthesia, intermittent sedation, and

analgesia for cortical mapping procedures. Direct brain stimulation enabled the ability to map language, motor,and sensory regions of the cerebral cortex, giving rise to the motor and sensory homunculus.

As shorter acting anesthetic agents become available, the trend toward awake craniotomies increased inneurosurgical intervention. Intracranial tumor resection is technically challenging. Surgical intracranial tumorresection in an anesthetized patient forces a reliance on indirect measurement instruments, which are impactedby various anesthetic agents. As a result, interrupting normal cerebral integrity and pathways is likely in ananesthetized patient. Awake craniotomies are quickly becoming the “gold standard” for certain intracranial tumorresections. The M. D. Anderson Cancer Center has adopted various anesthetic techniques in achieving awakecraniotomies for tumor resections on the motor strip, Broca area, Wernicke area, arcuate fasciculus, and theinsula. More recently, the M. D. Anderson Cancer Center has progressed to performing awake craniotomies in anintraoperative magnetic resonance imaging suite. Nurse anesthetists provide a critical role in providingappropriate anesthesia techniques, such as sedation, analgesia, hemodynamic optimization, and airway

management. Transdisciplinary collaboration within the neurosurgical team is critical to optimal patient outcomesand patient safety.

Bibliography

Hentschel SJ, Lang FF. Surgical resection of intrinsic insular tumors. Neurosurgery. 2005;57(1 suppl):176-183.

Miller RD. Miller's Anesthesia. 7th ed. Philadelphia, PA: Churchill Livingstone/Elsevier; 2010.

Penfield W. Combined regional and general anesthesia for craniotomy and cortical exploration, part I:neurosurgical considerations. Int Anesthesiol Clin. 1986;24(3):1-11.

Penfield W, Roberts L. Speech and Brain-Mechanisms . Princeton, NJ: Princeton University Press; 1959.

Sarang A, Dinsmore J. Anaesthesia for awake craniotomy: evolution of a technique that facilitates awakeneurological testing. Br J Anaesth. 2003;90(2):161-165.