Conscious sedation for awake craniotomy in intraoperative magnetic resonance imaging operating theater

Abstract

This case report describes the first case in intraoperative magnetic resonance imaging operating theater (iMRI OT) (BrainSuite®) of awake craniotomy for frontal lobe glioma excision in a 24-year-old man undergoing eloquent cortex language mapping intraoperatively. As he was very motivated to take pictures of him while being operated upon, the authors adapted conscious sedation technique with variable depth according to Ramsey's scale, in order to revert to awake state to perform the intended neurosurgical procedure. The patient tolerated the situation satisfactorily and was cooperative till the finish, without any event. We elicit in this report the special environment of iMRI OT for lengthy operation in pinned fixed patient having craniotomy.

Awake craniotomy for gliomas in a high-field intraoperative magnetic resonance imaging suite: analysis of 42 cases

“…2,3,[11][12][13][14]18,[22][23][24] In some earlier work we showed that intraoperative multimodality electrophysiological mapping can be seamlessly incorporated into high-field iMRI for tumor resections. 15 Initially when we started the procedure of combining awake craniotomy with high-field iMRI, there were a number of challenges to overcome, including patient comfort and position as well as new draping and anesthetic techniques unique to the iMRI environment.…”

Anesthetic challenges and outcomes for procedures in the intraoperative magnetic resonance imaging suite: A systematic review

“…The included manuscripts mainly consisted of informal (non-systematic) reviews (n=10) [2][3][4][5][6][25][26][27][28][29], institutional experiences (n=10) [30][31][32][33][34][35][36][37][38][39], and case series/retrospective studies (n=12) [40][41][42][43][44][45][46][47][48][49][50][51], with only a few prospective studies (n=4) [52][53][54][55]. We also included 11 references that were published only in abstract form [56][57][58][59][60][61] or case report format [62][63][64][65][66]. Original data pertinent to the topics of interest could be extracted from the case series/ retrospective studies, prospective studies, and from 5 abstracts (see…”

“…The largest case series by Kamata et al was published only in abstract format and reported critical events during 365 awake craniotomies [56]. The other 4 references consisted of one abstract describing a single case [65], one case report [64], and 2 smaller case series describing the institutional experience with 42 and 7 cases, respectively [50,63]. The authors noted challenges related to patient positioning, the noise burden during scanning, and the added difficulty of anesthesia management in an iMRI environment while providing care to an awake but inaccessible patient with an unsecured airway.…”

“…Aside from detailing specifics of anesthetic care in the iMRI setting, many authors noted safety concerns specific to the iMRI environment: There was wide agreement regarding the need for safety protocols and ferromagnetic object counts prior to moving the iMRI machine to the patient or transferring the patient into the scanner [3-6, 26-29, 32, 33, 36, 38, 43, 45, 55, 59-62]. Several manuscripts described a risk for dislodgment or disconnection of an airway or vascular access devices, typically associated with transfer into the scanner or from vibrations caused by the scanning process [2,4,6,28,33,38,39,44,46,53,55,62,64]. Another commonly voiced concern was that the available MRI-compatible physiologic monitors have limitations in their functionality [2-6, 25-29, 32-39, 43-47, 49, 51, 53,55, 57, 59, 61, 64, 66]: electrocardiogram artifacts and poor ST segment monitoring ability were consistently reported, as was lack of MRI-safe temperature monitoring in earlier references.…”

“…The prolonged preparation time and case duration related to the complex setup and extensive safety measures was frequently mentioned [6,25,28,31,32,34,35,39,42,44,50,51,55,57,59,63,65]. A few authors specifically commented on the unfamiliarity of the iMRI suite or distractions, including the noise burden [3,6,26,29,33,34,38,39,45,46,55,61,63,64,65]. Several demanded extra personnel, either as a designated safety person or to assist with airway/patient management during crisis due to the limited access to the patient and long distance from the anesthesia equipment [2,5,26,31,32,38,50,55,60].…”