Minimal Invasive

17
Awake Craniotomy, Epilepsy, Minimally Invasive,

and Robotic Surgery
Armin Schubert, Logan Emory, Jonathan Riffle, Joseph Keen, and Lora Kahn
AWAKE CRANIOTOMY the brain surface is exposed, anesthesia or sedation is discontinued to

accomplish speech, memory, or motor testing. The MAC technique
Awake craniotomy refers to surgery performed on the brain while uses sedative doses of propofol and dexmedetomidine, with remifen-
the patient is in a state of awareness and able to cooperate with func- tanil analgesia. Performance of awake craniotomy without sedation
tional testing of the cortex. It is usually performed when the area to be has also been described, termed the awake-awake-awake technique.15
resected is in close proximity to eloquent cortical tissue that is involved This approach depends on superior therapeutic communication and
in one or more of the following critical functions: movement, vision, or psychological support to the patient by the anesthesiologist. Analgesia
language. This may include resection of a tumor, vascular malforma- is provided with scalp blocks (as is also done with the other anesthetic
tion, or ictal focus. techniques) and remifentanil only as needed.
Benefits Preparation for Awake Craniotomy

The patient’s awake state reduces the anesthetic interference to allow for Appropriate patient selection and preparation are the most important
mapping of the brain near the area to be resected, which avoids mor- factors in the success of anesthesia for awake craniotomy. The selection
bidity related to the resection of eloquent tissue. Awake craniotomy process should consider: age and maturity, anxiety, claustrophobia,
has been shown to reduce the size of the resection, surgery time, post- psychiatric disorders, presence or likelihood of a difficult airway, and a
operative neurologic deficits, early postoperative nausea and vomiting, history of reflux or nausea and vomiting. Literature and experience sug-
and length of hospital stay.1 Vasopressor use and hypertension during gest that hypertension, alcohol abuse, and lack of maturity may be risk
head pinning are also decreased.2 Length of hospital stays have been factors for sedation failure.16 We generally recommend against children
reported to be as short as 1 day for patients with good functional status younger than 14 years, although the developmental status of each indi-
and uncomplicated tumors.3,4 Lower postintensive care unit inpatient vidual should be assessed.17 Furthermore, a patient with a potentially
costs were found in patients undergoing glioma resection under seda- difficult airway, or who is likely to obstruct their airway while sedated,
tion versus general endotracheal anesthesia.5 Awake craniotomy has is a poor candidate for awake craniotomy. Because the patient’s head
even been studied as a potential outpatient procedure with no reported will be in pins and positioned by the surgeon, sudden conversion to
adverse outcomes.6 This technique has been shown to have excellent endotracheal intubation may be difficult. A plan for airway manage-
patient acceptance.7 Despite the most common complaints being about ment must be agreed upon between the anesthesia and surgical teams
pain from the head holder, inadequate local anesthesia, and uncom- in the event airway patency is lost. Patients with a history of obstruc-
fortable position,8 patients have better postoperative pain scores and tive sleep apnea (OSA), difficult ventilation, or difficult intubation may
use less opioid analgesics postprocedure. be considered at higher risk for adverse outcomes; although successful
management of awake craniotomy has been reported in such patients,
Anesthetic Technique—General Considerations using high-flow oxygen.18
The goal of anesthetic management is to ensure optimal resection or Preoperative patient evaluation and education are essential. The
ablation outcomes while ensuring patient comfort and safety. Awake anesthesiologist should clearly outline for the patient what to expect
craniotomy procedures have three phases, which can be described as during the procedure including: the varying states of sedation and
preresection, resection, and postresection. The two primary anesthetic awareness, the method of positioning, the possible discomfort, and
approaches are referred to as monitored anesthesia care (MAC) and the testing process. A strong rapport between the patient and the anes-
“asleep-awake-asleep,” with “asleep” meaning general anesthesia, with thesiologist should be established prior to the procedure; familiarity
or without a natural airway. These techniques require applying varying with positioning techniques for patient comfort, scalp block, anes-
levels of sedation or general anesthesia before and after the awake inter- thetic selection, and communication tools are paramount. The anes-
val. One needs to assure that anesthetic effects do not interfere with thesiologist must keep in mind the psychological state of the patient
brain mapping techniques, carefully monitor patients, and guide them and attempt to alleviate anxiety and discomfort as much as possible to
through the conscious mapping and testing process. Only the resection ensure the success of the anesthetic technique and the surgery.
phase requires the patient to be truly awake and interactive. General
anesthetics may be conducted using a laryngeal mask airway (LMA),9 Positioning
endotracheal intubation, or with airway adjuncts such as a nasal air- Patient comfort and access during the awake period is important in a
way; these techniques have been described10,11 and found to be safe.12 successful awake craniotomy. Lateral or semilateral positioning is com-
In current practice endotracheal intubation is rarely used.13 Sedation monly used to allow for patient comfort and to offer the anesthesia
MAC paradigms without a fully protected airway have proven safe and team ideal access to the patient. Adequate padding and pillows should
effective, with lower operative time and a similar safety profile.14 After be provided and pressure points carefully checked. The patient should
331
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332 CHAPTER 17 Awake Craniotomy, Epilepsy, Minimally Invasive, and Robotic Surgery
confirm an acceptable level of comfort prior to sedation, as he or she physical response in the sedated patient or an increase in heart rate and
will be in pins upon emergence from sedation and must remain still blood pressure in the patient under general anesthesia would indicate
during the period when repositioning is not feasible. The patient must block failure. Boluses of propofol may be necessary to temporarily res-
also be positioned and draped for easy access by the anesthesia or cue the inadequately sedated patient; if safe from the perspective of
neurological teams, who need to speak with the patient to test speech, total local anesthetic dose, scalp blocks can also be supplemented by
motor function, and sensation. Tenting the drapes upward from the additional injection of local anesthetic, for example, at the site of the
patient on the side of the anesthesia team provides an area of access and head pins.
may also reduce the patient’s sense of claustrophobia. Fig. 17.1 illus-
trates a configuration for setup in the operating room. The patient’s Anesthetic Technique—Specific Options
position is stabilized with the use of a deflatable beanbag or a backrest A number of different anesthetic techniques may be useful to accom-
fixed to the operating table, and the patient is secured on the operating plish anesthetic goals through the three phases of awake craniotomy
table with wide straps and tape. procedures. Some may choose varying levels of sedation, including very
deep sedation, as tolerated by the patient with a natural airway. Others
Scalp Block use a general anesthetic for the initial phase, with or without an arti-
Reliable blockade of the innervation of the scalp is essential to the suc- ficial airway. When deeper sedation or general anesthesia is employed
cessful performance of an awake craniotomy. The technique for local before and after the resection phase, this is frequently referred to as the
scalp block for craniotomy is well described.19,20 Individually blocking “asleep-awake-asleep” technique.
the auriculotemporal, zygomaticotemporal, supraorbital, supratroch- One may thus choose to perform a general anesthetic from induc-
lear, lesser occipital, and greater occipital nerves is necessary to pro- tion to completion of exposure and awaken the patient for neuro-
vide complete analgesia of the scalp. Ropivacaine and levobupivacaine cognitive and neurofunctional testing. If this method is chosen, it is
can be safely used up to doses of 4.5 mg/kg21 and 2.5 mg/kg, respec- important to remember that the patient will be emerging in head pins
tively.22 Mepivacaine may also be used adjunctively if a faster setup is and bucking must be avoided assiduously to prevent patient morbidity.
required. These blocks achieve peak plasma concentrations approxi- Conversely, one may choose merely sedation during the initial surgical
mately 15 minutes after injection. Severe bradycardia after scalp block exposure, keeping in mind that spontaneous ventilation must be main-
has been reported.23 tained and airway reflexes should be preserved. This approach, espe-
If general anesthesia is performed for the initial asleep period, nec- cially with a primarily dexmedetomidine-based sedation technique,
essary venous access, invasive monitors, and urinary catheters may be has been described as MAC.24 There is evidence that this technique is
placed after induction of anesthesia. However, if sedation (in contrast associated with benefits such as decreased opioid use, vasoactive medi-
to general anesthesia) is selected, it should be deep enough for the cations, respiratory events, and length of hospital stay.25,26
patient to comfortably tolerate these invasive procedures with mini- Droperidol and fentanyl were used in the past, which was referred
mal discomfort and recall. Prior to these interventions, a scalp block to as neuroleptanalgesia. This technique has given way to modern
may also be performed with mild sedation. An early indication of the anesthetic regimes that are faster acting and have a shorter offset.
block’s success is the patient’s response to head pin placement. Obvious Propofol, dexmedetomidine, and opioid infusions have been safely
Anesthesia
machine
A
Microscope
Surgical drapes IV pole
Instrument table
Fig. 17.1 Operating room setup for right-sided craniotomy performed for the awake patient. Note the arrangement of the surgical
drapes, which ensures access to the patient’s face. The pin holder is not shown. A, anesthesiologist; N, nurse; S, surgeon. (From
Schubert A. Epilepsy Surgery. Clinical Neuroanesthesia. 2nd ed. Cleveland, OH: Cleveland Clinic Press; 2006, p 66.)
CHAPTER 17 Awake Craniotomy, Epilepsy, Minimally Invasive, and Robotic Surgery 333
and successfully used for awake craniotomy in present-day anesthetic patient is guided through the process, he or she must be reassured that
practice. Volatile anesthetics have been used for general anesthesia involuntary movements and speech patterns may occur as a result of
during the asleep portion of the procedure. While the patient is in cortical stimulation by the surgical team. The anesthesia team must
head pins, one should be cognizant of the danger of laryngospasm dur- be prepared to address any anxiety and discomfort that may occur.
ing emergence and tracheal extubation or LMA removal. Total intra- Motor, sensory, cognitive, and speech testing may be performed dur-
venous anesthesia (TIVA) is a viable choice for awake craniotomy.27 ing this time. The patient may be asked to verbally identify objects or
Propofol-only anesthesia with spontaneously breathing patients has pictures, read passages aloud, perform specific motor tasks, or identify
been described as safe. Propofol is begun with a bolus of 0.5 mg/kg and paresthesias or other sensations. Cortical evoked potentials and elec-
continued at a rate of 75–250 μg/kg/min.12 Practitioners have safely and trocorticography (ECoG) may be used to identify functional tissue
successfully used a combination of propofol or dexmedetomidine with and seizure foci. The results of this testing will guide the surgeon in
an opioid such as remifentanil, sufentanil, or boluses of fentanyl. The resecting pathologic lesions with minimal disruption to eloquent tissue
rapid clearance of remifentanil makes it an appealing choice for quickly in order to reduce patient morbidity. Surgical resection then proceeds
achieving the awake state. However, remifentanil may cause hypopnea while the patient completes verbal tasks (speech area assessment) or
in the spontaneously ventilating patient. A dose range of 0.01–0.1 μg/ performs motor tasks (motor area assessment). Seizure activity is also
kg/min28 has been reported. In Manninen and colleagues’ 2006 study, possible during this phase, and the anesthesiologist must be prepared
propofol infusion combined with intermittent administration of fen- for prompt treatment, possible airway intervention, and conversion to
tanyl yielded similar patient satisfaction, recall, and intraoperative general endotracheal anesthesia.
complications when compared to remifentanil, with a slightly higher When brain mapping and functional testing are complete, the
rate of respiratory depression in the propofol and fentanyl group.29 patient should be sedated once more for closure of the dura, calvar-
Emergence from remifentanil-propofol has been described as occur- ium, and scalp. This period can be very stimulating to the patient and
ring within approximately 9 minutes.30 Still, up to 17% of patients fail adequate sedation can usually be achieved with remifentanil, propo-
to be awake by 20 minutes after discontinuation of propofol and remi- fol, dexmedetomidine, or a combination of these agents, as has been
fentanil.31 This prolonged emergence is associated with increasing age, described.
nonsmoking status, and higher ASA classification. Alfentanil is known
to induce epileptiform discharges in the hippocampal area and should Adverse Events and Management
be used with caution in patients with complex partial epilepsy.32 For Seizures, respiratory depression, nausea, vomiting, anxiety, discomfort,
patient comfort, an opioid infusion may be continued at a low dose and agitation may occur during awake craniotomy. As is commonly the
during awake testing and titrated to allow patient cooperation. Such case with sedation, airway obstruction, hypercarbia, and hypoxemia are
an opioid regimen during the awake phase may increase the need all possible, and careful preoperative assessment of the airway is vital.
for antiemetics.33 Longer-acting analgesia may be necessary prior to We have also experienced laryngospasm with a LMA during the asleep
emergence. portion of the asleep-awake-asleep technique. An extensive review of
The alpha-2-agonist dexmedetomidine has been recommended anesthetic complications of awake craniotomies showed an 18.4% rate
for sedation, due to lack of interference with electrophysiologic test- of hypoxemic events for patients undergoing sedation for the proce-
ing, sedation with minimal respiratory effects,34,35 its anxiolytic effects, dure compared to merely 1% in patients who received endotracheal
and analgesic qualities. A loading dose of 0.5–1 μg/kg is delivered intubation. Airway or ventilation complications occurred in just 2%
over 10–15 minutes with an infusion rate of 0.2–0.7 μg/kg/h. Doses when patients received propofol-only sedation.12 The rate of conversion
are higher in children. Dexmedetomidine use as a lone sedating agent to general anesthesia has been reported to be 2%.10 Dexmedetomidine
has been described, as well as a combined anesthetic with propofol or appears significantly better than propofol for rate of respiratory depres-
opioids, or both.36 The use of remifentanil combined with dexmedeto- sion.10 Dexmedetomidine has been described for rescue of a patient
midine has also been reported.37 Like remifentanil, dexmedetomidine unable to tolerate awake brain mapping after a propofol-remifentanil
may be continued at low doses during brain mapping and functional sedation regimen,43 and is now used more commonly as a primary
testing if needed for patient comfort. Dexmedetomidine is known to sedative. Airway-assist maneuvers and the use of oral or nasal airways
have a significant synergistic effect when used in combination with are common in patients undergoing sedation and should be expected
other sedative agents.38 The use of multiple agents has been reported to treat transient obstruction.
and requires substantive reduction in dosage. In one report, the dex- Vomiting and aspiration are possible in the sedated patient. As
medetomidine loading dose was eliminated and the infusion dose the airway will be unprotected using this technique, administration
reduced by approximately 50% when this sedative was combined with of prophylactic antiemetics is strongly advised, and rapid treatment
remifentanil and propofol. The dose of the latter two agents was also should be provided if nausea occurs. The incidence of nausea and
reduced by 50–70%.39 While dexmedetomidine, remifentanil, and suf- vomiting is 4% for mixed sedation techniques44 and even less for the
entanil are used in combination with propofol, recent evidence would use of propofol.12 Once symptoms occur, they can be controlled with
suggest that the incidence of side effects such as nausea, vomiting, a hydroxytryptamine-3 (HT-3) receptor antagonist, such as metoclo-
respiratory depression, and seizures are associated with remifentanil- pramide 10 mg. Nausea can also result from inadequate analgesia of
based regimens.40,41 dural attachments and meningeal vessels. Additional local anesthetic
should be administered by the surgeon and supplemental sedation
Brain Mapping and Cognitive Testing administered by anesthesia.
As patients emerge from deep sedation or anesthesia, the anesthesi- Sedation with spontaneous ventilation may pose the problem of
ologist must take responsibility for safely reorienting the patient, pro- brain swelling, particularly when mass-effect already exists, due to
viding a calming influence, and guiding him or her through the brain hypopnea or periods of apnea and concomitant increase in partial
mapping and cognitive testing phase. The use of bispectral-index mon- pressure of carbon dioxide (PaCO2). However, spontaneous ventilation
itoring to shorten emergence has been described and may be useful.42 also may assist in keeping the brain relaxed due to maintenance of neg-
The patient may be disoriented for a brief period after sedation. Again, ative intrathoracic pressure and promotion of cerebral venous outflow.
preoperative preparation becomes essential during this phase. As the Mannitol or furosemide administration may be necessary to reduce
swelling and improve the surgical field. Patient movement—with Anesthetic regimens have a significant effect on cortical mapping
the head in pins or during craniotomy—can have morbid outcomes, for epilepsy and may reduce or improve the effectiveness of testing and
including scalp and soft tissue injury, brain swelling from straining, surgery. While many anesthetic agents have anticonvulsant properties,
and placing the cervical spine at risk. It is critical to anticipate possible many also have varying profiles of proconvulsant or pharmacoactivat-
patient movement—during times like emergence from sedation or as ing properties that can be useful in intraoperative localization of epilep-
a result of seizure initiated during mapping or delirium—and control togenic foci. Alternately, other agents may confound ECoG testing and
the movement quickly. Deepening sedation with propofol boluses may lead to poor localization and less effective outcomes. Pharmacologic
be effective, and conversion to general anesthesia must be considered interactions between anticonvulsant medications and anesthetic drugs
if necessary. It is important to be aware that deepening sedation may must also be taken into account. Pharmacoactivation of interictal epi-
result in hypopnea or apnea, and the anesthetic team must be prepared leptiform activities (IEAs) can be necessary in patients who do not
to take control of the airway. demonstrate spontaneous interictal discharges during ECoG. The goals
Seizures may occur from electrical stimulation during brain map- of the anesthetic regimen should be discussed with the neurosurgeon,
ping or from a patient’s underlying condition. Vigilance is critical neurologist, or neurophysiologist to determine if pharmacoactivation
because the untreated seizure while in head pins could be catastrophic. will be required. This may change during the procedure if the patient
Seizure activity can be treated with propofol (0.75–1.25 mg/kg) or fails to generate IEAs spontaneously or under electrical stimulation. A
benzodiazepines, depending on the need for subsequent electroen- goal-oriented anesthetic plan in concert with the neurosurgical team
cephalography (EEG). A 4.9% incidence of seizures was reported with and knowledge of the activating properties of various anesthetic agents
cortical mapping in an unselected series of 610 awake craniotomies.3 At are essential.
the end of the procedure, benzodiazepines and antiepileptics may also
be used more freely. Pharmacology of Anesthetic Agents
Proper sedation can be achieved through the use of a variety of anes-
thetic plans. In many cases, a general endotracheal anesthetic may be
EPILEPSY SURGERY preferable. In others, an awake craniotomy is performed for better
Epilepsy is a disease of the brain characterized by two unprovoked functional testing and identification of seizure activity. Visualization
seizures greater than 24 hours apart; one unprovoked seizure and a of seizure activity that is similar to the patient’s typical seizures can be
probability of seizures similar to the general recurrence risk; after two very helpful in identifying the true epileptogenic focus. Iatrogenic acti-
unprovoked seizures occurring over the next 10 years; or diagnosis of vation of IEAs may be achieved with administration of proconvulsant
an epilepsy syndrome.45 It is present in 0.5–2.2% of the general popu- anesthetics and awareness of their anticonvulsant activities. EEG sup-
lation.46 Because 30–40% of epileptics do not respond adequately to ports altering the activation and inhibition of the cerebral cortex with
pharmacologic intervention,47 more than 400,000 people still have administration of anesthetic agents. For example, during light seda-
medically uncontrolled epilepsy in the United States. However, only tion, cortical activation with higher-frequency beta activity predomi-
10–30% of patients with seizures refractory to medical management nates, which progresses to slow-wave activity as sedative or anesthetic
are appropriate candidates for seizure surgery, and only 1% eventually depth increases.50
undergo the procedure.
Epilepsy is classified as focal onset, generalized onset, or unknown Sedative-Hypnotic Agents
onset; psychogenic nonepileptiform seizures (PNES) are also a known As a group, sedative-hypnotic agents have the greatest variation and
entity. Focal seizures are characterized by electrical disturbances local- most confusing profile regarding effects on epileptogenic activity. Most
ized to one area of one cerebral hemisphere. Focal seizures without agents can generate neuroexcitatory effects when used at low doses and
impairment of awareness are not associated with a loss of conscious- neurodepressive effects when used at higher doses. Several anesthetic
ness and generally last 1 minute or less. Focal seizures with impairment induction agents, such as propofol and thiopental, can induce myo-
of awareness are characterized by a loss of consciousness or awareness clonic movements not associated with EEG excitatory activity, whereas
and spread from their localized focus to other regions. Focal seizures others, such as etomidate and methohexital, have been shown to gen-
may further be characterized as motor or nonmotor (including sen- erate both myoclonus and EEG-documented epileptiform activity in
sory) symptoms. Focal seizures may become generalized, now referred patients.51,52 Motor stimulatory phenomena, such as myoclonus, opis-
to as “focal to bilateral tonic-clonic.”48 Generalized seizures have no thotonos, and tonic-clonic activity, may occur with varying frequency
demonstrated focal onset, although they may evolve from focal sei- in both epileptic and nonepileptic patients during induction of anes-
zures, affect both hemispheres of the brain, and are characterized by thesia with these agents, but only a few drugs actually produce cortical
a loss of consciousness. They are subcategorized as generalized tonic- electrical activity suggestive of seizures.
clonic (grand mal), tonic, clonic, myoclonic, myoclonic-tonic-clonic, Barbiturates and benzodiazepines have substantiated anticonvul-
myoclonic-atonic, atonic, epileptic spasms, and nonmotor, including sive properties and are recommended for treatment of refractory status
absence. PNES are psychogenic episodes that may be characterized by epilepticus.53
seizure-like physical manifestations but have no corresponding epilep- Propofol is among the most commonly used induction and main-
tiform activity on EEG and are considered conversion reactions. tenance agents in general anesthesia for epilepsy surgery and awake
Surgical management of epilepsy may be an option for patients craniotomy. Propofol depresses ECoG recordings and decreases the
with intractable epilepsy refractory to medical treatment. With suc- frequency of epileptogenic spike activity; it produces a minimal effect
cessful surgical intervention, quality of life improves, although most on spontaneous IEAs. It decreases the frequency of epileptogenic
patients continue anticonvulsant drug therapy. Chin et al.49 reported spikes and quiets existing seizure foci, particularly in the lateral and
that the rate of employment improved only modestly in their group of mesial temporal areas.54 Spike activation with low-dose propofol has
375 patients, from 39.5% fully employed status preoperatively to 42.8% been reported,55 as have been isolated instances of patients who mani-
postoperatively; however, the rate of part-time employment nearly fested tonic-clonic seizures with propofol administration, in particu-
doubled, from 6.9% to 12.4%.49 Patients do experience improvement in lar on emergence from anesthesia.55 Myoclonic activity not related to
quality of life, including reduction in depression, after epilepsy surgery. excitatory EEG activity may be seen more commonly. Propofol may
obscure spike wave activity for up to 20 minutes after termination of Enflurane, used with or without N2O, has been the most common
infusion and should be discontinued prior to ECoG testing. offender, with reports of intraoperative and postoperative myoclonus
Etomidate has been shown to activate EEG seizure activity at induc- and epileptiform activity on the EEG in both epileptic and nonepilep-
tion doses in patients with a history of epilepsy and may also generate tic patients.16,59,63,64,74 The incidence of EEG spike wave production with
myoclonic activity. It has been shown to have a high activation rate and enflurane appears to be dose dependent. The end-tidal concentration
demonstrates successful spike activation during intracranial electrode of enflurane that triggers maximum epileptiform activity is reduced
testing. At higher doses, etomidate may produce burst suppression and during hypocapnia. Enflurane has fallen out of favor as new inhala-
break status epilepticus.56,57 To date, its use in intraoperative ECoG has tional agents have become available, and it is now rarely used clinically
not been studied.58 in the United States. Enflurane should be avoided in patients with epi-
Methohexital can activate EEG seizure activity in patients with lepsy unless the desired effect is to trigger seizures during ECoG.
epilepsy and may assist with activation of ictal foci during ECoG. It Sevoflurane (but not desflurane)75 has been reported to generate
is associated with a high percentage of spike activation (50–85%),59 convulsions as well as electrical spike waves in both epileptic and non-
although with questionable specificity, showing up to 43% inappropri- epileptic patients.78,79 The frequency of spike wave activity with sevoflu-
ate activation in one study.60 rane increases with dose escalation and hyperventilation (Fig. 17.2).75,80
Dexmedetomidine has a pharmacologic profile favorable for awake Hisada and colleagues81 reported that widespread neuroexcitatory
craniotomy due to its sedative, analgesic, and anxiolytic effect coupled activity associated with sevoflurane did not facilitate seizure focus
with minimal respiratory impairment and the absence of motor stimu- localization in patients with temporal lobe epilepsy.81 Hyperventilation
lation. Dexmedetomidine does not affect background ECoG activity or decreases the prediction specificity of leads with ictal spikes and should
IEAs and may be the best alternative for awake craniotomy.27,28,61 be employed cautiously during ECoG.82
Ketamine may induce nonspecific activation of IEAs, especially
in the limbic areas, and can activate seizure activity in patients with Muscle Relaxants
epilepsy.62,63 It has been used to assist with activation of ictal foci dur- Long-term anticonvulsant therapy with phenytoin, carbamazepine, or
ing intraoperative ECoG.64–67 Ketamine appears to have a dose-depen- both is associated with resistance to the effect of nondepolarizing neu-
dent threshold for seizure generation, with most reported cases of romuscular blockers, including pancuronium, vecuronium,83–85 meto-
clinical seizure activity occurring when doses larger than 4 mg/kg are curine, cisatracurium, and rocuronium, but less so with atracurium.86,87
administered.68,69 The etiology of this phenomenon is likely both pharmacodynamic and
pharmacokinetic, for example, through upregulation of acetylcholine
Opioids receptors and increased hepatic metabolism, respectively.88,89
Synthetic opioids such as remifentanil and sufentanil are commonly
used in neurosurgical anesthesia because of their short duration of
action and their ability to minimize cortical effects with continuous
Anesthetic Management
infusions. High doses of synthetic opioids have proepileptic proper- Goals
ties. Standard maintenance doses of these agents do not significantly Preoperative assessment of the patient’s neurologic condition, as well
increase the risk of perioperative seizures or effects on ECoG. However, as comorbidities, is essential. Careful attention should be paid to the
bolus doses of synthetic opioids, such as alfentanil and remifentanil, interaction of antiepileptic drugs (AEDs) with anesthetic agents, such
increase spike wave activity in the interictal foci of patients undergo- as the resistance to nondepolarizing neuromuscular block and others
ing intraoperative ECoG.70,71 Due to their high effectiveness and speci- mentioned below. Intraoperative goals include maintenance of appro-
ficity, bolus doses of these agents are used to facilitate location of the priate cerebral blood flow and perfusion, control of brain bulk, immo-
ictal cortex through stimulation of spike wave phenomenon with con- bility, and rapid emergence from anesthesia for effective postoperative
comitant depression of background EEG. Alfentanil has been shown neurologic evaluation. In the event that seizure induction is desired,
to be the most effective and specific synthetic opioid for pharmaco- the goals of the anesthesiologist include selection of effective inducing
activation.72 Fentanyl has been associated with epileptiform electrical agents and avoidance of patient injury. Careful postoperative monitor-
activity in subcortical nonictal cortical tissue and has been shown to ing of the patient’s neurologic status is required, and postoperative sei-
be associated with contralateral activity.73 The clinical history of the use zure control may be necessary.
of synthetic opioids in large numbers of epileptic patients undergoing
ablative procedures suggests that synthetic opioids can be used safely Preoperative Evaluation
in this patient population without a significant increase in the risk of Neurologic History. The patient’s seizure history should be thor-
perioperative seizures. Morphine and hydromorphone used at clini- oughly understood prior to surgery. It may be difficult to discriminate
cally relevant doses do not appear to have significant proconvulsant seizure activity in the perioperative period from prolonged emergence
activity.74 or emergence delirium. Knowledge of the patient’s known seizure pat-
terns may help to determine postoperative intervention. Prolonged
Volatile Inhalational Agents and Nitrous Oxide emergence, characteristic motor activity, and poor responsiveness
The epileptogenic potential of isoflurane, desflurane, and halothane should raise suspicion for perioperative seizure activity.
appears low. When these agents are used alone, seizures are not The anesthesiologist should be vigilant for a number of medical
reported.75 However, myoclonic activity with a normal EEG has been conditions associated with epilepsy. Neurofibromatosis, also known
observed. Convulsions with spike and wave activity on EEG have been as von Recklinghausen’s disease, is an inherited condition that leads
reported with combinations of isoflurane and nitrous oxide (N2O).76,77 to tumor growth on nerve tissue. Variable expression means that the
Although N2O has been associated with seizure generation when used severity of this condition is wide ranging, from benign, asymptom-
to supplement other agents, it appears to be fairly inert in both the atic tumors to acoustic neuromas, significant intracranial lesions,
development and the treatment of seizure activity in humans.74 Both and peripheral lesions. These tumors may involve cranial nerves or
N2O and isoflurane have been used for many years at multiple institu- respiratory tract tumors leading to airway and respiratory compro-
tions with a good safety record in epileptic patients. mise, including chronic aspiration, pulmonary fibrosing alveolitis,
Fig. 17.2 Effect of sevoflurane on electroencephalogram (EEG). At 0.5 minimum alveolar concentration (MAC) sevoflurane, EEG is
comparable to preictal awake EEG. At 1.5 MAC sevoflurane, EEG is similar to interictal periods before anesthesia. (From Kurita N,
Kawaguchi M, Hoshida T, et al. The effects of sevoflurane and hyperventilation on electrocorticogram spike activity in patients with
refractory epilepsy. Anesth Analg. 2005;101:517–523.)
pulmonary hypertension, and cor pulmonale. Tuberous sclerosis is a medications.95 Sedation and lethargy are common side effects of many
disease causing widespread benign tumor growth in the brain, heart, antiepileptic agents, including newer agents such as lamotrigine and
lungs, kidneys, skin, and eyes. While it is less common than neuro- oxcarbazepine, and may potentiate the central nervous system depres-
fibromatosis, tumors may cause obstructive hydrocephalus, cardiac sant effects of anesthetics. Chronic topiramate intake has been associ-
dysrhythmias, intracardiac tumors, cerebrovascular embolization, ated with intraoperative metabolic acidosis.96 Topiramate is associated
renal dysfunction, and arterial aneurysms. Echocardiography revealed with an asymptomatic non-anion-gap acidosis.97 Carbamazepine may
intracardiac tumors (rhabdomyomas) in approximately 32.8–48% of cause a severe depression of the hematopoietic system and cardiac
patients with tuberous sclerosis.90,91 These patients should undergo toxicity in rare cases. This drug’s metabolism is materially slowed by
a full preoperative cardiac evaluation. Down syndrome, Angelman erythromycin and cimetidine, drugs that may be administered peri-
syndrome, and Sturge–Weber syndrome are also associated with epi- operatively. Likewise, a ketogenic diet, sometimes used as an adjunct
leptiform activity. Open craniotomy is considered a moderate-risk pro- anticonvulsant therapy, predisposes patients to metabolic acidosis.
cedure (indicating a less than 5% risk of cardiac events) with regard to Valproic acid therapy results in dose-related thrombocytopenia and
its effects on the cardiovascular system of the patient.92 Due to possible platelet dysfunction.98 While additional bleeding risk during surgery
significant pneumocephalus up to 1 month after craniotomy,93 N2O is likely to be low in a patient taking valproic acid,99 it is reasonable to
should be avoided in patients who have undergone recent intracranial consider stopping its use perioperatively (if clinically appropriate) or
electrode placement. giving desmopressin at the neurosurgeon’s discretion to help counter-
Medication History. Medications for patients with epilepsy may act platelet dysfunction.
present significant interactions with the conduct of anesthesia. As men- Patient Preparation. Regardless of the anesthetic approach
tioned, certain anticonvulsants significantly elevate dose requirements selected, intraoperative awareness during ECoG is a possibility, due to
for both nondepolarizing muscle blockers88 and opioids.94 Both phenyt- reduced anesthetic dosing or the use of awake techniques. The patient
oin and carbamazepine are associated with resistance to nondepolar- should be reassured that this experience is usually described as a pain-
izing neuromuscular blockade and elevated liver function parameters. less awareness. Careful explanation and reassurance to the patient and
A direct relationship between the number of anticonvulsants a patient family of this and other risks, such as perioperative seizure, nausea,
receives and the dose of fentanyl required for intraoperative anes- vomiting, and airway compromise, is essential. Neuropsychological
thetic maintenance has been reported.94 Elevated liver enzymes seen impairment is commonly associated with epilepsy and psychiatric dis-
on liver function tests are commonly associated with anticonvulsant orders, and impaired cognition is increased in this population.100 The
anesthesiologist must be aware of these issues when selecting and pre- better brain relaxation than isoflurane or sevoflurane in patients with
paring a patient for an awake technique. mass lesions106 suggests its efficacy in craniotomies. However, these
benefits may be less clinically significant when lower MAC doses of
such volatile agents are used.107 Prospective studies have not been suf-
Diagnostic Surgical Procedures for Intractable ficiently powered to allow determination of the impact of anesthetic
Epilepsy technique on neurologic and functional outcome after craniotomy as
Subdural grid electrodes may be placed for identification of epilepto- of this time. Antihistamines can activate seizure foci in patients with
genic foci in preparation for resection. A craniotomy is performed and epilepsy and should be avoided as premedicants.
the grid electrodes are placed under general anesthesia. Usual anes- By contrast, when intraoperative brain mapping is anticipated,
thetic concerns for craniotomy should be observed. Hyperventilation additional anesthetic goals and planning need to be considered. As
to relax the brain during exposure may be efficacious but should be described above, many anesthetic agents may promote or suppress
considered carefully against the risk of precipitating seizure activity in epileptiform activity. The anesthesiologist must take care that medica-
the epileptic patient. Hyperventilation may be less effective in patients tions administered to the patient will not interfere with intraoperative
with focal seizures, who may have lower carbon dioxide (CO2) reac- monitoring and the mapping of ictal foci. Likewise, it may be desirable
tivity of cerebral blood flow.101 Arterial line placement for blood gases in some instances to administer agents that will promote epileptiform
and accurate blood pressure monitoring as well as adequate IV access discharges and improve mapping.
are indicated. Since intraoperative testing is not performed, anesthetic Benzodiazepine premedication is avoided because it may elevate
techniques may be used without regard to their effect on EEG. As the seizure threshold, making ECoG recording of epileptogenic activ-
always, rapid emergence from anesthesia for neurologic assessment is ity more difficult. There is evidence that nitrous and other inhala-
preferred. tional anesthetics should be avoided because of undesirable effects on
In recent years in the United States, “depth” electrode place- ECoG.101,108 Ebrahim and colleagues109 recommended that propofol
ment, or stereo EEG (sEEG), has largely supplanted subdural strips administration be stopped 20–30 minutes prior to ECoG, because
and grids as a phase II localization surgery. sEEG has proved highly it elicits high-frequency beta EEG activity (Fig. 17.3) for as long as
effective for exploring deep regions of the brain and providing a 3D 30 minutes after discontinuation, although other investigators have
exploration of seizure onset zone. A robot may be used as a surgi- reported that this type of EEG activity did not prevent ECoG inter-
cal adjuvant. The procedure usually is uneventful and not associated pretation.110 Likewise, low concentrations of isoflurane or desflurane
with significant bleeding. A general anesthetic is used, typically with may be used provided that these agents can be eliminated well before
an arterial line to allow for tight blood pressure control intraopera- the start of corticography. Isoflurane may decrease the frequency and
tively. Unlike in open craniotomy, diuresis and hyperventilation are spatial distribution of epileptogenic spikes, although it is unclear
not employed, as it is imperative not to introduce any brain shift in whether this effect persists at low concentrations.111 Low-dose sevo-
this procedure that depends on accurate neuronavigation. The anes- flurane would be preferred, given its mild proconvulsant properties
thetic team should also be prepared for transport to and from com- and short duration of action, again provided it can be eliminated
puted tomography (CT) scan to confirm placement of stereotactic prior to ECoG recording. During ECoG recording dexmedetomi-
headframe or fiducial screws and sEEG electrodes, depending on the dine and remifentanil can be used safely. If an inhaled anesthetic is
surgeon’s preference and workflow. Benzodiazepines should not be necessary to prevent intraoperative awareness, low-dose sevoflurane
administered as they may make it harder to capture seizures in the is preferred because of its minimal effects on ECoG spike activity.108
postoperative monitoring period. A low-dose propofol infusion can be added to reduce the likelihood
of intraoperative recall with virtually no effect on the EEG.112 Mild-
Resection of Epileptogenic Brain Regions Under to-moderate hypocapnia (PaCO2 30–35 mmHg), however, is often
necessary to assist in brain volume control and brain relaxation. If
General Anesthesia hyperventilation must be initiated during sevoflurane anesthesia, the
Anesthetic planning for epileptogenic brain resection procedures anesthesiologist should be aware that the specificity of ictal lead pre-
depends greatly on the need for intraoperative brain mapping for sei- diction may diminish.82
zure foci localization. In some cases, resection of epileptogenic foci If cortical motor area stimulation is necessary for the surgeon to
is performed without brain mapping under general anesthesia. The accomplish safe resection, particular attention must be paid to the
anesthetic goals are then much like those of most open craniotomy management and dosage of neuromuscular blocking agents. As a gen-
procedures. If EEG is not planned, benzodiazepines may be given preop- eral rule, neuromuscular blockade should be minimal to allow motor
eratively for patient comfort. Monitoring should include direct arterial stimulation. If moderate residual neuromuscular block persists, neo-
blood pressure monitoring and intravenous access should be adequate stigmine or sugammadex can be administered to achieve its complete
to replace rapid blood loss. Brain relaxation is desirable to facilitate reversal.
surgical exposure and resection. Maintenance of adequate cerebral per- Cortical stimulation for localization as well as light anesthesia and
fusion without brain engorgement is essential. Immobility is critical brain manipulation may lead to intraoperative seizures. Treatment
to the safety of the patient, as is adequate anesthesia to avoid patient of seizure activity during ongoing intraoperative ECoG, therefore,
awareness and pain. The anesthesiologist should always be prepared requires the use of short-acting anticonvulsants (such as methohexi-
to manage intraoperative seizures. Neurological evaluation needs to be tal) as one weighs the therapeutic goals of gross seizure control against
able to be performed in the immediate postoperative period. Therefore, the potential for interference with critical electrocortical monitoring.
the anesthetic plan should allow for rapid emergence. This may include Therefore, irrigation of the cortical surface with cold saline may be
the use of the ultra-short-acting remifentanil, which facilitates rapid instituted as a first measure and usually highly effective means to sup-
emergence and early neurologic examination when compared to other press an intraoperative seizure with brain surface exposed.
opioids.102–105 However, addition of a longer-acting opioid in the imme- When intraoperative EEG recordings fail to reveal seizure spikes,
diate postoperative period will be required for pain control. TIVA with and in consultation with the surgeon and the electroencephalographer,
propofol and remifentanil may be considered. Propofol’s property of the anesthesiologist may be asked to administer anesthetics known to
Fig. 17.3 β-electroencelographic activation 10 minutes after propofol injection (right temporal and central convexity). (From Ebrahim
ZY, Schubert A, Van Ness P, et al. The effect of propofol on the electroencephalogram of patients with epilepsy. Anesth Analg.
1994;78:275–279.)
promote epileptiform discharges, although this practice has been dis- patients. Hypothermia and metabolic acidosis was observed in five
couraged because of the risk of nonspecific activation, with the pos- patients. Urine output was a poor indicator of volume status because of
sible exception of remifentanil.108 EEG activating anesthetics include frequent massive glycosuria. Zuckerberg and colleagues118 report sev-
methohexital (25–50 mg),59,64 alfentanil (20 μg/kg),24,113 and etomidate eral children younger than 5 years in whom severe decreases in cardiac
(0.2 mg/kg).63 Alfentanil is the most active of these agents, provok- index, bradycardia, increased systemic vascular resistance, and an alve-
ing abnormal EEG spike activity in 83% of patients, compared with olar-to-arterial gradient suggestive of neurogenic pulmonary edema
50% for methohexital.24 However, as mentioned, controversy exists developed after hemispherectomy with extensive subcortical resection.
over the correlation of pharmacologically elicited seizure spikes with Removal of the endotracheal tube at the conclusion of procedures with
the patients’ native epileptogenic foci.60 Severe bradycardia has been large-volume resuscitation and with a high potential for postoperative
reported during amygdalohippocampectomy that is not seen during complications would, therefore, seem unwise. Postoperative hemody-
routine anterior temporal lobe resection. This problem is thought to be namic instability is common, and the airway may be compromised by
the result of surgical limbic system stimulation resulting in enhanced seizure activity. Early postoperative recovery is best accomplished in an
neural vagal activity.114,115 intensive care environment. As has been reported in adults,119 children
undergoing major brain resection become hypercoagulable as early as
Cerebral Hemispherectomy during dural closure.120 Although the clinical significance of this find-
On occasion, the seizure foci are so diffuse as to require resection of ing is debated, thrombotic complications should be anticipated.
substantial portions of an entire cerebral hemisphere. Frequently, this
procedure is performed in children and can be associated with signifi- Vagal Nerve Stimulator Placement
cant morbidity and mortality related to massive blood loss, electrolyte Vagal nerve stimulation is a noncranial neurostimulator for patients
and metabolic disturbances, coagulopathy, cerebral hemorrhage, and with refractory epilepsy. Similar to cardiac pacemakers, the vagal nerve
seizures. Hemispherectomy requires a very large craniectomy, which stimulator (VNS) emits electrical pulses from a generator through an
increases the chance of bleeding and tearing of dural sinuses. Air implanted wire to an electrode wrapped around the left vagus nerve
embolism has also been reported and may lead to serious morbidity. to modulate cerebral neuronal excitatory activity.121 It has been dem-
Kofke and associates116 compared three different surgical techniques onstrated to reduce seizure frequency and severity. Although the
(anatomical, functional, and lateral) for hemispherectomy. Lateral mechanism of action is not well understood, proposed mechanisms
hemispherectomy was associated with the lowest intraoperative blood of action include activation of the limbic system, locus coeruleus, and
loss, the shortest intensive care stay, and the lowest complication rate. amygdala.122
Functional hemispherectomy had the highest rate of reoperation, The VNS is placed on the left side to avoid the vagal fibers that affect
whereas patients undergoing anatomical hemispherectomy had the the sinoatrial node associated with the right vagus nerve and to reduce
longest hospital stays, greatest requirement for cerebral spinal fluid the likelihood of clinically significant bradycardia.123 The patient is
(CSF) diversion, and highest postoperative fever. Patients with cortical positioned supine with the head turned to the right. The bed may be
dysplasia had the largest intraoperative blood loss.116 kept with the head toward the anesthesiologist or rotated 180 degrees.
Continuous monitoring of blood pressure by arterial catheter is The left vagus nerve is exposed, taking care not to injure the left carotid
required, as is central venous access and monitoring of cardiac filling and jugular that flank the nerve within the carotid sheath. The genera-
pressure. In addition, vasopressor and inotropic infusions should be tor pocket is created above the left pectoralis muscle. The lead is tun-
readily available to combat low cardiac output states.97 Brian et al.117 neled from the nerve to the generator pocket in the chest. The electrode
report a series of 10 patients, aged 3 months to 12 years, whose intra- array is attached to the nerve. The generator is connected, and the unit
operative blood replacement amounted to 1.5 blood volumes on aver- is tested before it is sewn into the pocket.
age. In seven patients, a coagulopathy developed intraoperatively and VNS placement is usually performed under general endotracheal
required administration of platelets, fresh frozen plasma, or both. anesthesia. Standard American Society of Anesthesiologists (ASA)
Progressive hypokalemia requiring replacement occurred in four monitors are used. Additional monitoring should be based on the
patient’s medical condition. Perioperative complications may include arterial lines placed to facilitate blood pressure control at a level of
seizures; bradycardia; vocal cord paralysis or hoarseness from recur- <140 mmHg to minimize bleeding risk. MRI-compatible anesthetic
rent and superior laryngeal nerve injury or activation; and hematoma. and monitoring equipment is required.
Unilateral vocal cord paralysis has been reported as well, as has a
predisposition to chronic pulmonary aspiration.124 Complete atrio- Deep Brain Stimulation Therapy
ventricular block and ventricular asystole have also been reported, Long employed for treatment of movement disorders, deep brain stim-
particularly during the testing phase, so it is advisable to have atro- ulation (DBS) is now applied for epilepsy as well, having been FDA
pine available.125 If cardiac dysrhythmias occur, stimulation of the vagal approved in 2018 for the anterior nucleus of the thalamus. Unlike DBS
nerve should be stopped immediately and additional rescue measures for movement disorders, which has historically been performed awake
may be necessary. with microelectrode recording, DBS for epilepsy is typically done
Anesthetic management with regard to the patient’s seizure disor- under general anesthesia, either in the MRI or with direct stereotac-
der is the same as has been described for other procedures under gen- tic guidance from the robot or other stereotactic placement apparatus.
eral anesthesia without mapping. It is recommended that patients take This is because the recommended trajectory requires passing through
their seizure medications as scheduled prior to the procedure, and the the ependyma of the lateral ventricles, unlike for movement disorders
anesthesiologist should be aware of interactions and effects with regard targets; there is an unacceptably high rate of lead repositioning without
to anesthetic agents. Management of intraoperative and postoperative direct targeting. Chest-mounted pulse generators may be implanted
seizures may be necessary. the same day or, more commonly, on an outpatient basis on a future
date.
Responsive Neurostimulator Placement
Responsive neurostimulator (RNS) is another neurostimulator aimed Emergence From Anesthesia and Postoperative
to reduce seizure frequency and severity.126 FDA approved in 2014 for
patients with focal seizures who are 18 or older; the device comprises Management
a skull-mounted pulse generator with connection to one or two intra- As with most intracranial procedures, rapid emergence from anes-
cranial strips or depth electrodes (each with four contacts).127 The leads thesia is helpful for postoperative neurologic assessment. However,
may be placed anywhere in the brain or subdural space; the generator patients with seizure disorders and a long history of anticonvulsant
is most commonly placed over one of the parietal bosses and requires use may experience lethargy and slower emergence from anesthesia.
full-thickness craniectomy for installation. The device allows for both A loading dose of phenytoin for treatment of seizures may increase
recording and treatment of seizures. the risk of delayed emergence from general anesthesia. Coughing and
When depth electrodes are placed, anesthetic considerations are bucking on emergence are undesirable as they may increase the risk of
similar to those employed for sEEG electrode placement; when strips intracranial bleeding and CSF leak. Hypertension should be avoided. If
are placed, the protocol is similar to that for subdural strip and grid short-acting opioids were used, postoperative pain control with longer-
placement. ECoG is always checked at the end of the procedure. acting agents may be necessary. The anesthesiologist should remain
Surgeons may request that steroids not be administered given the risk vigilant for changes in the patient’s mental status in the recovery phase
for infection of the implanted hardware. All AEDs should be continued that may indicate seizure activity, bleeding, or hematoma formation.
in the perioperative period. Minor postoperative complications occur in 5.1–10.9% of patients
undergoing surgical procedures for epilepsy.129 CSF leak was the most
Laser Interstitial Thermal Therapy common minor complication. Neurologic complications involv-
Laser interstitial thermal therapy (LITT) is a surgical technique by ing speech, visual, motor, and memory deficits may occur. Cerebral
which a laser catheter is stereotactically implanted via a burr hole to edema may occur in patients with temporary subdural grid electrode
ablate tissue under real-time magnetic resonance imaging (MRI) ther- implants. Nausea and vomiting occur in 38% of intracranial neurosur-
mography guidance. LITT is most commonly employed to treat deep- gical cases.130 Prophylactic administration of antiemetics is effective131
seated epileptogenic zones, such as the amygdala and hippocampus, in and advisable.
mesial temporal sclerosis and hypothalamic hamartoma.128 The tech- If patients have tapered or discontinued anticonvulsant medica-
nique may also be applied to oncologic disease, such as for radiation tions prior to surgery, the anesthesiologist must be especially vigilant
necrosis. for postoperative seizures. Benzodiazepines and propofol may be
Similar to sEEG placement, the laser catheter is typically placed administered to control seizure activity, and the airway may need to be
under stereotactic guidance, either with an MRI-compatible head secured. Administration of anticonvulsants such as phenytoin also may
frame or frameless insertion, such as a stereotactic tower or robot. This be necessary and is begun at 50 mg/min to a total dose of 20 mg/kg,
may require a trip to and from the CT scanner, depending on the insti- assuming the patient has not previously been treated with phenytoin.
tution’s workflow. Once the catheter has been adequately placed, the
patient is then transferred to the MRI suite (or the entire case may be
performed in the MRI suite via frameless placement apparatus). Once
MINIMALLY INVASIVE CRANIAL
the patient is in the MRI scanner, the scanner space becomes stereotac- NEUROSURGERY
tic space, making it imperative that the patient not move, lest the whole
image acquisition needs to be restarted. Background and Anesthetic Goals
Anesthetic management includes careful preoperative assessment The evolution of minimally invasive neurosurgery (MIN) or key-
as would be done for patients with epilepsy or brain tumor. While hole surgery has led to improved patient safety, decreased morbidity,
local anesthesia and MAC has been reported, many practices choose decreased intraoperative blood loss, and shorter hospital stays com-
general anesthesia to ensure immobility and optimal MRI quality. pared to open procedures. Another benefit is a decrease in throm-
Intraoperative administration of antiepileptic medication and dexa- boembolic complications and other hospital-acquired conditions.132
methasone are desirable to reduce seizure risk and counteract LITT- Improvements in surgical instrumentation, operating microscopes,
induced cerebral edema.128 At our hospital, patients typically have endoscopic technology, digital imaging, and neuronavigation have
allowed greater access to surgical sites with less disruption of non-

target tissue while providing patient satisfaction due to less pain and
TABLE 17.1 Indications for Minimally Invasive
better cosmesis.133 MIN approaches have also enabled the perfor- Surgery on the Central Nervous System*
mance of certain procedures on an outpatient or day surgery setting. Diagnosis Intervention
They include stereotactic brain biopsy, supratentorial brain tumors, Hydrocephalus Third ventriculostomy for aqueductal
and clipping of small unruptured aneurysms. Both general anesthesia stenosis,113 fourth ventricular outlet
and monitored anesthesia care are compatible with outpatient neu- obstruction,114 or pineal neoplasm115
rosurgical procedures. Lesions need to be easily accessible to a MIN Septostomy116
technique and patients need to be selected carefully to assure success. Endoscopic ventriculoperitoneal
OSA, absence of home care support, and significant medical comor- shunts117,118
bidities were exclusion criteria for the performance of outpatient Colloid cysts Endoscopic removal119
unruptured cerebral aneurysm clipping.134 Most complications (new Arachnoid cysts Fenestration120
Hematoma Endoscopic drainage for subdural,121,136
neurological deficits and seizures) occur within the first 6 hours, thus
intracerebral,122 epidural137
necessitating a close postoperative observation period. Patient edu-
Brain abscess Endoscopic drainage123
cation and attention to home support are critical. With these guide- Image-guided stereotactic drainage124
lines, minimally invasive cranial surgery can be performed safely on Pituitary tumor Endoscopic transnasal
an outpatient basis.135 hypophysectomy125
MIN comes with its own set of considerations and concerns that must Periventricular tumor Biopsy126
be anticipated by the anesthesiologist. In step with technological advances Cranial synostosis Endoscopic strip craniectomy127
in imaging, computing, and optics, the field of MIN has evolved rapidly. Cerebral aneurysm Endoscope-assisted microsurgery128
The potential benefit of MIN results from enhanced patient safety, shorter Acoustic neuroma Endoscope-assisted microsurgery
hospital stay, reduced invasiveness, and lower postoperative morbidity Arteriovenous Endoscope-assisted surgery132,133
malformation
compared to open surgical procedures. Table 17.1 describes the most com-
Parkinson’s disease,134 Deep brain stimulation
mon indications for cranial disease. General goals for anesthetic manage-
behavioral disor- (uses stereotaxis)
ment are to: (1) keep the patient immobile to prevent injury and ensure ders,135,138 essential
targeting accuracy in neuronavigation, (2) ensure safe, rapid emergence tremor139
from anesthesia for prompt neurologic assessment, (3) minimize post- Spinal disease Syringostomy140
operative complications, (4) facilitate intraoperative neurophysiologic (syringomyelia, palmar Transthoracic endoscopic
monitoring and neuronavigation techniques, and (5) collaborate in the hyperhidrosis, disk sympathectomy141
management of intracranial pressure (ICP). herniation, spine Arthroscopic microdiskectomy142
Whether the procedure requires general anesthesia or MAC, pre- deformities, instability, Lumbar diskectomy143
operative evaluation should be as thorough and comprehensive as tumors) Video-assisted thoracoscopic
surgery144,145
for other surgical procedures. Immobility is crucial to the success of
Kyphoplasty146
minimally invasive procedures. The choice of neuromuscular blocking
Spinal fusion147
drugs and the methods for monitoring their effects are critically impor- Tumor resection148–150
tant, because immobilization must be complete yet also rapidly revers- Spine trauma151
ible. Once the patient has entered stereotactic space (i.e., the patient’s *
Superscript numbers refer to references in this chapter.
anatomic location has been registered against and is aligned with the
previously obtained brain images), any movement would render neuro-
navigation targeting inaccurate and would require reregistration. Head
fixation is required for some procedures, and movement during use
of head pins must be scrupulously avoided. As many MIN procedures pathologies, including tumors, hemorrhage, hematomas, and cysts.
rely on the accuracy of neuronavigation technology, the use of osmotic Other uses include craniosynostosis, trigeminal nerve procedures, and
agents and hyperventilation are avoided so as to keep the intracranial CSF leaks. Visualization of the surgical site is achieved with burr-holes
relationships consistent with the imaging sources on which neuronavi- instead of open craniotomy. The endoscope is passed through the burr
gation is based. Some neuronavigation techniques depend on infrared hole and the frontal cortex to reach the ventricle, as shown in Fig.
cameras that pinpoint the surgical location to the previously acquired 17.4. However, the use of saline or lactated Ringer's solution and the
CT or MRI images. Because pulse oximeters use infrared light at over- direct and indirect pressure of irrigation present their own challenges.
lapping frequencies, interference with pulse oximetry occur. This can Neuroendoscopy is most commonly used for treatment of noncom-
be eliminated by completely covering the pulse oximeter probe, which municating hydrocephalus with an endoscopic third ventriculostomy
shields it from infrared camera interference. Procedures are of variable (ETV). During ETV, the floor of the third ventricle is fenestrated to
duration, depending on the neuropathology being treated. It is gen- create flow between the ventricle and the subarachnoid space (see Fig.
erally more difficult for the anesthesiologist to keep track of surgical 17.4). The surgical risk of ETV is approximately 5% for significant mor-
progress in MIN procedures than during conventional craniotomy. The bidity,138 with an overall success rate of 60–90%.139,140 Intraoperative
anesthesia team must maintain a dialogue with surgical team members mortality is reported at 0–1% for neuroendoscopy in general. However,
about the progress of the procedure while also closely observing the the incidence of intraoperative and postoperative complications ranges
surgical video screens, the surgical field, and neurologic and anesthetic widely from 5% to 30%.141–143
monitoring systems.
Preoperative Concerns
Neuroendoscopy It is common to see patients presenting with signs of increased intra-
Neuroendoscopic surgical procedures may be indicated for the cranial pressure for neuroendoscopic procedures. Depressed mental
treatment of hydrocephalus and intraventricular or periventricular status, confusion, headache, nausea, and vomiting are all common in
Significant increases in intracranial pressure and direct stimulation or

damage to the hypothalamus by the irrigating jet may explain these
cardiovascular phenomena. They usually improve with the release of
Lateral ventricle the CSF or \drainage of the irrigation solution. However, severe bra-
dycardia leading to cardiac arrest requiring cardiopulmonary resus-
MB citation has also been reported.150,151 Stimulation of the hypothalamus
MB
posteriorly causes an increase in heart rate and blood pressure. While
stimulation in the preoptic area, decreases heart rate and blood pres-
Ventriculostomy sure. Hypothalamic stimulation and traction, as well as significant
opening increases in ICP, may be the cause of bradycardia during ETV due to
a Cushing-type response.152 Hypothalamic injury can occur and may
lead to syndrome of inappropriate antidiuretic hormone secretion
(SIADH) or diabetes insipidus.
Third ventricle
The temperature, type, and volume of irrigating solutions can have
Fourth ventricle significant effects. Cold irrigation can cause bradycardia. Lactated
Fig. 17.4 Endoscopic third ventriculostomy and endoscopic Ringer’s solution warmed to body temperature has been used most
view of the floor of the third ventricle. MB, mammillary body. commonly, although it can result in hyperkalemia.152 Warm nor-
mal saline irrigation has been advocated153 but may cause CSF aci-
dosis, with a pH reduction greater than 0.2, at volumes larger than
patients with hydrocephalus, especially if the latter develops acutely. 500 mL.154 Hypothermia has been described in small children due to
Nausea and vomiting present obvious pulmonary aspiration risks, as the exchange of CSF and irrigating fluid as well as surface tempera-
well as the possibility of metabolic derangements. Preoperative investi- ture loss due to wet drapes from drained irrigation.143 Intraoperative
gation should include a history and physical examination focusing on bleeding may occur and obfuscate the operative field, and basilar and
signs and symptoms of increased intracranial pressure or other neuro- perforating artery injuries have resulted in intraoperative death.141,155
logic sequelae and testing for electrolyte abnormalities. Preoperative The anesthesiologist should always be prepared for conversion to
sedation should be avoided, as patients may already have an altered open craniotomy. In two case series, venous air embolism occurred
or depressed mental status. Ventricular shunt revision is commonly in 0.35–4% of patients. None of the reported episodes of venous air
performed to relieve hydrocephalus in patients with prior shunt place- embolism in the minimally invasive surgery cases resulted in hemo-
ments. Less often, shunt revision aims to correct overdrainage of CSF. dynamic compromise.147,156 Pneumocephalus and transient hernia-
If central venous access is planned, knowledge of the location of these tion syndromes due to CSF drainage and irrigation have also been
shunts and tubing is essential to avoid puncture during central line reported.138
placement.
Postoperative Concerns
Intraoperative Concerns Patients undergoing neuroendoscopic procedures should be monitored
Despite the minimally invasive nature of neuroendoscopy, general closely in the postoperative period for complications associated with
anesthesia remains strongly advocated for to ensure immobility, increased intracranial pressure, hypothalamic injury, cranial nerve II
although local anesthetic with sedation has been described.144 After and IV injury, and metabolic derangements.157 Delayed emergence is
induction of general anesthesia, the patient may be positioned in neu- commonly seen.158 The most common postoperative complication is
rosurgical head pins or a “horseshoe” headrest. A common operating transient neurologic deficit, which occurs in 8–38% of patients.141,142
room configuration is shown in Fig. 17.5. Invasive arterial pressure Hyperkalemia,152 confusion, transient pupillary dysfunction, tran-
monitoring is strongly advised due to possible perturbations of hemo- sient hemiplegia, and memory loss,141,142,159 possibly from injury of the
dynamics during neuroendoscopy and potential rupture of the basilar fornix, are among postoperative complications. High pressure levels
or perforating arteries during the fenestration of the third ventricu- inside the endoscope are reportedly associated with delayed arousal
lar floor.145–147 The anesthesiologist must be aware of the possibility of and a higher rate of postoperative complications.142 Careful control of
expansion pneumocephalus with N2O and avoid its use. Delayed emer- irrigating pressure may reduce postoperative risk and avoid delayed
gence has been reported to occur in up to 15% of patients undergo- emergence. Respiratory arrest has been reported in infants during the
ing neuroendoscopy.142 Burr hole incision sites are small and are often first hours after neuroendoscopy, necessitating the use of apnea moni-
injected with local anesthetic by the surgeon, so postoperative pain is tors.160 Postoperative monitoring of serum electrolyte levels is war-
not a significant problem. ranted because diabetes insipidus and hypothalamic dysfunction have
Despite the minimal brain penetration required with the use of an been reported.141,159,161 Late infectious complications, such as meningitis
endoscope, a number of potentially serious complications can occur. and ventriculitis, have significantly contributed to morbidity; there-
The pressure generated by the continuous irrigation system can cre- fore patients should be monitored for signs of central nervous system
ate significant intraoperative events owing to intracranial circulatory infection.141,143
insufficiency.148 Mean arterial pressure should be carefully monitored
to ensure adequate cerebral perfusion pressure. Measurement of Endoscopic Transsphenoidal Hypophysectomy
intracranial pressure through the endoscope or other methods is rec- Anesthetic and surgical considerations for hypophysectomy are dis-
ommended as it has been shown to correlate with ICP and cerebral cussed in Chapter 19.
perfusion pressure.142,148 Hemodynamic effects of neuroendoscopy may
range from mild, transient dysrhythmias and hypotension to cardiac Endoscopic Strip Craniectomy
arrest. Cardiovascular instability, bradyarrhythmias, and ventricu- The development of endoscopic surgery has advanced markedly, espe-
lar irritability are most commonly reported, occurring in 28–32% of cially for the treatment of craniosynostosis in infants. The concept of
patients,142,143 with bradyarrhythmias occurring in as many as 41%.149 using minimally invasive surgery to remold the skull is not new and
Instrument table
N
S S
Anesthesia
machine
Arm support
Stereotactic
navigation
system IV pole
Camera
Fig. 17.5 Operating room setup for functional neurosurgery procedures. A, anesthesiologist; N, nurse; S, surgeon.
dates back to the early part of the 20th century, when neurosurgeons stay, in addition to the use of fewer blood products, and the elimi-
performed strip craniectomies to remove abnormal, premature suture nation of internal plating systems, all add up to a decrease in overall
fusions. Today, the endoscopic cranial vault remodeling technique cost of the procedure.
involves more than a simple strip craniectomy through a small endo- One disadvantage of endoscopic procedures is that the surgery
scopic port. It is a wide sutural excision combined with lateral oste- needs to be performed at a young age, preferably before 4 months. The
otomies and osteectomies that allow for normalization of the cranial reason is that the cranial bones in children this young are thin enough
skeleton. Endoscopic strip craniectomy is a minimally invasive method to allow osteotomies with endoscopic shears. In addition, there is less
of remolding the cranial vault in children with craniosynostosis, which bleeding associated with the bone cutting because the cancellous space
involves premature fusion of one or more cranial sutures. It is most between the two cortices of the skull is still underdeveloped. Lastly,
commonly used to treat sagittal synostosis and performed on children endoscopic cranial vault remodeling involves the added expense of the
under 6 months of age, although other suture fusions can be treated. cranial orthotic molding helmet as well as the prolonged and frequent
The fused suture is excised from within the cranial vault under endo- postoperative follow-up (8–15 months) to ensure that cranial form is
scopic visualization followed by parietal “barrel stave” osteotomies. normalizing.
Postoperatively, an orthotic molding helmet is used to promote normal Preoperative Concerns. Patients presenting for endoscopic strip
development of the calvarium. craniectomy are usually younger than 4 months. Ideally, the surgery
Endoscopic cranial vault remodeling has several distinct advan- should be scheduled past the physiologic nadir of the infant’s hemato-
tages over conventional reconstruction techniques. The endoscopic crit value, which occurs between the second and third month of life, to
approach reduces scarring and alopecia risks, operative time, blood reduce the need for transfusion. Some centers give recombinant eryth-
loss, and length of hospital stay. Mean operative time is gener- ropoietin at a dose of 600 IU/kg/week for 3 weeks prior to surgery to
ally less than 1 hour, compared with approximately 3 hours for the increase the preoperative hematocrit.164 Preoperative laboratory analy-
conventional open approach. Instead of a typical 5-day postopera- sis should include a baseline complete blood count. Although blood
tive course with an intensive care admission, patients undergoing loss and blood transfusions are significantly decreased with endoscopic
endoscopic surgery may be discharged on the first postoperative surgery, there is always the risk of significant blood loss due to injury
day.162 More than 90% of patients undergoing open calvarial surgery of a cerebral sinus. A blood specimen for type and screen can be sent
require transfusion,163 compared with 10% of those receiving endo- on the day of surgery after the placement of an intravenous cannula. If
scopic surgery.162 A shorter operative time and reduced hospital the patient has received previous blood transfusions and has potential
antibody formation, a blood cross-match should be obtained before the right mainstem bronchus and then pull back until bilateral breath
start of surgery. sounds are appreciated. Endotracheal tube depth and bilateral breath
Craniofacial anomalies may be associated with cardiac and other sounds should be noted prior to positioning and rechecked when
congenital or chromosomal abnormalities, including Apert syndrome, the patient is in the final surgical position. Appropriate intravenous
Crouzon syndrome, Pfeiffer syndrome, Saethre–Chotzen syndrome, access should be achieved with the understanding that the anesthesi-
and Muenke syndrome.165 Awareness of coexisting congenital anoma- ologist’s access to the patient is limited. Arterial line placement is at
lies is important for appropriate intraoperative management. Patients the discretion of the anesthesiologist who will take into consideration
may have a difficult airway, cervical spine abnormalities, cardiovascular the patient’s medical risk factors and those represented by the surgical
problems, altered respiratory mechanics, gastroesophageal reflux, and procedure. Pressure points must be padded, and pressure must not
other organ involvement. Undiagnosed OSA syndrome might coexist be placed on bony prominences or vital structures such as the eyes.
and add to the perioperative morbidity in these children.166 Butler and Owing to the small size of the infant, minimal shifting of the position
associates167 provide an excellent review of complications with recom- can cause significant changes in pressure points. In two series, venous
mended presedation evaluations and a checklist of potential problems air embolism occurred in 0.35–4% of patients. None of the earlier
for common and uncommon genetic disorders. Associated cervical reported episodes of venous air embolism in the minimally invasive
spine abnormalities are of particular importance, as patients may be in surgery cases resulted in hemodynamic compromise.147,156 Although
the “sphinx” or “sea-lion” position for endoscopic strip craniectomies. the risk of venous air embolism is considerably less than with open
This is a modified prone position (Fig. 17.6) with the neck extended procedures, patients should be monitored with precordial Doppler
and supported by an inflatable bag. Neck extension results in cephalad ultrasonography probe throughout the case.
movement of the endotracheal tube, which can lead to displacement of Postoperative Concerns. No infections, dural sinus tears, CSF
its tip into the glottis or above.168 The sphinx position may be contra- leaks, or neurologic injuries were reported in a representative series of
indicated in patients with cervical spine anomalies. If a difficult airway patients undergoing endoscopic strip craniectomy.162 Although care-
is anticipated, fiberoptic intubation equipment and an assortment of ful monitoring is needed in the immediate postoperative period, many
LMAs should be available. Pretreatment with glycopyrrolate (6–10 μg/ patients are discharged within 24 hours.
kg) as an antisialagogue may be indicated. Patients receiving anticon-
vulsants or other therapeutic agents should continue to take them dur- Other Applications for MIN
ing the perioperative period. Anticonvulsant levels should be checked MIN approaches include treatment of chronic subdural hema-
for optimal dosing. toma,136,171 acute epidural hematoma,137 and cerebral aneurysm.172 MIN
Intraoperative Concerns. Issues of greatest importance in strip for acute epidural hematoma involves digital subtraction angiography
craniectomy include airway control, patient positioning, venous air to embolize the bleeding point from the middle meningeal artery. It is
embolism, elevated intracranial pressure, and possible rapid blood followed by placement of burr holes for catheter drainage augmented
loss. Although many patients experience minimal blood loss (espe- by injection of urokinase to help lyse the clot. Only local anesthesia with
cially with repair of fused lambdoid sutures), the anesthetic team sedation was required for these procedures despite substantial hema-
should be prepared for significant intraoperative bleeding, such as toma volumes and degree of midline shift. Treatment of chronic sub-
from injury to the dural sinus or emissary veins. Except for lambdoid dural hematoma with middle meningeal artery embolization has been
sutures, the transfusion rate is about 50%; metopic craniosynostosis accomplished with either general anesthesia or MAC.136 The anesthetic
repair is associated with the highest blood loss.169 Preoperative hemo- considerations for endoscopic-assisted cerebral aneurysm clipping are
globin and hematocrit values, type and cross-match, and availability similar to those of conventional neurosurgical approaches. Endoscopic
of packed red blood cells are, therefore, indicated. Inhalation induc- indocyanine-green angiography may be used, which can transiently
tion is usually performed and reliable intravenous access is obtained. affect pulse oximetry and near-infrared spectroscopy readings.173
Brain volume control is achieved with mannitol and hyperventila-
tion.169 Brain volume control is important as endoscopic techniques Robotic Operating Surgical Assistant Neurosurgery
require room to maneuver so as to allow dissection of dura from Robotic-assisted cranial neurosurgery is principally used for improved
the fused suture. Intracranial hypertension is particularly common targeting of lesions and anatomic structures. For example, it has been
in patients with complex craniosynostoses.170 After endotracheal used to optimize approach trajectories and minimize traction on brain
tube placement, it is important to be aware of possible endotracheal structures during endoscopic third ventriculostomy.174 Anesthetic
tube repositioning with extension of the neck during positioning. implications for robotic surgery are not different from those for other
Endobronchial intubation or accidental extubation during position- MIN procedures, although robotic procedures increase the duration
ing is possible.168 One can advance the endotracheal tube into the during the early part of the experience curve.
Prone position
with neck extension
Arm support
Fig. 17.6 Positioning for endoscopic strip craniectomy.
Functional Neurosurgery and Deep Brain Preoperative Concerns

Stimulation The term minimally invasive surgery does not inherently confer low
perioperative risk. Blood loss, perioperative physiologic stress, and
Surgical and anesthetic considerations for deep brain stimulation are postoperative complications vary significantly with the type of mini-
discussed in Chapter 18. mally invasive spinal surgery performed and with the patient’s comor-
bid status. Thoracoscopically and laparoscopically assisted scoliosis
MINIMALLY INVASIVE SPINE SURGERY correction, multilevel spinal fusions, and thoracic corpectomies should
still be considered intermediate- to high-risk procedures. A recent
Minimally invasive spine surgery encompasses a large group of pro- addition has been thoracoscopically assisted anterior vertebral body
cedures that offer an alternative to open reconstructive surgery, in an tethering.192 This surgical technique gradually corrects the deformity
effort to reduce surgical trauma and improve outcomes. Continued by tethering the spine and reshaping vertebral bodies using a screw
advancements in microsurgery, endoscopy, and percutaneous tech- and cable combination. Should VATS be selected for the surgical
niques have diversified the possible approaches to the treatment of a approach, patients must be evaluated and prepared for one-lung ven-
number of spinal pathologies with a goal to reduce treatment morbid- tilation. Pulmonary function test may be indicated. In patients with
ity. Common indications are listed in Table 17.1. chronic kyphoscoliosis restrictive lung disease and associated con-
genital anomalies may be present and should be thoroughly evaluated.
Benefits Some neuromuscular diseases predispose to a higher risk of malig-
Transluminal, percutaneous, and “key-hole” approaches have contin- nant hyperthermia. Coagulation abnormalities, fibrotic lung disease,
ued to evolve, allowing safer and less invasive access to surgical sites. pulmonary hypertension, and cervical spine pathology may be seen
Smaller incisions are possible through the extensive use of operating in patients with spine disorders related to connective tissue diseases.
microscope, fluoroscopic guidance, stereotactic neuronavigation, and Children with idiopathic scoliosis should be screened for other con-
special instruments such as tubular retractors, disk space dilators, and genital abnormalities including cardiac.
special cage devices for structural support.175 Endoscopic approaches
reduce the amount of muscle dissection required for access to the
spine and are associated with less blood loss. They decrease postop- Intraoperative Concerns
erative pain, recovery time, and hospital stay.176 Medical complications Patients are usually placed in the lateral position for transthoracic spinal
of minimally invasive spine surgery are reduced compared to open surgery. The operating room arrangement for VATS is shown in Fig. 17.7.
approaches.177 Because the lower extremities are positioned below the level of the heart,
venous return may be restricted, predisposing to hypotension. One-lung
Anesthetic Technique ventilation facilitates the surgeons’ view through the endoscope, which
Neuraxial and general anesthesia are both commonly used and studied would otherwise be obliterated by the nondeflated lung. The possibility
for spine surgery. Spinal anesthesia for lumbar spine surgery is virtually of prolonged one-lung ventilation should be anticipated during anterior
free of the risk of post-dural-puncture headache and reduces postpro- release and multiple-level spine fusions. Endoscopic visualization of lung
cedural pain, nausea, and bleeding.178 In one study,179 shorter operative reexpansion at the end of the procedure can be helpful.192 Nitrous oxide is
times, less nausea and use of opioids, and less urinary retention were avoided. Either a double-lumen endotracheal tube or a bronchial blocker
demonstrated in patients undergoing lumbar spine surgery. Another can be used to isolate and deflate the nondependent lung. Double-lumen
study180 demonstrated lesser use of opioids and less nausea in epi- tubes may be difficult to place in patients with significant thoracic kyphosis
dural and combined spinal epidural than with spinal anesthesia alone. because of tracheobronchial distortion.
Epidural anesthesia had been shown to be reliable, safe, and cost effec- Combined anterior-posterior fusions may require changing the
tive.181 Specifically applied in minimally invasive transforaminal lumbar double-lumen tube to a single-lumen tube prior to placing the patient
interbody fusion (TLIF), spinal anesthesia also reduces operative time, in the prone position. This position change creates an inherent risk
postoperative pain, and time to first ambulation.182 However, motor of loss of the secured airway. The alternative is to withdraw the bron-
examination cannot be readily or reliably performed with electrophys- chial portion of the double-lumen tube into the trachea, but it has the
iologic monitoring under neuraxial anesthesia. Contraindications to disadvantage of potential tube malposition during prone ventilation.
neuraxial anesthesia would include coagulopathy, patient refusal, and Therefore we prefer to use a bronchial blocker or change to a single-
lesion at the site of injection. Currently, both regional and general anes- lumen tube using a tube exchanger. Anesthetic and muscle relaxant
thesia should be considered safe and effective for lumbar spine surgery.
Regional anesthesia may be a better choice in patients at higher risk for
complications of general anesthesia.183 TABLE 17.2 Comparison of Video-Assisted
Thoracoscopic Surgery (VATS) With Open
Video-Assisted Thoracoscopic Surgery Thoracotomy
Video-assisted thoracoscopic surgery (VATS) is used for intrathoracic
VATS Thoracotomy
procedures of the lung and surrounding tissue. It has also been applied
for treatment of thoracic disc disease,184 spondylitis,185,186 anterior tho- Operating time (min) 205 (80–542) 268 (210–690)
Blood loss (mL) 327 (125–1500) 683 (250–1200)
racic spine release, fusion for scoliosis/kyphosis or spine trauma,185,187
Chest tube (days) 1.5 (0–6) 3.5 (2.8–9.1)
and thoracic sympathetic ganglionectomy for hyperhidrosis.188 The Narcotics (mg/day) 3.7 (1.5–15) 20.4 (5–60)
advantages of the minimally invasive approach to the spine are less Hospital stay (days) 6.5 (2–24) 16.2 (5–34)
surgical time,189 less acute postoperative pain, improved postoperative Pulmonary dysfunction 7% 33%
respiratory function, and faster functional recovery compared with Neurological 16% 50%
conventional procedures.190 Table 17.2 compares VATS with open tho- deterioration
racotomy. Robotic-assisted thoracic surgery (RATS) techniques have From Rosenthal D, Dickman CA. Thoracoscopic microsurgical excision of herni-
been introduced that may offer improved surgical precision.191 ated thoracic discs. J Neurosurg. 1998;89:224–235.
Video
Anesthesia
monitor
machine
IV pole
Instrument
N table
S S
Fig. 17.7 Operating room setup for video-assisted thoracoscopic spine surgery. A, anesthesiologist; N, nurse; S, surgeon.
Postoperative Concerns
TABLE 17.3 Risk of Blood Loss in Video-
Assisted Thoracoscopic Surgery* Intercostal neuralgia, pneumothorax, and Horner’s syndrome have
been reported after thoracoscopic procedures.200 Pulmonary complica-
Author Blood Loss Indication tions such as atelectasis may prolong hospitalization.201 Proper atten-
Singh et al.188 418 +/− 191mL Tubercular spondylitis tion should be directed to appropriate chest-tube management and
Liu et al.197 50–200mL Anterior spine release assurance of good pulmonary toilet. Chylothorax, hemidiaphragm
(scoliosis) and pericardial penetration, tension pneumothorax, and long thoracic
Kapoor et al.198 497 +/− 302mL Tubercular spondylitis nerve injury have also been reported.185
Liu and Kit199 175–266mL Thoracic scoliosis
correction Kyphoplasty and Vertebroplasty
Superscript numbers refer to references in this chapter.
*
Kyphoplasty and vertebroplasty are similar minimally invasive per-
cutaneous procedures that have shown short-term benefits in pain
relief202 in patients with osteoporotic and osteolytic fractures of the
thoracic and lumbar vertebrae. The procedures reduce pain through
restrictions are required for somatosensory and motor evoked poten- cementing of the fractured vertebrae with polymethylmethacrylate
tial monitoring.193,194 This can make it difficult to avoid patient coughing cement to reduce movement of bony fragments. Kyphoplasty is slightly
from carinal stimulation due to the double-lumen tube. Remifentanil more invasive than vertebroplasty in that it uses balloon tamps to reex-
has been shown to improve depth of anesthesia and tolerance of the pand the vertebrae to their original height and to create a potential
endotracheal tube195 and to prevent patient movement in the absence space prior to cement application.
of neuromuscular blockade.196 The risk of patient movement during
VATS or RATS must be balanced against the gain from neurophysi- Preoperative Concerns
ologic monitoring; it may be possible to reduce risk of movement by While these procedures may present low surgical risks, significant
restricting avoidance of neuromuscular blockade only for critical mon- comorbidities are associated with these conditions. The older adult
itoring periods. The anesthetic and surgical teams must be prepared patient population often chosen for these procedures may present with
for unintended surgical injury to large intrathoracic vessels, such as the a broad spectrum of advanced illnesses as well as specifically associated
azygos vein. The prophylactic placement of arterial and venous access pathologies such as metastatic cancer, steroid-dependent pulmonary
lines is advocated, and blood should be available. Risk of blood loss or inflammatory diseases, and severe osteoporosis. Careful preop-
with various VATS procedures is described in Table 17.3. erative evaluation and preparation are, as always, recommended. In
An alternative procedure involves a combined posterior and lateral patients with pulmonary inflammatory disease, pulmonary function
chest approach in the prone position.197 This technique entails surgical should be optimized prior to surgery and stress-dose steroids may be
preparation of the right chest as well as the back for optimal surgical required for patients on long-term steroid treatment. Chronic pain is
access. Lung isolation is not necessary because the lung falls away from a common comorbidity in many of these patients. Opioid tolerance
the surgical endoscope, aided either by an atmospheric pneumothorax should be anticipated and adequate intraoperative and postoperative
or by mild tension pneumothorax induced by low-pressure insuffla- pain-control measures planned.
tion with CO2. Insufflation should be performed slowly to avoid sud-
den decreases of venous return to the thorax.191 Advantages include Intraoperative Concerns
shorter procedure times, because placement of double-lumen tracheal Kyphoplasty and vertebroplasty may be performed under MAC or general
tube and confirmatory bronchoscopy are avoided, as is the reposition- anesthesia. The anesthesiologist determines the patient’s ability to undergo
ing from the lateral to the prone position. Furthermore, a lower rate of general anesthesia safely; patients who are too frail should be consid-
pulmonary complications has been observed.198 ered for MAC. During a MAC, dexmedetomidine may be preferable to
remifentanil as it results in fewer respiratory events and hemodynamic for lumbar spine surgery has been studied and shown to have shorter
effects.203 Local anesthesia with dexmedetomidine sedation is associated operative times; less bleeding, postprocedural pain, opioid use, and
with good patient satisfaction and fewer transient side effects such as nausea; and no postdural puncture headache risk. Less opioid use and
hypoxemia and sore throat.204 Such sedation was needed for better patient nausea were also seen in epidural and combined spine epidural tech-
comfort compared with local anesthesia alone.205 Additional consider- niques than with just spinal anesthesia. Coagulopathy, a lesion at the
ations for the choice of anesthetic include the patient’s ability to tolerate the intended site, or patient refusal are contraindications to a neuraxial
prone position for the duration of the procedure, tolerance of limb position technique. Motor examination cannot be reliably performed under
in patients with osteoarthritis or rheumatoid arthritis, whether the patient neuraxial anesthesia. Isobaric bupivacaine (0.5%) with epinephrine
is a good candidate for monitored sedation, and access to the patient’s air- and fentanyl has been used successfully with minimal cardiovascular
way. General anesthesia was associated with shorter operative time, and effect.
better radiologic measures for deformity correction.206 But cardiopul- Postoperative pain requirements after microdiskectomy depend
monary risks associated with general anesthesia should be considered.207 significantly on preoperative pain severity.218 A combination of anes-
Positive pressure ventilation may also reduce cement leakage.208,209 A light thetic techniques, utilizing spinal anesthesia, supplemental epidural
anesthesia regimen using short-acting anesthetic agents is appropriate, clonidine, and subcutaneous bupivacaine administered at the inci-
aiming at rapid recovery to facilitate same-day discharge. sion site,219 may be of further benefit to improve postoperative pain
Padding and gentle positioning are crucial in patients with severe control.
osteoporosis. Skin lacerations and rib fractures have been reported in Percutaneous hemonucleolysis with the use of papain as well as
these patients during prone positioning.202 The procedures require only blind nucleotomy and laser disk decompression has largely fallen out
a minimal incision and are generally well tolerated despite the acute of favor because of allergic complications, neurovascular injury, and
illness level of this patient population. Arterial oxygenation decreases transverse myelitis.220 Instead, arthroscopic technology, using instru-
during vertebroplasty under sedation; the decrement in partial pres- ments that can be visualized, and endoscopic fiberoptic techniques are
sure of oxygen is related to the number of spinal segments treated.210 being developed and show considerably greater promise.
It is not clear whether this relationship is the result of higher seda-
tive doses or a greater amount of cement used. Rare occurrences of Minimally Invasive Spinal Fusion
symptomatic pulmonary embolism and intraoperative death have been Minimally invasive techniques for spinal fusion include TLIF, extreme
reported during vertebroplasty.211,212 lateral interbody fusion (XLIF), and the less commonly used anterior
lumbar interbody fusion (ALIF) and axial lumbar interbody fusion
Postoperative Concerns (AxiaLIF).
Patients are commonly discharged on the day of surgery; however, TLIF procedures are usually performed in the prone position. The
those with end-stage pulmonary disease or severe perioperative pain incision is small, facilitated by microscopic technique, computer or
may warrant closer monitoring and a hospital stay of up to 24 hours. precise fluoroscopic localization, and tubular retractors. The surgeon
begins by performing a total facetectomy, after which annulotomy and
Endoscopic Cervical Diskectomy and Foraminotomy diskectomy are accomplished. After the disk space is freed up, it is filled
Anterior microforaminotomy has long been in use for radiculopathic with morselized cancellous bone or a metal cage for structural support.
conditions and has now been advocated to replace anterior verte- Autologous bone from the iliac crest may be harvested. Stabilization
brectomy for removal of tumors located anterior to the spinal cord. may be augmented through the use of limited open or percutaneous
Minimally invasive endoscopic cervical foraminotomy (MEF) is being pedicle screw fixation.
increasingly used for cervical root decompression and results in less XLIF is performed in the lateral position with the operating table
blood loss, shorter hospitalizations, and a much lower postoperative flexed at the interspace of interest. The surgical approach entails risk
pain medication requirement than open cervical laminoforaminot- of injury to the peritoneal cavity, pleural cavity, great vessels, and
omy.213 Postoperative pain is minimal. Neither bony fusion nor a cer- lumbosacral plexus. To deal with the latter, intraoperative electro-
vical brace is needed, and patients undergoing MEF are kept in the myographic monitoring may be used, which limits the use of neu-
hospital only overnight.214 romuscular blockade. If the interspace to be treated is thoracic, the
The prone or sitting position may be used for posterior cervical MEF. potential for development of intraoperative pneumothorax should be
The sitting position decreases epidural venous engorgement and has considered.
been shown to entail less blood loss than MEF performed in the prone Transperitoneal or retroperitoneal laparoscopic approaches may
position215 but obviously confers the potential risk of venous air embo- still be used to access the lumbar spine.221 They have been used success-
lism. Other potential complications of MEF include the risk of dural fully for both lumbar diskectomy and ALIF. The laparoscopic approach
puncture or nerve root injury with guidewires.216 Injury to the sympa- to the lumbar spine requires steep head-down positioning and the use
thetic chain causing postoperative Horner’s syndrome can occur during of shoulder braces, which can cause brachial neurapraxia if they are
anterior cervical foraminotomy. However, the intraoperative complica- placed too medially. The patient’s arms may need to be crossed and
tion of most concern with this approach is injury to the vertebral artery placed on the anterior chest. The usual precautions for laparoscopic
during drilling of the uncovertebral joint.214 The risk of arterial injury is procedures must be followed, and potential problems anticipated,
highest at the level of C6–C7. Vertebral artery injury requires intraop- such as pulmonary barotrauma, CO2 embolism, hypercapnia, and
erative control of bleeding and postoperative angiographic assessment to right main-stem intubation. The bifurcation of the iliac vessels occurs
assess for dissection or pseudoaneurysm formation.216 around the level of the L4–L5 interspace; thus, an anterior laparoscopic
approach to the lower lumbar disk spaces requires the mobilization of
Microdiskectomy and Percutaneous Disk Space these vessels, raising the risk of laceration. Iatrogenic injury to bowel
and superior hypogastric plexus has also been reported. Surgeons have
Treatment reported prolonged surgical times, which has led some to prefer a
Both general anesthesia and neuraxial techniques may be used for mini-open procedure to laparoscopic assistance.222 These procedures
open lumbar microdiskectomy.217 As noted above, spinal anesthesia have become less favored.
Newer developments have made an axial approach to the lower S U M M A RY

lumbar spine possible. Axial approaches to spinal fusion are thought
to have substantial biomechanical advantages.175 This approach affords Awake craniotomy is a safe, effective technique for treatment of certain
the surgeon access to the spine via the presacral space through a key- lesions that reduces morbidity and length of hospital stay and may pro-
hole incision, avoiding the risks of body cavity, ligamentous, muscle, vide better overall patient outcomes when eloquent cortex is involved.
and neural plexus injury inherent in ALIF, TLIF, and XLIF. The patient Anesthetic techniques for awake craniotomy vary among institutions
is positioned prone, and extensive use of fluoroscopy and special but generally feature a period of sedation or general anesthesia fol-
instrumentation is required. lowed by an awake phase for mapping and in some cases resection,
Perioperative anesthetic management for spinal fusion includes after which the patient is sedated again for the remainder of the pro-
thorough preoperative evaluation and optimization. For example, cedure. Awake craniotomy may be used for tumor resection, epilepsy
anemia should be corrected. Preoperative administration of acet- surgery, as well as DBS placement. In the case of DBS insertion, the
aminophen and gabapentin is recommended as part of a multi- patient is sedated only when absolutely necessary so that awake testing
modal analgesic regimen. The goals of anesthetic management for optimal lead placement can be performed.
should include facilitating the monitoring of intraoperative spinal Minimally invasive techniques have continued to improve vari-
cord monitoring. Incorporating ketamine and dexmedetomidine ables such as recovery periods, operative time, length of hospital
into the anesthetic plan assists with providing additional pain con- stay, and patient discomfort. Continuing advances in technology and
trol and the latter is associated with a lower incidence of postopera- technique allow for a variety of procedures that may be performed
tive nausea and vomiting (PONV).223 When compared to systemic with minimally invasive surgery. Anesthetic management will vary
morphine, intrathecal morphine was found to reduce postopera- by procedure and patient, but the anesthesiologist contributes to the
tive pain, constipation, urinary retention, and length of hospital outcome for the patient through an awareness of the patient’s con-
stay while increasing mobilization after minimally invasive spine dition and comorbidities, an understanding of the procedure and
surgery.224 its possible complications, and a working knowledge of currently
accepted techniques. Further technological advances in visualization
Minimally Invasive Tethered Cord Release and robotic tools will likely continue to advance and evolve in this
Tethered cord syndrome (TCS) is a condition characterized by the field in the coming years.
inelastic attachment of the lumbosacral spinal cord to causal struc-
tures. Tension on the spinal cord produces symptoms including back
pain, lower extremity neurologic findings, and incontinence. Early
REFERENCES
surgical intervention is associated with improved outcome in patients 1. Brown T, Shah AH, Bregy A, et al. Awake craniotomy for brain
with TCS. MIN for TCS has become more commonplace and is asso- tumor resection: the rule rather than the exception? J Neurosurg
ciated with fewer complications when compared to the open lumbar Anesthesiol. 2013;25(3):240–247.
laminectomy approach. Anesthetic considerations include evaluation 2. Rajan S, Cata JP, Nada E, Weil R, Pal R, Avitsian R. Asleep-
for coexisting congenital abnormalities, including trachea-esophageal awake-asleep craniotomy: a comparison with general anes-
and cardiovascular malformations. Furthermore, patients with TCS, thesia for resection of supratentorial tumors. J Clin Neurosci.
especially with attendant myelomeningocele, may be allergic to latex. 2013;20(8):1068–1073.
Anesthetic techniques need to be adjusted to optimize monitoring of 3. Serletis D, Bernstein M. Prospective study of awake craniotomy
the electromyogram with direct nerve stimulation, as well as somato- used routinely and nonselectively for supratentorial tumors. J
sensory evoked potentials.170 Neurosurg. 2007;107:1–6.
4. Blanshard HJ, Chung F, Manninen PH, et al. Awake craniotomy
Robotic-Assisted Spine Surgery for removal of intracranial tumor: considerations for early dis-
Robotic-assisted surgery represents another major technological charge. Anesth Analg. 2001;92:89–94.
advancement that may significantly alter the field of neurosurgery. 5. Peruzzi P, Bergese SD, Viloria A, Puente EG, Abdel-Rasoul M,
It has been employed for screw and rod insertion in spinal surgery, Chiocca EA. A retrospective cohort-matched comparison of
vertebroplasty, tumor resection, and anesthetic nerve blocks. In conscious sedation versus general anesthesia for supratentorial
addition, advancements have allowed for the utilization of neu- glioma resection. J Neurosurg. 2011;114(3):633–639.
ronavigation systems to assist in diskectomies, osteotomies, cor- 6. Purzner T, Purzner J, Massicotte EM, Bernstein M. Outpatient
pectomies, and interbody cage placement. Robotic platforms may brain tumor surgery and spinal decompression: a prospective
be utilized via a minimally invasive percutaneous or a traditional study of 1003 patients. Neurosurgery. 2011;69(1):119–126.
open approach to the spine. The most attractive feature of robotic- 7. Wrede KH, Stieglitz LH, Fiferna A, et al. Patient accep-
assisted neurosurgery is improved accuracy of hardware placement tance of awake craniotomy. Clin Neurol Neurosurg.
and identification of bony anatomy which is often obscured or 2011;113(10):880–884.
altered especially in the setting of revision spinal surgery. These fea- 8. Whittle IR, Midgley S, Georges H, et al. Patient perceptions
tures reduce the likelihood of potentially catastrophic neurovascu- of “awake” brain tumour surgery. Acta Neurochir (Wien).
lar injury and suboptimal hardware placement. In addition, shorter 2005;147:275–277.
surgical times, reduced exposure to radiation, and a decrease in 9. Hagberg CA, Gollas A, Berry JM. The laryngeal mask airway for
surgeon fatigue may be achieved.225 The workflow may be arduous awake craniotomy in the pediatric patient: report of three cases.
initially, but well-trained teams are able to overcome this hurdle. J Clin Anesth. 2004;16:43–47.
The development of more robotic-guided tools should allow for 10. Archer DP, McKenna JM, Morin L, Ravussin P. Conscious-
expansion of the practice and optimize patient outcomes. Robotic- sedation analgesia during craniotomy for intractable epi-
assisted neurosurgery is a growing field and will likely become the lepsy: a review of 354 consecutive cases. Can J Anaesth.
gold standard in the coming years. 1988;35:338–344.
11. Sarang A, Dinsmore J. Anaesthesia for awake craniotomy—evo- before awake functional brain mapping. Anesth Analg.
lution of a technique that facilitates awake neurological testing. 2005;101:502–508.
Br J Anaesth. 2003;90:161–165. 31. Lai YM, Boer C, Eijgelaar RS, et al. Predictors for time to
12. Skucas AP, Artru AA. Anesthetic complications of awake crani- awake in patients undergoing awake craniotomies. J Neurosurg.
otomies for epilepsy surgery. Anesth Analg. 2006;102:882–887. 2021;136(6):1560–1566.
13. Arzoine J, Levé C, Pérez-Hick A, et al. Collaborators of the 32. Keene DL, Roberts D, Splinter WM, et al. Alfentanil medi-
ELGGN. Anesthesia management for low-grade glioma awake ated activation of epileptiform activity in the electrocortico-
surgery: a European Low-Grade Glioma Network survey. Acta gram during resection of epileptogenic foci. Can J Neurol Sci.
Neurochir (Wien). 2020;162(7):1701–1707. 1997;24:37–39.
14. Eseonu Awake craniotomy anesthesia: a comparison of the 33. Shiraki A, Goto W, Fukagawa H, et al. Effects of low-dose remi-
monitored anesthesia care and asleep-awake-asleep techniques. fentanil infusion on analgesic or antiemetic requirement during
World Neurosurgery. 2017;104:679–686. brain function mapping: a retrospective cohort study. Acta
15. Hansen Awake craniotomies without any sedation: Anaesthesiol Scand. 2020;64(6):735–741.
the awake-awake-awake technique. Acta Neurochir. 34. Coursin DB, Coursin DB, Maccioli GA. Dexmedetomidine.
2013;155(8):1417–1424. Curr Opin Crit Care. 2001;7:221–226.
16. Senel FC, Buchanan Jr JM, Senel AC, Obeid G. Evaluation of 35. Rozet I. Anesthesia for functional neurosurgery: the role of
sedation failure in the outpatient oral and maxillofacial surgery dexmedetomidine. Curr Opin Anaesthesiol. 2008;21(5):537–543.
clinic. J Oral Maxillofac Surg. 2007;65:645–650. 36. Souter MJ, Rozet I, Ojemann JG, et al. Dexmedetomidine seda-
17. Klimek M, Verbrugge SJ, Roubos S, et al. Awake crani- tion during awake craniotomy for seizure resection: effects on
otomy for glioblastoma in a 9-year-old child. Anaesthesia. electrocorticography. J Neurosurg Anesthesiol. 2007;19:38–44.
2004;59:607–609. 37. Bekker AY, Kaufman B, Samir H, et al. The use of dexme-
18. Wong JWM, Kong AHS, Lam SY, Woo PYM. High-flow detomidine infusion for awake craniotomy. Anesth Analg.
nasal oxygen in patient with obstructive sleep apnea under- 2001;92:1251–1253.
going awake craniotomy: a case report. A A Case Rep. 38. Bustillo MA, Lazar RM, Finck AD, et al. Dexmedetomidine
2017;9(12):353–356. may impair cognitive testing during endovascular embolization
19. Drummond JC, Iragui-Madoz VJ, Alksne JF, Kalkman CJ. of cerebral arteriovenous malformations: a retrospective case
Masking of epileptiform activity by propofol during seizure report series. J Neurosurg Anesthesiol. 2002;14:209–212.
surgery. Anesthesiology. 1992;76:652–654. 39. Prontera A, Baroni S, Marudi A, et al. Awake craniotomy
20. Girvin JP. Neurosurgical considerations and general methods anesthetic management using dexmedetomidine, propofol, and
for craniotomy under local anesthesia. Int Anesthesiol Clin. remifentanil. Drug Des Devel Ther. 2017;11:593–598.
1986;24:80–114. 40. Elbakry AE, Ibrahim E. Propofol-dexmedetomidine ver-
21. Costello TG, Cormack JR, Hoy C, et al. Plasma ropivacaine sus propofol-remifentanil conscious sedation for awake
levels following scalp block for awake craniotomy. J Neurosurg craniotomy during epilepsy surgery. Minerva Anestesiol.
Anesthesiol. 2004;16:147–150. 2017;83(12):1248–1254.
22. Costello TG, Cormack JR, Mather LE, et al. Plasma levobupiva- 41. Abaziou T, Tincres F, Mrozek S, et al. Incidence and predicting
caine concentrations following scalp block in patients undergo- factors of perioperative complications during monitored anes-
ing awake craniotomy. Br J Anaesth. 2005;94:848–851. thesia care for awake craniotomy. J Clin Anesth. 2020;64:109811.
23. Chowdhury T, Baron K, Cappellani RB. Severe bradycardia dur- 42. Conte V, L´Acqua C, Rotelli S, Stocchetti N. Bispectral index
ing scalp nerve block in patient undergoing awake craniotomy. during asleep-awake craniotomies. J Neurosurg Anesthesiol.
Saudi J Anaesth. 2013;7(3):356–357. 2013;25(3):279–284.
24. Kim SH, Choi SH. Anesthetic considerations for awake crani- 43. Moore TA, Markert JM, Knowlton RC. Dexmedetomidine as
otomy. Anesth Pain Med (Seoul). 2020;15(3):269–274. rescue drug during awake craniotomy for cortical motor map-
25. Suero Molina E, Schipmann S, Mueller I, et al. Conscious seda- ping and tumor resection. Anesth Analg. 2006;102:1556–1558.
tion with dexmedetomidine compared with asleep-awake-asleep 44. Manninen PH, Tan TK. Postoperative nausea and vomiting
craniotomies in glioma surgery: an analysis of 180 patients. J after craniotomy for tumor surgery: a comparison between
Neurosurg. 2018;129(5):1223–1230. awake craniotomy and general anesthesia. J Clin Anesth.
26. Goettel N, Bharadwaj S, Venkatraghavan L, et al. 2002;14:279–283.
Dexmedetomidine vs propofol-remifentanil conscious sedation 45. Fisher RS, Acevedo C, Arzimanoglou A, et al. ILAE official
for awake craniotomy: a prospective randomized controlled report: a practical clinical definition of epilepsy. Epilepsia.
trial. Br J Anaesth. 2016;116(6):811–821. 2014;55(4):475–482.
27. Silbergeld DL, Mueller WM, Colley PS, et al. Use of propofol 46. Kelvin EA, Hesdorffer DC, Bagiella E, et al. Prevalence of self-
(Diprivan) for awake craniotomies: technical note. Surg Neurol. reported epilepsy in a multiracial and multiethnic community in
1992;38:271–272. New York City. Epilepsy Res. 2007;77:141–150.
28. Berkenstadt H, Perel A, Hadani M, et al. Monitored anesthesia 47. Bazil CW. Comprehensive care of the epilepsy patient-con-
care using remifentanil and propofol for awake craniotomy. J trolled, comorbidity, and cost. Epilepsia. 2004;45:3–12.
Neurosurg Anesthesiol. 2001;13:246–249. 48. Fisher RS, Cross JH, French JA, Higurashi N, et al. Operational
29. Manninen PH, Balki M, Lukitto K, Bernstein M. Patient satisfac- classification of seizure types by the International League
tion with awake craniotomy for tumor surgery: a comparison of Against Epilepsy: position paper of the ILAE commission for
remifentanil and fentanyl in conjunction with propofol. Anesth classification and terminology. Epilepsia. 2017;58(4):522–530.
Analg. 2006;102:237–242. 49. Chin PS, Berg AT, Spencer SS, et al. Employment outcomes fol-
30. Keifer JC, Dentchev D, Little K, et al. A retrospective analysis lowing resective epilepsy surgery. Epilepsia. 2007;48:
of a remifentanil/propofol general anesthetic for craniotomy 2253–2257.
50. Kiersey DK, Bickford RG, Faulconer Jr A. Electro- 71. Cascino GD, So EL, Sharbrough FW, et al. Alfentanil-induced
encephalographic patterns produced by thiopental sodium epileptiform activity in patients with partial epilepsy. J Clin
during surgical operations: description and classification. Br J Neurophysiol. 1993;10:520–525.
Anaesth. 1951;23:141–152. 72. McGuire G, El-Beheiry H, Manninen P, et al. Activation of elec-
51. Modica PA, Tempelhoff R, White PF. Pro- and anticonvulsant trocorticographic activity with remifentanil and alfentanil dur-
effects of anesthetics (part II). Anesth Analg. 1990;70:433–444. ing neurosurgical excision of epileptogenic focus. Br J Anaesth.
52. Reddy RV, Moorthy SS, Dierdorf SF, et al. Excitatory effects and 2003;91:651–655.
electro-encephalographic correlation of etomidate, thiopental, 73. Tempelhoff R, Modica PA, Bernardo KL, Edwards I. Fentanyl-
methohexital, and propofol. Anesth Analg. 1993;77:1008–1011. induced electrocorticographic seizures in patients with complex
53. Walker M. Status epilepticus: an evidence based guide. BMJ. partial epilepsy. J Neurosurg. 1992;77:201–208.
2005;331:673–677. 74. Modica PA, Tempelhoff R, White PF. Pro- and anticonvulsant
54. Rampil IJ, Lopez CE, Laxer KD, Barbaro NM. Propofol sedation effects of anesthetics (part I). Anesth Analg. 1990;70:303–315.
may disrupt interictal epileptiform activity from a seizure focus. 75. Vakkuri AP, Seitsonen ER, Jantti VH, et al. A rapid increase in
Anesth Analg. 1993;77:1071–1073. the inspired concentration of desflurane is not associated with
55. Smith M, Smith SJ, Scott CA, Harkness WF. Activation of the epileptiform encephalogram. Anesth Analg. 2005;101:396–400.
electrocorticogram by propofol during surgery for epilepsy. Br J 76. Hymes JA. Seizure activity during isoflurane anesthesia. Anesth
Anaesth. 1996;76(4):499–502. Analg. 1985;101:396–400.
56. Opitz A, Marschall M, Degan R, et al. General anesthesia in 77. Harrison JL. Postoperative seizures after isoflurane anesthesia.
patients with epilepsy and status epilepticus. In: Delgado- Anesth Analg. 1986;64:367–368.
Escueta AV, Wasterlain CG, Treiman DM, eds.Advances in 78. Schultz B, Schultz A, Grouven U, Korsch G, Epileptiform EEG.
Neurology: Status Epilepticus, Mechanisms of Brain Damage and activity: occurrence under sevoflurane and not during propofol
Treatment. New York: Raven Press; 1983:531–535. application. Anaesthetist. 2001;50:43–45.
57. Yeoman P, Hutchinson A, Byrne A, et al. Etomidate infusions for 79. Woodforth IJ, Hicks RG, Crawford MR, et al. Electro-
the control of refractory status epilepticus. Intensive Care Med. encephalographic evidence of seizure activity under deep
1989;15:255–259. sevoflurane anesthesia in a non-epileptic patient. Anesthesiology.
58. Chui J, Manninen P, Valiante T, Venkatraghavan L. The anes- 1997;87:1579–1582.
thetic considerations of intraoperative electrocorticography 80. Watts AD, Herrick IA, McLachlan RS, et al. The effect of
during epilepsy surgery. Anesth Analg. 2013;117(2):479–486. sevoflurane and isoflurane anesthesia on interictal spike activ-
59. Wyler AR, Ritchey ET, Atkinson RA, Hermann BP. Methohexital ity among patients with refractory epilepsy. Anesth Analg.
activation of epileptogenic foci during acute electrocorticogra- 1999;89:1275–1281.
phy. Epilepsia. 1987;28:490–494. 81. Hisada K, Morioka T, Fukui K, et al. Effects of sevoflu-
60. Fiol ME, Torres F, Gates JR, Maxwell R. Methohexital (Brevital) rane and isoflurane on electrocorticographic activities in
effect on electrocorticogram may be misleading. Epilepsia. patients with temporal lobe epilepsy. J Neurosurg Anesthesiol.
1990;31:524–528. 2001;13:333–337.
61. Talke P, Stapelfeldt C, Garcia P. Dexmedetomidine does not 82. Kurita N, Kawaguchi M, Hoshida T, et al. The effects of
reduce epileptiform discharges in adults with epilepsy. J sevoflurane and hyperventilation on electrocorticogram spike
Neurosurg Anesthesiol. 2007;19(3):195–199. activity in patients with refractory epilepsy. Anesth Analg.
62. Rockoff MA, Goudsouzian NG. Seizures induced by methohexi- 2005;101:517–523.
tal. Anesthesiology. 1981;54:333–335. 83. Koenig HM, Hoffman WE. The effect of anticonvulsant therapy
63. Ebrahim ZY, DeBoer GE, Luders H, et al. Effect of etomidate on two doses of rocuronium-induced neuromuscular blockade. J
on the electroencephalogram of patients with epilepsy. Anesth Neurosurg Anesthesiol. 1999;11:86–89.
Analg. 1986;65:1004–1006. 84. Richard A, Girard F, Girard DC, et al. Cisatracurium-induced
64. Hufnagel A, Burr W, Elger CE, et al. Localization of the epileptic neuromuscular blockade is affected by chronic phenytoin or car-
focus during methohexital-induced anesthesia. Epilepsia. bamazepine treatment in neurosurgical patients. Anesthesiology.
1992;33:271–284. 2005;100:538–544.
65. Rysz A, Bachanski M, Bidzinski J, Bacia T. The comparison 85. Ornstein E, Matteo RS, Young WL, Diaz J. Resistance to meto-
of ketamine with methohexital and thiopental in the intraop- curine-induced neuromuscular blockade in patients receiving
erative EEG in drug-resistant epilepsy. Neurol Neurochir Pol. phenytoin. Anesthesiology. 1985;63:294–298.
1998;32:237–245. 86. Spacek A, Neiger FX, Spiss CK, Kress HG. Atracurium-induced
66. Hansen HC, Drenck NE. Generalised seizures after etomidate neuromuscular block is not affected by chronic anticonvul-
anaesthesia. Anaesthesia. 1988;43:805–806. sant therapy with carbamazepine. Acta Anaesthesiol Scand.
67. Nicoll K, Callender J. Etomidate-induced convulsion prior to 1997;41:1308–1311.
electroconvulsive therapy. Br J Psychiatry. 2000;177:373. 87. Tempelhoff R, Modica PA, Jellish WS, Spitznagel Jr EL.
68. Bennett DR, Madsen JA, Jordan WS, et al. Ketamine anesthesia Resistance to atracurium-induced neuromuscular blockade in
in brain-damaged epileptics: electroencephalographic and clini- patients with intractable seizure disorders treated with anticon-
cal observations. Neurology. 1973;23:449–460. vulsants. Anesth Analg. 1990;71:665–669.
69. Kugler J, Doenicke A. Ketamine—anticonvulsive and proconvul- 88. Ornstein E, Matteo RS, Schwartz AE, et al. The effect of
sive actions. Anaesthetist. 1994;43:S2–S7. phenytoin on the magnitude and duration of neuromuscular
70. Wass CT, Grady RE, Fessler AJ. The effects of remifentanil on block following atracurium or vecuronium. Anesthesiology.
epileptiform discharges during intraoperative electrocorti- 1987;67:191–196.
cography in patients undergoing epilepsy surgery. Epilepsia. 89. Alloul K, Whalley DG, Shutway F, et al. Pharmacokinetic
2001;42:1340–1344. origin of carbamazepine-induced resistance to vecuronium
neuromuscular blockade in anesthetized patients. 107. Todd MM, Warner DS, Sokoll MD, et al. A prospective, com-
Anesthesiology. 1996;84:330–339. parative trial of three anesthetics for elective supratentorial
90. Isaacs H. Perinatal (fetal and neonatal) tuberous sclerosis: a craniotomy. Anesthesiology. 1993;78:1005–1020.
review. Am J Perinatol. 2009;26(10):755–760. 108. Kacar Bayram A, Yan Q, Isitan C, et al. Effect of anesthesia on
91. Jóźwiak S, Kotulska K, Kasprzyk-Obara J, et al. Clinical and electrocorticography for localization of epileptic focus: literature
genotype studies of cardiac tumors in 154 patients with tuberous review and future directions. Epilepsy Behav. 2021;118:107902.
sclerosis complex. Pediatrics. 2006;118(4):e1146–e1151. 109. Ebrahim ZY, Schubert A, Van Ness P, et al. The effect of propofol
92. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline on the electroencephalogram of patients with epilepsy. Anesth
update for perioperative cardiovascular evaluation for non- Analg. 1994;78:275–279.
cardiac surgery, Executive summary a report of the American 110. Herrick IA, Craen RA, Gelb AW, et al. Propofol sedation
College of Cardiology/American Heart Association Task during awake craniotomy for seizures: patient-controlled
Force on Practice Guidelines (Committee to Update the 1996 administration versus neurolept analgesia. Anesth Analg.
Guidelines on Perioperative Cardiovascular Evaluation for 1997;84:1285–1291.
Noncardiac Surgery). Circulation. 2002;105:1257–1267. 111. Ito BM, Sato S, Kufta CV, et al. Effect of isoflurane and enflurane
93. Reasoner DK, Todd MM, Scamman FL, et al. The incidence on the electrocorticogram of epileptic patients. Neurology.
of pneumocephalus after supratentorial craniotomy: observa- 1988;38:924–928.
tions on the disappearance of intracranial air. Anesthesiology. 112. Bekker A, Sturaitis MK. Dexmedetomidine for neurological
1994;80:1008–1012. surgery. Neurosurgery. 2005;57(Suppl 1):1–10.
94. Tempelhoff R, Modica PA, Spitznagel Jr EL. Anticonvulsant 113. Cascino GD, Sharbrough FW, So EL, et al. Intraoperative alfen-
therapy increases fentanyl requirements during anaesthesia for tanil hydrochloride in temporal lobe epilepsy: correlation with
craniotomy. Can J Anaesth. 1990;37:327–332. MRI-based volume studies. Epilepsia. 1992(33):85.
95. Wall M, Baird-Lambert J, Buchanan N, et al. Liver function 114. Sato K, Shamoto H, Yoshimoto T. Severe bradycardia during
tests in persons receiving anticonvulsant medications. Seizure. epilepsy surgery. J Neurosurg Anesthesiol. 2001;13:
1992;1:187–190. 329–332.
96. Rodriguez L, Valero R, Fabregas N. Intraoperative metabolic 115. Sinha PK, Neema PK, Manikandan S, et al. Bradycardia and
acidosis induced by chronic topiramate intake in neurosurgical sinus arrest following saline irrigation of the brain during epi-
patients. J Neurosurg Anesthesiol. 2008;20:67–68. lepsy surgery. J Neurosurg Anesthesiol. 2004;16:160–163.
97. Soriano SG, Bozza P. Anesthesia for epilepsy surgery in children. 116. Kofke WA, Tempelhoff R, Dasheiff RM. Anesthesia for epileptic
Childs Nerv Syst. 2006;22:834–843. patients and for epilepsy surgery. In: Cottrell JE, Smith DS, eds.
98. Gidal B, Spencer N, Maly M, et al. Valproate-mediated distur- Anesthesia and Neurosurgery. St. Louis: Mosby; 1994:495–524.
bance of hemostasis: relationship to dose and plasma concentra- 117. Brian JE Jr, Deshpande JK, McPerson RW. Management of cere-
tion. Neurology. 1994;44:1418–1422. bral hemispherectomy in children. J Clin Anesth. 1990;2:
99. Anderson GD, Lin YX, Berge C, Ojemann GA. Absence 91–95.
of bleeding complications in patients undergoing corti- 118. Zuckerberg AL, Tobin JR, Fleisher L, et al. The physiopatho-
cal surgery while receiving valproate treatment. J Neurosurg. logical consequences of cerebral hemispherectomy in children.
1997;87:252–256. Anesthesiology. 1993;79:A1187.
100. Seidenberg M, Pulsipher DT, Hermann B. Association 119. Abrahams JM, Torchia MB, McGarvey M, et al. Perioperative
of epilepsy and comorbid conditions. Future Neurol. assessment of coagulability in neurosurgical patients using
2009;4(5):663–668. thromboelastography. Surg Neurol. 2002;58:5–11.
101. Artru AA, Lettich E, Colley PS, et al. Nitrous oxide: suppression 120. Goobie SM, Soriano SG, Zurakowski D, et al. Hemostatic
of focal epileptiform activity during inhalation and spreading of changes in pediatric neurosurgical patients as evaluated by
seizure activity following withdrawal. J Neurosurg Anesthesiol. thrombelastograph. Anesth Analg. 2001;93:887–892.
1990;2:189–193. 121. Hatton KW, McLarney JT, Pittman T, Fahy BG. Vagal nerve
102. Coles JP, Leary TS, Monteiro JN, et al. Propofol anesthesia for stimulation: overview and implications for anesthesiologists.
craniotomy: a double-blind comparison of remifentanil, alfent- Anesth Analg. 2006;103(5):1241–1249.
anil, and fentanyl. J Neurosurg Anesthesiol. 2000;12:15–20. 122. Ramani R. Vagus nerve stimulation therapy for seizures.
103. Balakrishnan G, Raudzens P, Samra SK, et al. A comparison of J Neurosurg Anesthesiol. 2008;20:29–35.
remifentanil and fentanyl in patients undergoing surgery for 123. Koh JL, Egan B, McGraw T. Pediatric epilepsy surgery: anes-
intracranial mass lesions. Anesth Analg. 2000;91:163–169. thetic considerations. Anesthesiol Clin. 2012;30(2):191–206.
104. Gerlach K, Uhlig T, Huppe M, et al. Remifentanil-propofol 124. Zalvan C, Sulica L, Wolf S, et al. Laryngopharyngeal dysfunc-
versus sufentanil-propofol anaesthesia for supratentorial crani- tion from the implant vagal nerve stimulator. Laryngoscope.
otomy: a randomized trial. Eur J Anaesthesiol. 2003;20:813–820. 2003;113:221–225.
105. Sneyd JR, Whaley A, Dimpel HL, et al. An open, randomized 125. Tatum 4th WO, Moore DB, Stecker MM, et al. Ventricular
comparison of alfentanil, remifentanil and alfentanil followed asystole during vagus nerve stimulation for epilepsy in humans.
by remifentanil in anaesthesia for craniotomy. Br J Anaesth. Neurology. 1999;52(6):1267–1269.
1998;81:361–364. 126. McGovern RA, Alomar S, Bingaman WE, Gonzalez-Martinez J.
106. Peterson KD, Landsfeldt U, Cold GE, et al. Intracranial pressure Robot-assisted responsive neurostimulator system placement in
and cerebral hemodynamic in patients with cerebral tumors: a medically intractable epilepsy: instrumentation and technique.
randomized prospective study of patients subjected to crani- Oper Neurosurg (Hagerstown). 2019 Apr 1;16(4):455–464.
otomy in propofol-fentanyl, isoflurane-fentanyl, or sevoflurane- 127. Saipetch C, Sachs E, Haneef Z. Epilepsy: five new things. Neurol
fentanyl anesthesia. Anesthesiology. 2003;98:329–336. Clin Pract. 2016;6(5):444–451.
128. Wicks RT, Jermakowicz WJ, Jagid JR, et al. Laser interstitial 146. Ganjoo P, Sethi S, Tandon MS, et al. Incidence and pattern of
thermal therapy for mesial temporal lobe epilepsy. Neurosurgery. intraoperative hemodynamic response to endoscopic third
2016;79(Suppl 1):S83–S91. ventriculostomy. Neurol India. 2009;57(2):162–165.
129. Hader WJ, Tellez-Zenteno J, Metcalfe A, et al. Complications of 147. Ganjoo P, Sethi S, Tandon MS, et al. Perioperative complications
epilepsy surgery: a systematic review of focal surgical resections of intraventricular neuroendoscopy: a 7-year experience. Turk
and invasive EEG monitoring. Epilepsia. 2013;54(5): Neurosurg. 2010;20(1):33–38.
840–847. 148. Fabregas N, Valero R, Carrero E, et al. Episodic high irriga-
130. Manninen PH, Raman SK, Boyle K, et al. Early postopera- tion pressure during surgical neuroendoscopy may cause
tive complications following neurosurgical procedures. Can J intermittent intracranial circulatory insufficiency. J Neurosurg
Anaesth. 1999;46:7–14. Anesthesiol. 2001;13:152–157.
131. Madenoglu H, Yildiz K, Dogru K, et al. Randomized, double- 149. El Dawlatly AA, Murshid WR, Elshimy A, et al. The incidence
blinded comparison of tropisetron and placebo for prevention of bradycardia during endoscopic third ventriculostomy. Anesth
of postoperative nausea and vomiting after supratentorial crani- Analg. 2000;91:1142–1144.
otomy. J Neurosurg Anesthesiol. 2003;15:82–86. 150. Fukuhara T, Vorster S, Luciano M. Risk factors for failure of
132. Vallejo FA, Eichberg DG, Morell AA, et al. Same-day dis- endoscopic third ventriculostomy for obstructive hydrocepha-
charge after brain tumor resection: a prospective pilot study. J lus. Neurosurgery. 2000;46:1100–1109.
Neurooncology. 2022;157(2):345–353. 151. Handler M, Abbott III R, Lee M. A near-fatal complication of
133. Reisch R, Marcus HJ, Hugelshofer M, et al. Patients’ cosmetic endoscopic third ventriculostomy: case report. Neurosurgery.
satisfaction, pain, and functional outcomes after supraor- 1994;33:525–527.
bital craniotomy through an eyebrow incision. J Neurosurg. 152. Anandh B, Madhusudan Reddy KR, Mohanty A, et al.
2014;121(3):730–734. Intraoperative bradycardia and postoperative hyperkalemia in
134. Goettel N, Chui J, Venkatraghavan L, et al. Day surgery cra- patients undergoing endoscopic third ventriculostomy. Minim
niotomy for unruptured cerebral aneurysms: a single center Invasive Neurosurg. 2002;45:154–157.
experience. J Neurosurg Anesthesiol. 2014;26:60–64. 153. El Dawlatly AA. Blood biochemistry following endoscopic
135. Sheshadri V, Venkatraghavan L, Manninen P, Bernstein third ventriculostomy. Minim Invasive Neurosurg. 2004;47:
M. Anesthesia for same day discharge after craniotomy: 47–48.
review of a single center experience. J Neurosurg Anesthesiol. 154. Salvador L, Valero R, Carrero E, et al. Cerebrospinal fluid com-
2018;30(4):299–304. position modification after neuroendoscopic procedures. Minim
136. Kan P, Maragkos GA, Srivatsan A, et al. Middle meningeal artery Invasive Neurosurg. 2007;50:51–55.
embolization for chronic subdural hematoma: a multi-center 155. McLaughlin MR, Wahlig JB, Kaufmann AM, Albright AL.
experience of 154 consecutive embolizations. Neurosurgery. Traumatic basilar aneurysm after endoscopic third ventriculos-
2021;88(2):268–277. tomy: case report. Neurosurgery. 1997;41:1400–1403.
137. Zhang Y, Li Q, Zhao R, et al. Novel minimally invasive treatment 156. Fàbregas N. Neurological monitoring in anesthesiology. Where
strategy for acute traumatic epidural hematoma: endovascular are we and where are we going? [Spanish]. Rev Esp Anestesiol
embolization combined with drainage surgery and use of uroki- Reanim. 2000;47(10):439–441.
nase. World Neurosurg. 2018;110:206–209. 157. Meier PM, Guzman R, Erb TO. Endoscopic pediatric neu-
138. Brockmeyer D, Abtin K, Carey L, Walker ML. Endoscopic rosurgery: implications for anesthesia. Pediatric Anesthesia.
third ventriculostomy: an outcome analysis. Pediatr Neurosurg. 2014;24:666–677.
1998;28:236–240. 158. Kawsar KA, Haque MR, Chowdhury FH. Avoidance and
139. Cinalli G, Salazar C, Mallucci C, et al. The role of endoscopic management of perioperative complications of endoscopic
third ventriculostomy in the management of shunt malfunction. third ventriculostomy: the Dhaka experience. J Neurosurg.
Neurosurgery. 1998;43:1323–1327. 2015;123(6):1414–1419.
140. Hopf NJ, Grunert P, Fries G, et al. Endoscopic third ventricu- 159. Choi J, Kim D, Kim S. Endoscopic surgery for obstructive
lostomy: outcome analysis of 100 consecutive procedures. hydrocephalus. Yonsei Med J. 1999;40:600–607.
Neurosurgery. 1999;44:795–804. 160. Enya S, Masuda Y, Terui K. Respiratory arrest after a ven-
141. Schroeder HW, Niendorf WR, Gaab MR. Complications triculoscopic surgery in infants: two case reports. Masui.
of endoscopic third ventriculostomy. J Neurosurg. 1997;46:416–420.
2002;96:1032–1040. 161. Teo C, Jones R. Management of hydrocephalus by endoscopic
142. Fabregas N, Lopez A, Valero R, et al. Anesthetic management third ventriculostomy in patients with myelomeningocele.
of surgical neuroendoscopies: usefulness of monitoring the Pediatr Neurosurg. 1996;25:57–63.
pressure inside the neuroendoscope. J Neurosurg Anesthesiol. 162. Jimenez DF, Barone CM, Cartwright CC, Baker L. Early man-
2000;12:21–28. agement of craniosynostosis using endoscopic-assisted strip
143. Ambesh SP, Kumar R. Neuroendoscopic procedures: anes- craniectomies and cranial orthotic molding therapy. Pediatrics.
thetic considerations for a growing trend: a review. J Neurosurg 2002;110:97–104.
Anesthesiol. 2000;12:262–270. 163. Faberowski LW, Black S, Mickle JP. Blood loss and transfusion
144. Longatti PL, Barzoi G, Paccagnella F, et al. A simplified endo- practice in the perioperative management of craniosynostosis
scopic third ventriculostomy under local anesthesia. Minim repair. J Neurosurg Anesthesiol. 1999;11:167–172.
Invasive Neurosurg. 2004;47:90–92. 164. Helfaer MA, Carson BS, James CS, et al. Increased hematocrit
145. van Aken J, Struys M, Verplancke T, et al. Cardiovascular and decreased transfusion requirements in children given eryth-
changes during endoscopic third ventriculostomy. Minim ropoietin before undergoing craniofacial surgery. J Neurosurg.
Invasive Neurosurg. 2003;46:198–201. 1998;88:704–708.
165. Bermejo E, Felix V, Lapunzina P, Galan E, et al. Craniofacial dys- 185. Liu GK, Kit WH. Video assisted thoracoscopic surgery for spinal
synostosis: description of the first four Spanish cases and review. conditions. Neurol India. 2005;53(4):489–498.
Am J Med Genet A. 2005;132:41–48. 186. Singh R, Gogna P, Parshad S, Karwasra RK, Karwasra PK,
166. Pijpers M, Poels PJ, Vaandrager JM, et al. Undiagnosed obstruc- Kaur K. Video-assisted thoracic surgery for tubercular spon-
tive sleep apnea syndrome in children with syndromal craniofa- dylitis. Minim Invasive Surg. 2014;2014:963497. https://doi.
cial synostosis. J Craniofac Surg. 2004;15:670–674. org/10.1155/2014/963497.
167. Butler MG, Hayes BG, Hathaway MM, Begleiter ML. Specific 187. Lile A, Lenfant F, Tapie MC, et al. Anesthesia for video-assisted
genetic diseases at risk for sedation/anesthesia complications. surgery of the thoracic and lumbar spine: a survey of 44 patients
Anesth Analg. 2000;91:837–855. [French]. Neurochirurgie. 2007;53(1):18–22.
168. Sugiyama K, Yokoyama K. Displacement of the endotracheal 188. Ng CS, Yeung EC, Wong RH, Kwok MW. Single-port sympa-
tube caused by change of head position in pediatric anes- thectomy for palmar hyperhidrosis with Vasoview Hemopro 2
thesia: evaluation by fiberoptic bronchoscopy. Anesth Analg. endoscopic vein harvesting device. J Thorac Cardiovasc Surg.
1996;82:251–253. 2012;144(5):1256–1257.
169. Dalle Ore CL, Dilip M, Brandel MG, et al. Endoscopic surgery 189. Huang EY, Acosta JM, Gardocki RJ, et al. Thoracoscopic ante-
for nonsyndromic craniosynostosis: a 16-year single-center rior spinal release and fusion: evolution of a faster, improved
experience. J Neurosurg Pediatr. 2018;22:335–343. approach. J Pediatr Surg. 2002;37:1732–1735.
170. Lee JM, Gee E, Liu CA. Anesthesia for innovative pediatric 190. Kokoska ER, Gabriel KR, Silen ML. Minimally invasive anterior
surgical procedures. Anesthesiol Clin. 2020;38:493–508. spinal exposure and release in children with scoliosis. JSLS.
171. Rodziewicz GS, Chuang WC. Endoscopic removal of organized 1998;2:255–258.
chronic subdural hematoma. Surg Neurol. 1995;43:569–572. 191. Steenwyk B, Lyerly 3rd R. Advancements in robotic-assisted tho-
172. Zumofen DW, Rychen J, Roethlisberger M, et al. A review of racic surgery. Anesthesiol Clin. 2012;30(4):699–708.
the literature on the transciliary supraorbital keyhole approach. 192. Costanzo S, Pansini A, Colombo L, et al. Video-assisted thora-
World Neurosurg. 2017;98:614–624. coscopy for vertebral body tethering of juvenile and adolescent
173. Prabhakar H, Mahajan C, Kapoor I. Anesthesia for mini- idiopathic scoliosis: tips and tricks of surgical multidisciplinary
mally invasive neurosurgery. Curr Opin Anaesthesiol. management. Children (Basel). 2022;9(1):74.
2017;30(5):546–550. 193. Banoub M, Tetzlaff JE, Schubert A. Pharmacologic and
174. Hoshide R, Calayag M, Meltzer H, et al. Robot-assisted endo- physiologic influences affecting sensory evoked potentials.
scopic third ventriculostomy: institutional experience in 9 Anesthesiology. 2003;99:716–737.
patients. J Neurosurg Pediatr. 2017;20(2):125–133. 194. Lotto ML, Banoub M, Schubert A. Effects of anesthetic agents
175. Shen FH, Samartzis D, Khanna AJ, Anderson DG. Minimally and physiologic changes on intraoperative motor evoked poten-
invasive techniques for lumbar interbody fusions. Orthop Clin tials. J Neurosurg Anesthesiol. 2004;16:32–42.
North Am. 2007;38:373–386. 195. Boulesteix G, Simon L, Lamit X, et al. Intratracheal intubation
176. Regan JJ, Yuan H, McAfee PC. Laparoscopic fusion of the without muscle relaxant with the use of remifentanil-propofol.
lumbar spine: minimally invasive spine surgery: a prospective Ann Fr Anesth Reanim. 1999;18:393–397.
multicenter study evaluating open and laparoscopic lumbar 196. Maurtua MA, Deogaonkar A, Bakri MH, et al. Dosing of
fusion. Spine. 1999;24:402–411. remifentanil to prevent movement during craniotomy in the
177. Goldstein CL, Macwan K, Sundararajan K, Rampersaud YR. absence of neuromuscular blockade. J Neurosurg Anesthesiol.
Perioperative outcomes and adverse events of minimally inva- 2008;20(4):221–225.
sive versus open posterior lumbar fusion: meta-analysis and 197. Engum SA. Minimal access thoracic surgery in the pediatric
systematic review. J Neurosurg Spine. 2016;24(3):416–427. population. Semin Pediatr Surg. 2007;16:14–26.
178. Tetzlaff JE, Dilger JA, Kodsy M, et al. Spinal anesthesia for elec- 198. Sucato DJ, Elerson E. A comparison between the prone and lat-
tive lumbar spine surgery. J Clin Anesth. 1998;10:666–669. eral position for performing a thoracoscopic anterior release and
179. McLain RF, Kalfas I, Bell GR, Tetzlaff JE, Yoon HJ, Rana M. fusion for pediatric spinal deformity. Spine. 2003;28:2176–2180.
Comparison of spinal and general anesthesia in lumbar lami- 199. Liu GK, Kit WH. Video assisted thoracoscopic surgery for spinal
nectomy surgery: a case-controlled analysis of 400 patients. J conditions. Neurol India. 2005;53:489–498.
Neurosurg Spine. 2005;2(1):17–22. 200. Lai YT, Yang LH, Chio CC, Chen HH. Complications in patients
180. Düger C, Gürsoy S, Karadağ O, et al. Anesthetic and analgesic with palmar hyperhidrosis treated with transthoracic endo-
effects in patients undergoing a lumbar laminectomy of spinal, scopic sympathectomy. Neurosurgery. 1997;41:110–113.
epidural or a combined spinal-epidural block with the addition 201. McAfee PC, Regan JR, Zdeblick T, et al. The incidence of com-
of morphine. J Clin Neurosci. 2012;19(3):406–410. plications in endoscopic anterior thoracolumbar spinal recon-
181. Ulutas M, Secer M, Taskapilioglu O, et al. General versus epi- structive surgery: a prospective multicenter study comprising
dural anesthesia for lumbar microdiscectomy. J Clin Neurosci. the first 100 consecutive cases. Spine. 1995;20:1624–1632.
2015;22(8):1309–1313. 202. Coumans JV, Reinhardt MK, Lieberman IH. Kyphoplasty for
182. De Biase G, Gruenbaum SE, West JL, et al. Spinal versus general vertebral compression fractures: 1-year clinical outcomes from a
anesthesia for minimally invasive transforaminal lumbar inter- prospective study. J Neurosurg Spine. 2003;99:44–50.
body fusion: implications on operating room time, pain, and 203. Lee JM, Lee SK, Lee SJ, et al. Comparison of remifentanil with
ambulation. Neurosurg Focus. 2021;51(6):E3. dexmedetomidine for monitored anaesthesia care in elderly
183. De Rojas JO, Syre P, Welch WC. Regional anesthesia versus patients during vertebroplasty and kyphoplasty. J Int Med Res.
general anesthesia for surgery on the lumbar spine: a review of 2016;44(2):307–316.
the modern literature. Clin Neurol Neurosurg. 2014;119:39–43. 204. Ge C, Wu X, Gao Z, Xu Z, Hao D, Dong L. Comparison of
184. Rosenthal D, Dickman CA. Thoracoscopic microsurgical exci- different anesthesia modalities during percutaneous kypho-
sion of herniated thoracic discs. J Neurosurg. 1998;89: plasty of osteoporotic vertebral compression fractures. Sci Rep.
224–235. 2021;11(1):11102.
205. Ren Z, Tahir E, Zhang B, Wang Y, Yang Y. Efficacy of intraopera- 216. Perez-Cruet MJ, Fessler RG, Perin NI. Complications of mini-
tive sedation combined with preemptive analgesia for single- mally invasive spinal surgery. Neurosurgery. 2002;51:26–36.
level kyphoplasty under local anesthesia: a randomized clinical 217. Dagher C, Naccache N, Narchi P, Hage P, Antakly MC.
trial. J Orthop Sci. 2022;27(6):1215–1221. Anesthésie locorégionale pour cure microchirurgicale des
206. Zhang S, Xu S, Yang J, Wang S, Wang Q. Analysis of percuta- hernies discales lombaires (Regional anesthesia for lumbar
neous kyphoplasty under different types of anesthesia for the microdiscectomy). J Med Liban. 2002;50(5–6):206–210.
treatment of multiple osteoporotic vertebral fractures. BMC 218. Fogarty P, Abalos A, Haas D, et al. Postoperative narcotic
Musculoskelet Disord. 2020;21(1):743. requirement following lumbar microdiscectomy is related to
207. Liu J, Wang L, Chai M, Kang J, et al. Analysis of anesthesia pre-operative pain, not to intraoperative ketorolac or bupiva-
methods in percutaneous kyphoplasty for treatment of vertebral caine. Anesth Analg. 1998;86:314.
compression fractures. J Healthc Eng. 2020 Jan 9: 2020:3965961. 219. Jellish WS, Thalji Z, Stevenson K, Shea J. A prospective random-
208. Katonis P, Hadjipavlou A, Souvatzis X, et al. Respiratory effects, ized study comparing short- and intermediate-term periop-
hemodynamic changes and cement leakage during multilevel erative outcome variables after spinal or general anesthesia
cement balloon kyphoplasty. Eur Spine J. 2012;21(9):1860–1866. for lumbar disk and laminectomy surgery. Anesth Analg.
209. Groen RJ, du Toit DF, Phillips FM, et al. Anatomical and 1996;83:559–564.
pathological considerations in percutaneous vertebroplasty and 220. Mathews HH, Long BH. Minimally invasive techniques for the
kyphoplasty: a reappraisal of the vertebral venous system. Spine. treatment of intervertebral disk herniation. J Am Acad Orthop
2004;29(13):1465–1471. Surg. 2002;10:80–85.
210. Uemura A, Numaguchi Y, Matsusako M, et al. Effect on partial 221. Henry LG, Cattey RP, Stoll JE, Robbins S. Laparoscopically
pressure of oxygen in arterial blood in percutaneous vertebro- assisted spinal surgery. JSLS. 1997;1:341–344.
plasty. AJNR Am J Neuroradiol. 2007;28:567–569. 222. Liu JC, Ondra SL, Angelos P, et al. Is laparoscopic anterior
211. Childers Jr JC. Cardiovascular collapse and death during verte- lumbar interbody fusion a useful minimally invasive procedure?
broplasty. Radiology. 2003;228:902–903. Neurosurgery. 2002;51:155–158.
212. Yoo KY, Jeong SW, Yoon W, Lee J. Acute respiratory distress 223. Debono B, Wainwright TW, Wang MY, et al. Consensus state-
syndrome associated with pulmonary cement embolism follow- ment for perioperative care in lumbar spinal fusion: Enhanced
ing percutaneous vertebroplasty with polymethylmethacrylate. Recovery After Surgery (ERAS®) society recommendations.
Spine. 2004;29:E294–E297. Spine J. 2021;21(5):729–752.
213. Fessler RG, Khoo LT. Minimally invasive cervical micro- 224. Araimo Morselli FSM, Zuccarini F, Caporlingua F, et al. A
endoscopic foraminotomy: an initial clinical experience. blinded randomized comparative prospective study. Spine.
Neurosurgery. 2002;51:37–45. 2017;42(5):281–284.
214. Jho HD, Ha HG. Anterolateral approach for cervical spinal cord 225. Lonjon N, Chan-Seng E, Costalat V, et al. Robot-assisted spine
tumors via an anterior microforaminotomy: technical note. surgery: feasibility study through a prospective case-matched
Minim Invasive Neurosurg. 1999;42:1–5. analysis. Eur Spine J. 2016;25(3):947–955.
215. King AG, Mills TE, Loe Jr WA, et al. Video-assisted thoraco-
scopic surgery in the prone position. Spine. 2000;25:2403–2406.

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17

Awake Craniotomy, Epilepsy, Minimally Invasive,

AWAKE CRANIOTOMY the brain surface is exposed, anesthesia or sedation is discontinued to

Benefits Preparation for Awake Craniotomy

Surgical drapes IV pole

allowed greater access to surgical sites with less disruption of non-

Significant increases in intracranial pressure and direct stimulation or

Fig. 17.6 Positioning for endoscopic strip craniectomy.

Functional Neurosurgery and Deep Brain Preoperative Concerns

Newer developments have made an axial approach to the lower S U M M A RY

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