Awake craniotomy for clipping of unruptured aneurysm: anesthesia concerns, management and challenges

Awake craniotomy is a neurosurgical technique performed either as an asleep-awake-asleep technique or a monitored anesthesia care technique, in combination with a scalp block. The surgery indication has been well documented for brain tumor excision at the eloquent cortex, epilepsy and deep brain stimulation surgery. However, this technique’s use during unruptured cerebral aneurysm clipping has only been recently reported. The main goal of awake craniotomy for unruptured cerebral aneurysm clipping is to prevent the risk of ischemia during temporary and permanent clipping by immediate awake neurological assessment during surgery. There have been limited reports on this surgery’s anesthesia issues. The aim of our case report is to discuss the anesthesia concerns, management and challenges during our first successful experience of this surgery. Key words: Awake craniotomy; Clipping; Cerebral aneurysm; Scalp block Citation: Hassan WMNW, Omar SC, Fui WT, Idris Z, Kandasamy R. Awake craniotomy for clipping of unruptured aneurysm: anesthesia concerns, management and challenges. Anaesth. pain intensive care 2021;25(1):96-101; DOI: 10.35975/apic.v25i1.1436 Received: 2 July 2020, Reviewed: 10 August 2020, Accepted: 3 September 2020

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Unruptured cerebral aneurysm clipping: association of combined open and endovascular expertise with outcomes

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-011986 ◽

2015 ◽

Vol 8 (9) ◽

pp. 977-981 ◽

Cited By ~ 5

Author(s):

Kimon Bekelis ◽

Dan Gottlieb ◽

George Bovis ◽

Yin Su ◽

Stavropoula Tjoumakaris ◽

...

Keyword(s):

Propensity Score ◽

Cerebral Aneurysm ◽

Readmission Rate ◽

Cerebral Aneurysms ◽

Postoperative Mortality ◽

Fee For Service ◽

Aneurysm Clipping ◽

Unruptured Cerebral Aneurysm ◽

Procedural Volume ◽

Unruptured Cerebral Aneurysms

BackgroundIt is often questioned if one physician can conduct both open and endovascular techniques successfully and safely.ObjectiveTo investigate the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm clipping.MethodsWe performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent surgical clipping for unruptured cerebral aneurysms between 2007 and 2012. To control for confounding we used propensity score conditioning, and controlled for clustering at the physician level.ResultsDuring the study, 3247 patients underwent clipping for unruptured cerebral aneurysms, and met the inclusion criteria. Of these, 766 (23.6%) underwent treatment by hybrid neurosurgeons, and 2481 (76.4%) by proceduralists, who performed only clipping. Multivariable regression analysis with propensity score adjustment demonstrated a lack of association of combined practice with 1-year postoperative mortality (OR=0.81; 95% CI 0.51 to 1.28), discharge to rehabilitation (OR=0.95; 95% CI 0.72 to 1.25), length of stay (adjusted difference 0.85 days; 95% CI −0.31 to 2.00), or 30-day readmission rate (OR=1.05; 95% CI 0.80 to 1.39). Higher procedural volume was independently associated with improved outcomes.ConclusionsIn a cohort of Medicare patients with unruptured aneurysms, we did not demonstrate a difference in mortality, discharge to rehabilitation, or readmission rate between hybrid neurosurgeons and surgeons performing only clipping.

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Head-up display may facilitate safe keyhole surgery for cerebral aneurysm clipping

Journal of Neurosurgery ◽

10.3171/2017.5.jns162692 ◽

2018 ◽

Vol 129 (4) ◽

pp. 883-889 ◽

Cited By ~ 4

Author(s):

Terushige Toyooka ◽

Naoki Otani ◽

Kojiro Wada ◽

Arata Tomiyama ◽

Satoru Takeuchi ◽

...

Keyword(s):

Cerebral Aneurysm ◽

Modern Technology ◽

Field Of View ◽

Minimum Size ◽

Keyhole Surgery ◽

Aneurysm Clipping ◽

Unruptured Cerebral Aneurysm ◽

Numeric Information ◽

Dural Opening ◽

3D Anatomy

OBJECTIVEThe head-up display (HUD) is a modern technology that projects images or numeric information directly into the observer’s sight line. Surgeons will no longer need to look away from the surgical view using the HUD system to confirm the preoperative or navigation image. The present study investigated the usefulness of the HUD system for performing cerebral aneurysm clipping surgeries.METHODSThirty-five patients underwent clipping surgery, including 20 keyhole surgeries for unruptured cerebral aneurysm, using the HUD system. Image information of structures such as the skull, cerebral vasculature, and aneurysm was integrated by the navigation software and linked with the positional coordinates of the microscope field of view. “Image injection” allowed visualization of the main structures that were concurrently tracked by the navigation image, and “closed shutter” switched the microscope field of view and the pointer image of the 3D brain image.RESULTSThe HUD system was effective for estimating the location and 3D anatomy of the aneurysm before craniotomy or dural opening in most patients. Scheduled keyhole minicraniotomy and opening of the sylvian fissure or partial rectal gyrus resection were performed on the optimized location with a minimum size in 20 patients.CONCLUSIONSThe HUD images superimposed on the microscope field of view were remarkably useful for less invasive and more safe aneurysm clipping and, in particular, keyhole clipping.

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The Effect of Propofol Based Total Intravenous Anesthesia for Neuromonitoring on the Intraoperative Water Homeostasis in Unruptured Cerebral Aneurysm Clipping Surgery

Case Medical Research ◽

10.31525/ct1-nct04058106 ◽

2019 ◽

Author(s):

Keyword(s):

Cerebral Aneurysm ◽

Total Intravenous Anesthesia ◽

Intravenous Anesthesia ◽

Water Homeostasis ◽

Aneurysm Clipping ◽

Unruptured Cerebral Aneurysm

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Papaverine is a confounding factor in neurological assessment after cerebral aneurysm clipping: Report of three cases and review of the literature

Journal of Neuroanaesthesiology and Critical Care ◽

10.4103/2348-0548.173243 ◽

2016 ◽

Vol 03 (01) ◽

pp. 040-042 ◽

Cited By ~ 1

Author(s):

Veena Sheshadri ◽

Rohini Surve ◽

B. Chandramouli

Keyword(s):

Cerebral Aneurysm ◽

Evoked Potential ◽

Confounding Factor ◽

Neurological Deficits ◽

Neurological Assessment ◽

Transient Phenomenon ◽

Pupillary Dilatation ◽

Aneurysm Clipping ◽

Evoked Potential Monitoring ◽

New Onset

AbstractIntracisternal papaverine instillation is being used across many centers after cerebral aneurysm clipping to prevent and treat cerebral vasospasm. Pupillary dilatation secondary to papaverine can interfere with the neurological assessment postoperatively. This report describes pupillary changes in three patients following the papaverine application after craniotomy and aneurysm clipping, with one patient developing contralateral pupillary dilatation and the other two having bilateral pupillary dilatation. The pupillary changes resolved over 30 min to 4 h postoperatively. We conclude that pupillary changes following papaverine instillation could be a transient phenomenon and should not be considered ominous in absence of new onset neurological deficits. Intraoperative somatosensory evoked potential monitoring also helped in postoperative decision making in all our cases.

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Endoscope-integrated indocyanine green video-angiography for cerebral aneurysm surgery: a more effective technique

Innovative Neurosurgery ◽

10.1515/ins-2015-0004 ◽

2015 ◽

Vol 3 (3-4) ◽

Author(s):

Ittichai Sakarunchai ◽

Yoko Kato ◽

Yasuhiro Yamada ◽

Thomas Tommy

Keyword(s):

Indocyanine Green ◽

Cerebral Aneurysm ◽

Conventional Technique ◽

Parent Artery ◽

Aneurysm Surgery ◽

Small Vessels ◽

Aneurysm Clipping ◽

Unruptured Cerebral Aneurysm ◽

Deep Area ◽

Perforating Arteries

AbstractMicroscope-integrated indocyanine green video-angiography (mICG-VA) is used as an adjunct to aneurysm surgery in checking for small compromised perforating arteries and the remnant of an aneurysmal neck. A limitation of mICG-VA is the inability to access the deep area where small vessels are located behind the aneurysm sac or the parent artery. The endoscope-integrated ICG-VA (eICG-VA) is not only a tool in obtaining a wide angle of surgical view, but also is a technique to detect real-time blood flow during aneurysm clipping.Patients with an unruptured cerebral aneurysm who had conventional endoscope-assisted microsurgery and eICG-VA were enrolled. We compared the efficacy and additional details of imaging from both types of procedures.The data of seven patients were reviewed. In two cases of small perforating arteries that were hidden by the aneurysm sacs, more details were detected by eICG-VA. While the performance of the conventional technique was limited, the eICG-VA revealed a wide view in the deep area during aneurysm clipping.The eICG-VA provides more details of the aneurysm, especially in small perforating vessels that were hidden by the aneurysm. It can resolve the limitations of the conventional endoscope and mICG-VA.

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Anaesthesia for awake craniotomy with the use of dexmedetomidine in combination with propofol infusion and ProSeal laryngeal mask airway

Journal of Society of Anesthesiologists of Nepal ◽

10.3126/jsan.v2i2.13539 ◽

2015 ◽

Vol 2 (2) ◽

pp. 84-86

Author(s):

Gentle Sunder Shrestha ◽

Megha Koirala ◽

Prakash Karki ◽

Navindra Raj Bista ◽

Gopal Sedain ◽

...

Keyword(s):

Laryngeal Mask Airway ◽

Laryngeal Mask ◽

Awake Craniotomy ◽

Tumour Resection ◽

Controlled Ventilation ◽

Adequate Sedation ◽

Scalp Block ◽

Eloquent Cortex ◽

The Brain ◽

Dexmedetomidine Infusion

Awake craniotomy for resection of tumour in the eloquent cortex aims to maximize tumour resection while sparing important areas of the brain. It poses several challenges to an anaesthesiologist. The goal is to provide adequate sedation, analgesia, and respiratory and haemodynamic control, but also an awake and cooperative patient for neurological testing. Here we report a case of awake craniotomy conducted safely with asleep-awake-asleep technique using dexmedetomidine infusion, scalp block and controlled ventilation with ProSeal laryngeal mask airway.Journal of Society of Anesthesiologists of Nepal 2015; 2(2): 84-86

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Thalamic syndrome caused by unruptured cerebral aneurysm

Journal of Neurosurgery ◽

10.3171/jns.1995.82.2.0291 ◽

1995 ◽

Vol 82 (2) ◽

pp. 291-293 ◽

Cited By ~ 8

Author(s):

Marcus A. Stoodley ◽

Jason D. Warren ◽

Peter E. Oatey

Keyword(s):

Cerebral Aneurysm ◽

Unruptured Aneurysm ◽

Sensory Disturbance ◽

Content Type ◽

Unruptured Cerebral Aneurysm ◽

Fine Print

✓ A case is reported of a 63-year-old woman with thalamic syndrome as the presenting feature of an unruptured cerebral aneurysm. Unruptured aneurysm is a rare cause of thalamic syndrome; the possible mechanisms of production of the sensory disturbance are discussed.

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