The Impact of Sedation on Brain Mapping

Ott, Christian; Kerscher, C.; Luerding, Ralf; Doenitz, Christian; Hoehne, Julius; Zech, Nina; Seemann, Milena; Schlaier, J.; Brawanski, Alexander

doi:10.1227/neu.0000000000000359

Cited by 25 publications

(6 citation statements)

References 21 publications

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“…This could have an impact on the success of awake surgery tasks. The influence of prior sedation on the cognitive and motoric ability to perform intraoperative tasks [ 73 ]. Reduction of propofol dosage was also the aim in a further of our included studies [ 48 ].…”

Section: Discussionmentioning

confidence: 99%

Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis

et al. 2016

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BackgroundAwake craniotomy (AC) renders an expanded role in functional neurosurgery. Yet, evidence for optimal anaesthesia management remains limited. We aimed to summarise the latest clinical evidence of AC anaesthesia management and explore the relationship of AC failures on the used anaesthesia techniques.MethodsTwo authors performed independently a systematic search of English articles in PubMed and EMBASE database 1/2007-12/2015. Search included randomised controlled trials (RCTs), observational trials, and case reports (n>4 cases), which reported anaesthetic approach for AC and at least one of our pre-specified outcomes: intraoperative seizures, hypoxia, arterial hypertension, nausea and vomiting, neurological dysfunction, conversion into general anaesthesia and failure of AC. Random effects meta-analysis was used to estimate event rates for four outcomes. Relationship with anaesthesia technique was explored using logistic meta-regression, calculating the odds ratios (OR) and 95% confidence intervals [95%CI].ResultsWe have included forty-seven studies. Eighteen reported asleep-awake-asleep technique (SAS), twenty-seven monitored anaesthesia care (MAC), one reported both and one used the awake-awake-awake technique (AAA). Proportions of AC failures, intraoperative seizures, new neurological dysfunction and conversion into general anaesthesia (GA) were 2% [95%CI:1–3], 8% [95%CI:6–11], 17% [95%CI:12–23] and 2% [95%CI:2–3], respectively. Meta-regression of SAS and MAC technique did not reveal any relevant differences between outcomes explained by the technique, except for conversion into GA. Estimated OR comparing SAS to MAC for AC failures was 0.98 [95%CI:0.36–2.69], 1.01 [95%CI:0.52–1.88] for seizures, 1.66 [95%CI:1.35–3.70] for new neurological dysfunction and 2.17 [95%CI:1.22–3.85] for conversion into GA. The latter result has to be interpreted cautiously. It is based on one retrospective high-risk of bias study and significance was abolished in a sensitivity analysis of only prospectively conducted studies.ConclusionSAS and MAC techniques were feasible and safe, whereas data for AAA technique are limited. Large RCTs are required to prove superiority of one anaesthetic regime for AC.

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Section: Discussionmentioning

confidence: 99%

Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis

et al. 2016

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“…With avoidance of sedation and thus lack of sedation overhang and with a minimized dose of remifentanil, patient performance was unimpaired in our study. Using the same method in awake craniotomies for tumour resection patients were more alert than after regional anaesthesia with mild sedation [14]. Other complications arise from termination of anaesthesia or sedation, such as hypertension with the risk of intracerebral haemorrhage, tracheal and pharyngeal irritation by withdrawal of an endotracheal tube or a laryngeal mask, or confusion with uncontrolled movements and dislocation of the head fixation [28].…”

Section: Discussionmentioning

confidence: 99%

“…Patients under conscious sedation and after interruption of anaesthesia might be considered “awake,” and the mean wake-up time after remifentanil and propofol for DBS has been reported to be 9 min [13]. However, more sophisticated measures of vigilance and alertness reveal cognitive impairments for at least 1 h [14], and even short-acting sedatives can interfere with test performance and cooperation. Based on these findings it is generally agreed that the less anaesthetic drugs have to be used the better, as long as optimal conditions for clinical testing and patient comfort are provided.…”

Section: Introductionmentioning

confidence: 99%

Deep Brain Stimulation Surgery without Sedation

Zech

Seemann

Seyfried

et al. 2018

Stereotact Funct Neurosurg

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Background: Sedatives and opioids used during deep brain stimulation (DBS) surgery interfere with optimal target localization and add to side effects and risks, and thus should be minimized. Objective: To retrospectively test the actual need for sedatives and opioids when cranial nerve blocks and specific therapeutic communication are applied. Methods: In a case series, 64 consecutive patients treated with a strong rapport, constant contact, non-verbal communication and hypnotic suggestions, such as dissociation to a “safe place,” reframing of disturbing noises and self-confirmation, were compared to 22 preceding patients under standard general anaesthesia or conscious sedation. Results: With introduction of the protocol the need for sedation dropped from 100% in the control group to 5%, and from a mean dose of 444 mg to 40 mg in 3 patients. Remifentanil originally used in 100% of the patients in an average dose of 813 µg was reduced in the study group to 104 µg in 31% of patients. There were no haemodynamic reactions indicative of stress during incision, trepanation, electrode insertion and closure. Conclusion: With adequate therapeutic communication, patients do not require sedation and no or only low-dose opioid treatment during DBS surgery, leaving patients fully awake and competent during surgery and testing.

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“…Series based on awake surgery showed a higher overall rate of improvement with less new/worsened deficits [17,19,21], probably due to a more sensitive brain mapping response [12].…”

Section: Patient Populationmentioning

confidence: 98%

Surgery on motor area metastasis

et al. 2015

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The role of surgery on central area metastasis remains unclear, and outcome data are still controversial. The aim of our study is to analyze the predictive value of clinical and surgical data on motor and functional outcome of patients, taking into account new emerging data on boundary irregularity of brain metastasis. We retrospectively analyzed 47 consecutive patients who underwent surgery assisted by neurophysiologic monitoring for a solitary metastasis in central area between 2010 and 2013. Inclusion criteria were as follows: good functional status (Karnofsky Performance Status (KPS) ≥70), controlled systemic disease, and absence of extra-cranial dissemination. At 1-month follow up, motor and functional outcomes were compared with preoperative clinical status, response to corticosteroids, extent of tumor resection, boundary irregularity, and size of tumor. Gross total resection was achieved in 93.6% of cases. In preoperative symptomatic patients, motor outcome (according to Medical Research Council grading scale) improved in 55.5% and worsened in 16.7%, while functional outcome (according to KPS score) improved in 50% and worsened in 14.2% of cases. No worsening occurred in preoperative asymptomatic patients. Motor outcome resulted to be not correlated with preoperative deficits, tumor volume, or preoperative response to corticosteroid treatment. Remarkably, motor outcome and extent of surgical resection appeared strongly correlated with tumor boundary irregularity (p < 0.05). Surgery with neurophysiologic monitoring on motor area metastasis can improve functional and motor condition in selected patients. Tumor volume does not represent a limit in surgery. The high correlation between clinical outcome, resection rate, and tumor boundary irregularity strengthens a new belief on the infiltrative growing pattern of brain metastasis. Motor function was evaluated according to Medical Research Council grading scale (Ott et al. 2014) while functional status was assessed according to KPS score.

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The Impact of Sedation on Brain Mapping

Cited by 25 publications

References 21 publications

Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis

Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis

Deep Brain Stimulation Surgery without Sedation

Surgery on motor area metastasis

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