Abstract
BackgroundAwake craniotomy (AC) renders an expanded role in functional neurosurgery. Yet, evidence for optimal anaesthesia management remains limited. We aimed to summarise the latest clinical evidence of AC anaesthesia management and explore the relationship of AC failures on the used anaesthesia techniques.MethodsTwo authors performed independently a systematic search of English articles in PubMed and EMBASE database 1/2007-12/2015. Search included randomised controlled trials (RCTs), observational trials, and case reports (n>4 cases), which reported anaesthetic approach for AC and at least one of our pre-specified outcomes: intraoperative seizures, hypoxia, arterial hypertension, nausea and vomiting, neurological dysfunction, conversion into general anaesthesia and failure of AC. Random effects meta-analysis was used to estimate event rates for four outcomes. Relationship with anaesthesia technique was explored using logistic meta-regression, calculating the odds ratios (OR) and 95% confidence intervals [95%CI].ResultsWe have included forty-seven studies. Eighteen reported asleep-awake-asleep technique (SAS), twenty-seven monitored anaesthesia care (MAC), one reported both and one used the awake-awake-awake technique (AAA). Proportions of AC failures, intraoperative seizures, new neurological dysfunction and conversion into general anaesthesia (GA) were 2% [95%CI:1–3], 8% [95%CI:6–11], 17% [95%CI:12–23] and 2% [95%CI:2–3], respectively. Meta-regression of SAS and MAC technique did not reveal any relevant differences between outcomes explained by the technique, except for conversion into GA. Estimated OR comparing SAS to MAC for AC failures was 0.98 [95%CI:0.36–2.69], 1.01 [95%CI:0.52–1.88] for seizures, 1.66 [95%CI:1.35–3.70] for new neurological dysfunction and 2.17 [95%CI:1.22–3.85] for conversion into GA. The latter result has to be interpreted cautiously. It is based on one retrospective high-risk of bias study and significance was abolished in a sensitivity analysis of only prospectively conducted studies.ConclusionSAS and MAC techniques were feasible and safe, whereas data for AAA technique are limited. Large RCTs are required to prove superiority of one anaesthetic regime for AC.
Highlights
RationaleAwake craniotomy (AC) was initially used for removal of epileptic foci with simultaneous application of brain mapping and electrical current
Meta-regression of studies. Eighteen reported asleep-awake-asleep technique (SAS) and monitored anaesthesia care (MAC) technique did not reveal any relevant differences between outcomes explained by the technique, except for conversion into general anaesthesia (GA)
We aimed to add to existing knowledge about the process of anaesthesia care for AC, the benefits and harms of the three anaesthesia techniques (MAC, SAS and AAA) for adult patients, from clinical studies published between January 2007 and December 2015
Summary
RationaleAwake craniotomy (AC) was initially used for removal of epileptic foci with simultaneous application of brain mapping and electrical current. AC with live intraoperative brain mapping and monitoring of neurological function and neurocognitive performance, allows maximal resection of malignant gliomas with a favourable survival prognosis and without language deficits [2]. The primary aim is to preserve or even improve the complex human brain function, while achieving maximal removal of tumours or epileptic foci [4]. One systematic review performed in 2013, focused on the anaesthesia technique for craniotomy [5]. They included only eight studies, published until 2012, which compared GA to AC, but the anaesthetic approach used for AC was not analysed in detail [5]. We aimed to summarise the latest clinical evidence of AC anaesthesia management and explore the relationship of AC failures on the used anaesthesia techniques
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