Awake craniotomies in the pediatric population: a systematic review

Abstract

OBJECTIVE Awake craniotomy (AC) is employed to maximize tumor resection while preserving neurological function in eloquent brain tissue. This technique is used frequently in adults but remains poorly established in children. Its use has been limited due to concern for children’s neuropsychological differences compared with adults and how these differences may interfere with the safety and feasibility of the procedure. Among studies that have reported pediatric ACs, complication rates and anesthetic management vary. This systematic review was performed to comprehensively analyze outcomes and synthesize anesthetic protocols of pediatric ACs. METHODS The authors followed PRISMA guidelines to extract studies that reported AC in children with intracranial pathologies. The Medline/PubMed, Ovid, and Embase databases were searched from database inception to 2021, using the terms ("awake") AND ("Pediatric*" OR "child*") AND (("brain" AND "surgery") OR "craniotomy"). Data extracted included patient age, pathology, and anesthetic protocol. Primary outcomes assessed were premature conversion to general anesthesia, intraoperative seizures, completion of monitoring tasks, and postoperative complications. RESULTS Thirty eligible studies published from 1997 to 2020 were included that described a total of 130 children ranging in age from 7 to 17 years who had undergone AC. Of all patients reported, 59% were male and 70% had left-sided lesions. Procedure indications included the following etiologies: tumors (77.6%), epilepsy (20%), and vascular disorders (2.4%). Four (4.1%) of 98 patients required conversion to general anesthesia due to complications or discomfort during AC. In addition, 8 (7.8%) of 103 patients experienced intraoperative seizures. Furthermore, 19 (20.6%) of 92 patients had difficulty completing monitoring tasks. Postoperative complications occurred in 19 (19.4%) of 98 patients and included aphasia (n = 4), hemiparesis (n = 2), sensory deficit (n = 3), motor deficit (n = 4), or others (n = 6). The most commonly reported anesthetic techniques were asleep-awake-asleep protocols using propofol, remifentanil or fentanyl, a local scalp nerve block, and with or without dexmedetomidine. CONCLUSIONS The findings of this systematic review suggest the tolerability and safety of ACs in the pediatric population. Although pediatric intracranial pathologies pose etiologies that certainly may benefit from AC, there is a need for surgeons and anesthesiologists to perform individualized risk-benefit analyses due to the risks associated with awake procedures in children. Age-specific, standardized guidelines for preoperative planning, intraoperative mapping, monitoring tasks, and anesthesia protocols will help to continue minimizing complications, while improving tolerability, and streamlining workflow in the treatment of this patient population.

Innovations in diagnostic and treatment options for pediatric epilepsy and their anesthetic implications

“…Over a 23-year period, the authors were able to identify 30 pediatric articles on pediatric awake craniotomies in children. Only 4 of those studies enrolled more than 10 patients [19].…”

The Use of Remimazolam During Awake Craniotomy for Seizure Foci Resection in Adolescents: A Case Series

“…Due to the inter-individual variability in the representation of specific motor and speech functions within the cortex, cortical mapping while the patient is awake allows the delineation of specific areas for resection while potentially avoiding neurologic deficits [ 3 ]. Various anesthetic regimens have been described using short-acting agents such as propofol, dexmedetomidine, and opioids to provide sedation and anesthesia during surgical incision and craniotomy while allowing for rapid awakening and verbal interaction during cortical mapping [ 4 , 5 ]. In the pediatric-aged patients, awake craniotomy may be performed with or without a native airway [ 4 , 5 ].…”

“…Various anesthetic regimens have been described using short-acting agents such as propofol, dexmedetomidine, and opioids to provide sedation and anesthesia during surgical incision and craniotomy while allowing for rapid awakening and verbal interaction during cortical mapping [ 4 , 5 ]. In the pediatric-aged patients, awake craniotomy may be performed with or without a native airway [ 4 , 5 ]. Regardless of the agents used, the goal is to generally maintain spontaneous ventilation and allow for the rapid return of consciousness during key portions of the procedure.…”