Comparison of the Asleep-Awake-Asleep Technique and Monitored Anesthesia Care During Awake Craniotomy: A Systematic Review and Meta-analysis

Abstract

Awake craniotomy (AC) is the preferred surgical option for intractable epilepsy and resection of tumors adjacent to or within eloquent cortical areas. Monitored anesthesia care (MAC) or an asleep-awake-asleep (SAS) technique is most widely used during AC. We used a random-effects modeled meta-analysis to synthesize the most recent evidence to determine whether MAC or SAS is safer and more effective for AC. We included randomized controlled trials and observational studies that explored the incidence of AC failure, duration of surgery, and hospital length of stay in adult patients undergoing AC. Eighteen studies were included in the final analysis. MAC was associated with a lower risk of AC failure when compared with SAS (global pooled proportion MAC vs. SAS 1% vs. 4%; odds ratio [ORs]: 0.28; 95% confidence interval [CI]: 0.11-0.71; P = 0.007) and shorter surgical procedure time (global pooled mean MAC vs. SAS 224.44 vs. 327.94 min; mean difference, −48.76 min; 95% CI: −61.55 to −35.97; P < 0.00001). SAS was associated with fewer intraoperative seizures (global pooled proportion MAC vs. SAS 10% vs. 4%; OR: 2.38; 95% CI: 1.05-5.39; P = 0.04). There were no differences in intraoperative nausea and vomiting between the techniques (global pooled proportion MAC vs. SAS: 4% vs. 8%; OR: 0.86; 95% CI: 0.30-2.45; P = 0.78). Length of stay was shorter in the MAC group (MAC vs. SAS 3.96 vs. 6.75 days; mean difference, −1.30; 95% CI: −2.69 to 0.10; P = 0.07). In summary, MAC was associated with lower AC failure rates and shorter procedure time compared with SAS, whereas SAS was associated with a lower incidence of intraoperative seizures. However, there was a high risk of bias and other limitations in the studies included in this review, so the superiority of 1 technique over the other needs to be confirmed in larger randomized studies.

A novel online calculator predicting short-term postoperative outcomes in patients with metastatic brain tumors

“…Our study also established surgery duration as an independent predictor for increased total hospital costs among metastatic brain tumor patients. Individualizing surgical approaches and investigating the efficacy of existing surgical practice patterns can potentially help increase operative efficiency and subsequently decrease operative duration [ 28 , 49 , 50 ].…”

Awake craniotomy for resection of insular astrocytoma

“…The Awake craniotomy technique is a globally accepted method in identifying eloquent cortical sites during brain tumor resection. In addition to tumor resection, this technique is widely used to treat epileptic seizures [3,4].…”

“…The most suitable anesthetic technique for the particular surgery needs to be decided, as it plays a key role during the procedure. The two established techniques are the Awake through-out technique and the Asleep/Awake/Asleep technique [4,5]. In our case, the latter was utilized.…”

“…The ultimate result is achieving higher extents of safe resection while preserving neurological functions. In addition, awake craniotomy has been proven to minimize hospital stay preserving resources, minimize intraoperative cardiorespiratory complications and decrease postoperative morbidity [4,6].…”

The Awake Craniotomy: A Patient’s Experience and A Literature Review

“…Two anesthetic methods used to complete the procedure include monitored anesthesia care (MAC) and asleep-awake-asleep techniques. Though the former has been found to be associated with a lower risk of surgical failure and shorter procedure time, MAC is also the authors’ preferred method of utilizing anesthesia during the procedure [ 6 ]. Further, a comparison of glioma resection between craniotomy under general anesthesia and awake craniotomy has also shown several benefits for the performance of craniotomy while awake [ 7 ].…”