While a significant amount of experience has accumulated for awake procedures for brain tumor, epilepsy and carotid surgery, its utility for intracranial neurovascular indications remains largely undefined. Awake surgery offers the advantage of precise brain mapping and robust neurological monitoring during surgery for lesions in eloquent areas, avoidance of potential hemodynamic instability, and possible faster recovery. Additionally, it opens the window for perilesional epileptogenic tissue resection with potentially less risk for iatrogenic injury. We report our consecutive preliminary experience with awake surgery for intracranial neurovascular diseases.
IRB approval was obtained for a retrospective review of our experience with awake surgery for intracranial neurovascular indications over the past 12 months from a prospectively maintained quality database. We reviewed clinical indications, clinical presentation, preoperative workup, intraoperative anesthetic and surgical techniques, intraoperative hemodynamic parameters, intraoperative and postoperative complications and imaging and clinical outcomes.
8 consecutive patients underwent 9 intracranial neurovascular awake procedures conducted by the senior author; two AVMs, four Moyamoya disease and 3 cavernomas. A standardized “Sedated-Awake-Sedated” protocol was utilized in all eight patients. For AVM patients and the cavernoma patients, awake brain surface and white matter mapping was performed before and during microsurgical resection. A neurological exam was obtained periodically throughout all 5 procedures. There were no intra-operative or peri-operative complications. Hypotension was avoided during the two Moyamoya revascularization procedures in the patient with a history of labile blood pressure. Postoperative imaging confirmed complete AVM and cavernoma resections. No new neurological deficits were noted on 3 month follow-up. The AVM and the cavernoma patients have remained seizure free since surgery.
Awake surgery appears to be safe for select patients with intracranial neurovascular pathologies. Potential advantages include greater safety, shorter length of stay and reduced cost. Further prospective studies are needed to better define indications and limitations.
This research is a stepping stone in the introduction of awake surgeries into the neurovascular field. The advantages are increased patient safety, decreased post operative neurological deficit, shortened length of hospital stay and reduction of costs.
Assessing the efficacy, feasability and safety of awake surgeries for intracranial neurovascular disease.