Embed Size (px)
DESCRIPTION
The Awake Craniotomy. April 2013 Mark Angle, M.D. Kuwait City. It’s how we started :. The Awake Craniotomy. Classical Indications Brain - mapping Cortical Stimulation Cortical Recording Patient- directed tumour resection in eloquent regions Positive Mapping – 5% deficits - PowerPoint PPT Presentation
Citation preview
1
The Awake CraniotomyApril 2013
Mark Angle, M.D.Kuwait City
Mark Angle, April 13th 2013
2
The Awake Craniotomy
It’s how we started :Unknown ~2200 BCE TrepanationUnknown 1640 Epilepsy
SurgeryHughling Jackson
1864 Epilepsy Surgery
Penfield 1920 Epilepsy Surgery
Archer 1988 Epilepsy + Tumour Surgery
Mark Angle, April 13th 2013
3
Awake Craniotomy
Classical Indications1. Brain-mapping
Cortical Stimulation Cortical Recording
2. Patient-directed tumour resection in eloquent regions
Positive Mapping – 5% deficits Negative Mapping – 2% deficits
Mark Angle, April 13th 2013
4
Awake Craniotomy
Why bother ?1. Neuroimaging (FMRI, Activation PET, ESAM)
renders 60-70% accuracy2. Neuroplasticity and transferrence alter
classical functional anatomy3. Neuronavigation loses accuracy post
durotomy and during resection
Mark Angle, April 13th 2013
5
Awake Craniotomy
Why bother ?4. Generally good physiological control
(BP, pCO2, SaO2)
5. Acceptable failure rates 5-8 %6. Acceptable deficit rates @ 15 %
Mark Angle, April 13th 2013
6
Awake Craniotomy
Why bother ?7. Function-limited tumour resection
Higher rate of total resection Maximum cytoreduction 20-30% deficits acutely diminishing to 5-8% at 3
months
Mark Angle, April 13th 2013
7
Awake Craniotomy
Why anaesthetists hate them :1. Failures :
Loss of communication 5% Seizures 2% Loss of airway 2% Loss of compliance 2%
2. Long periods of jeopardy Unsecured airway Risk of :
◦ Vomiting◦ Obstruction◦ Hemorrhage◦ Hyperventilation◦ Deficits
3. “A different type of practice”
Mark Angle, April 13th 2013
8
Awake Craniotomy
Goals1. Conditions for surgical success2. Patient compliance3. Patient safety4. Patient comfort (forgiveness)
Mark Angle, April 13th 2013
9
Awake Craniotomy
Understanding the goals1. Surface mapping for corticectomy
Limited wakefulness2. Brain mapping for tumours in eloquent
regions Moderate wakefulness
3. Function-limited tumour resection Prolonged wakefulness
Mark Angle, April 13th 2013
10
Awake Craniotomy
Understanding the goals4. Functions to be tested determine permissible
degrees of sedation SSEP Motor Speech Cognition
Mark Angle, April 13th 2013
11
Awake Craniotomy
Patient selection1. Exclude uncooperative patients2. Exclude significant deficits : motor, cognitive
and memory3. Exclude panic and claustrophobia4. Exclude children ≤ 8 years
Mark Angle, April 13th 2013
12
Awake Craniotomy
Patient assessment Comprehension / Cooperation Airway Mobility / Positioning Pain tolerance Surgical risks :
Hemorrhage Seizures Co-morbidities
Mark Angle, April 13th 2013
13
Awake Craniotomy
Pre-surgical Explanation / Complicity /Consent Clonidine 0.1 – 0.3 mg P.O. Nabilone 0.5 – 1.0 mg P.O
Mark Angle, April 13th 2013
14
Awake Craniotomy
Induction Zofran 8 mg Propofol / Remifentanyl “cocktail” Provocation / Sensitivity testing
Obstruction Apnea
Mark Angle, April 13th 2013
15
Awake Craniotomy
MonitoringArterial line contralateralFoley catheterNasal Et CO2SaO22 IV peripheral : bilateral
Mark Angle, April 13th 2013
16
Awake Craniotomy
Local Anaesthesia1. Mayfield pin sites2. Scalp block :
Auriculo-temporal Zygmatico-temporal Supra-Orbital Greater-Occipital Lesser-Occipital
3. Incisional block
Mark Angle, April 13th 2013
17
Awake Craniotomy
Positioning : (Post-Mayfield)Awake if possibleNo weight-bearing by MayfieldHands lightly restrainedFree movement of legsSight-lines clearAirway accessibleFresh-air blower
Mark Angle, April 13th 2013
18
Awake Craniotomy
Maintenance : TIVADroperidol / FentanylPropofol/ RemifentanylDexmedetomidine
Mark Angle, April 13th 2013
19
Awake Craniotomy
Maintenance : Remifentanyl/Propofol infusion, titrated to
stimulationRepeat Clonidine / Nabilone at hour 6Sips of H2O as requestedDistraction/Communication
Mark Angle, April 13th 2013
20
Awake Craniotomy
EventsObstructionHyperventilation / ApneaVomitingSeizuresLoss of compliance : pain, panicDeficits
EmergenceClosure under deep sedationInfusion (at lower dose) continued into PACU
Mark Angle, April 13th 2013
21
Awake Craniotomy
Conclusions:High success and satisfaction ratesClear facilitation of aggressive tumour
resection paradigmDemanding on both patient and anaesthetist
Mark Angle, April 13th 2013
