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LETTER TO THE EDITOR

Anesthesia for Craniotomy with Intraoperative Awakening: How to Avoid Respiratory Depression and Hypertension?

Department of Anesthesiology, Duke University Medical Center, Durham, NC, KEIFE001{at}mc.duke.edu

In Response:

The letter by Drs. Lobo and Amorim raises some important points requiring clarification.

The technique presented in our retrospective review (1) is most accurately described as a "wake up" craniotomy (2). This requires general anesthesia for the cranial and dural opening, emergence for intraoperative cortical mapping, and return to general anesthesia for the completion of the surgery. This anesthesiologist must control the airway and ventilation during the general anesthetic portion of the case while also providing a smooth emergence at the time of the cortical testing.

In a perfect world, one would select a technique which allowed for unobstructed spontaneous ventilation while the patient was in a lateral position with the head secured in a Mayfield head holder. At the time of surgical testing, the anesthetic would be discontinued and the patient would gently awaken with no stimulation of the airway. We took a minimalist approach in our series, securing the airway through positive airway pressure supplied by nasal trumpets. Other authors have used techniques ranging from laryngeal mask airway to endotracheal intubation to control the airway during the general anesthetic portion of the case. Whichever method is selected, however, one must consider several consequential decisions:

1. Is the anesthetic depth sufficient to enable the patient to tolerate airway instrumentation during general anesthesia?
   
2. Is it possible to remove the device from the airway to permit testing of speech capacity?
   
3. Is the airway adequately protected to prevent reflux for patients at risk?
   
4. Does the technique provide adequate ventilation, or permit the anesthesiologist to control ventilation if necessary?
   

Although not used routinely in our retrospective series, the laryngeal mask airway might address these concerns if used judiciously.

References

1. Keifer JC, Dentchev D, Little K et al. A retrospective analysis of a remifentanil/propofol general anesthetic for craniotomy before awake functional brain mapping. Anesth Analg 2005;101:502–8.[Abstract/Free Full Text]
2. Huncke K, Van de Wiele B, Fried I, Rubinstein EH. The asleep-awake-asleep anesthetic technique for intraoperative language mapping. Neurosurgery 1998;42:1312–6.[Web of Science][Medline]

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