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Anesthetic Approach to High-Risk Patients and Prolonged Awake Craniotomy Using Dexmedetomidine and Scalp Block

Garavaglia, Marco M. MD*; Das, Sunit MD, PhD†,‡; Cusimano, Michael D. MD, PhD†,‡; Crescini, Charmagne BSc*; Mazer, C. David MD*,†; Hare, Gregory M.T. MD, PhD*,†; Rigamonti, Andrea MD*

Journal of Neurosurgical Anesthesiology: July 2014 - Volume 26 - Issue 3 - p 226–233
doi: 10.1097/ANA.0b013e3182a58aba
Clinical Reports

Background: Awake craniotomy with intraoperative speech or motor testing is relatively contraindicated in cases requiring prolonged operative times and in patients with severe medical comorbidities including anxiety, anticipated difficult airway, obesity, large tumors, and intracranial hypertension. The anesthetic management of neurosurgical patients who possess these contraindications but would be optimally treated by an awake procedure remains unclear.

Methods: We describe a new anesthetic approach for awake craniotomy that did not require any airway manipulation, utilizing a bupivacaine-based scalp nerve block, and dexmedetomidine as the primary hypnotic-sedative agent. Using this technique, we provided optimal operative conditions to perform awake craniotomy facilitating safe tumor resection, while utilizing intraoperative electrocorticography for motor and speech mapping in a cohort of 10 patients at a high risk for airway compromise and complications associated with patient comorbidities.

Results: All patients underwent successful awake craniotomy, intraoperative mapping, and tumor resection with adequate sedation for up to 9 hours (median 3.5 h, range 3 to 9 h) without any loss of neurological function, airway competency, or the need to provide any active rescue airway management. We report 4 of these cases that highlight our experience: 1 case required prolonged surgery because of the complexity of tumor resection and 3 patients had important medical comorbidities and/or relative contraindication for an awake procedure.

Conclusions: Dexmedetomidine, with concurrent scalp block, is an effective and safe anesthetic approach for awake craniotomy. Dexmedetomidine facilitates the extension procedure complexity and duration in patients who might traditionally not be considered to be candidates for this procedure.

*Department of Anesthesia

Division of Neurosurgery, St. Michael’s Hospital, University of Toronto

Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada

Supported by the Departments of Anesthesia and Surgery (Division of Neurosurgery) at St. Michaela's Hospital, University of Toronto. Drs. Mazer, Hare and Rigamonti have received Merit Awards from the University of Toronto Department of Anesthesia.

The authors have no funding or conflicts of interest to disclose.

Reprints: Marco M. Garavaglia, MD, Department of Anesthesia, St. Michael’s Hospital, University of Toronto, 30 Bond Street, Toronto, ON M5B 1W8, Canada (e-mail:

Received March 27, 2013

Accepted July 17, 2013

© 2014 by Lippincott Williams & Wilkins