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- Awake craniotomy allows neurosurgeons to continuously monitor the patient's neurological functions during open surgery.
- Awake craniotomy and brain mapping can be carried out completely under regional anesthesia.
- Local anesthetics injected as a dedicated regional scalp block can be performed by directly blocking the 6 different nerves that provide sensory innervation of the scalp.
- The use of sedation is common to improve patient comfort during craniotomy and closure.
Materials and methods
- Surgical and anesthesia consent (including regional scalp block, monitored anesthesia care, and general anesthesia) were obtained from patient and her parents.
- Patient informed consent was obtained for submission of a medically challenging case report.
- 16 y/o F with Chiari malformation, refractory epilepsy (generalized tonic-clonic seizures) s/p many stereotactic EEG lead trials and vagal nerve stimulator implant and removal, was scheduled for awake craniotomy for resection of left-sided epileptic focus with brain mapping.
- Standard ASA monitors (EKG, pulse oximetry, NIBP) were applied and vital signs were obtained in the OR.
- Awake PIV x 2 and radial A line were placed. Patient was breathing spontaneously with 2 L O2 via nasal cannula with ETCO2 monitoring.
- Patient received single-shot left supraorbital, supratrochlear, auriculotemporal, greater auricular, greater occipital, and lesser occipital nerve blocks.
- Scalp block was performed with a 25G needle. A total of 15 ml of ropivacaine 0.5% mixed with clonidine 75 mcg and epinephrine 75 mcg was used for the scalp block. Each nerve was injected with 2-3 ml of local anesthetic.
- Patient tolerated regional anesthesia without any difficulty, and she was positioned in a neutral sitting position for surgery.
- Subsequently, sedation was achieved with propofol, remifentanil, and dexmedetomidine infusions, and the doses were progressively increased and titrated to adequate sedation (RASS +1 to -2).
- All sedatives were stopped after the brain was exposed. Patient was comfortable, awake, and responsive during brain mapping and resection of epileptic focus.
- She tolerated the surgery very well and had minimal pain postoperatively that was well controlled with tylenol, ibuprofen, and oxycodone as needed. She was discharged home on post-operative day 2.
- We present scalp block as an efficacious anesthetic plan for patients undergoing awake craniotomy and resection of lesions located in the vicinity of functionally relevant areas.
- Scalp block leads to a more hemodynamically stable anesthetic course during skull pin placement as well as during dural and skin closure.
- Additional benefits of scalp block include lower pain scores, reduced opioid consumption, improved functionality and patient satisfaction, and shorter hospital length of stay.
- Erickson K, Cole D. Anesthetic considerations for awake craniotomy for epilepsy and functional neurosurgery. Anesthesiol Clin 2012; 30:241-268.
- Garavaglia M, Das S, Cusimano M, et al. Anesthetic approach to high-risk patients and prolonged awake craniotomy using dexmedetomidine and scalp block. J Neurosurg Anesthesiol 2014; 26:226-233.
- Kemp W III, Tubbs R, Cohen-Gadol A. The innervation of the scalp: a comprehensive review including anatomy, pathology, and neurosurgical correlates. Surg Neurol Int 2011; 2:178.
- Potters J, Klimek M. Local anesthetics for brain tumor resection: current perspectives. Local and Regional Anesthesia 2018; 11:1-8.
- Stevanovic A, Rossaint R, Veldeman M, et al. Anaesthesia management for awake craniotomy: systematic review and meta-analysis. PLos One 2016; 11(5):e0156448.