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Year : 2008  |  Volume : 2  |  Issue : 2  |  Page : 52-56

Patient satisfaction following awake craniotomy

1 Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London Health Sciences Centre, 339 Windermere Road, London N6A 5A5. Canada
2 Department of Clinical Neurological Sciences (Division of Neurosurgery), University of Western Ontario, London Health Sciences Centre, 339 Windermere Road, London, N6A 5A5., Canada

Correspondence Address:
N Khalifah
Department of Anesthesia, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, P.O Box 3354, Saudi Arabia.

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Source of Support: None, Conflict of Interest: None

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Date of Web Publication18-Jul-2009


Background: Awake craniotomy using local anaesthesia and monitored conscious sedation is widely used for the excision of intracranial tumors or vascular abnormalities or for the management of refractory seizures. Propofol combined with remifentanil represents a popular technique for the provision of conscious sedation
during these procedures. This study evaluated patient satisfaction following awake craniotomy performed under propofol-remifentanil sedation. The study also assessed the incidence of intraoperative and postoperative complications associated with this technique.
Method: This prospective study evaluated the satisfaction of 25 adult patients undergoing awake craniotomy under propofol-remifentanil sedation. Evaluation involved interviewing patients at 1 hour, 24 hours, and 6 weeks postoperatively. Postoperative recall of pain, anxiety, and discomfort were assessed at 1 hour, 24 hours, and 6 weeks postoperatively. Surgeon and anesthesiologist satisfaction was also evaluated at the end of each procedure.
Results: At 1 hour postoperative assessment, twenty-four patients (96%) were satisfied with the anesthetic technique. Patient satisfaction scores were similar at 1 hour, 24 hours and 6 weeks postoperatively. Twenty­one of the twenty-four patients (84%) stated that they would choose the same anesthetic technique if they were to undergo the same procedure again. Surgeons and anesthesiologists were satisfied in twenty-three cases (92%).
Conclusion: This study confirms that monitored conscious sedation with propofol-remifentanil is a useful alternative technique for awake craniotomy with a high patient, surgeon and anesthetist satisfaction.

Keywords: Awake craniotomy; remifentanil

How to cite this article:
Khalifah N, Herrick I, Megyesi J, Parrent A, Steven D, Craen R. Patient satisfaction following awake craniotomy. Saudi J Anaesth 2008;2:52-6

How to cite this URL:
Khalifah N, Herrick I, Megyesi J, Parrent A, Steven D, Craen R. Patient satisfaction following awake craniotomy. Saudi J Anaesth [serial online] 2008 [cited 2023 Feb 2];2:52-6. Available from:

   Introduction Top

AWAKE CRANIOTOMY ALLOWS INTRAOPERATIVE brain mapping and optimal resection of intracranial lesion or epliptogenic brain focus close to eloquent areas of the brain [1],[2],[3] . However, the operative experience can be very stressful for the patient. The current challenge for the anesthesiologist is to find a technique that provides adequate level of sedation and analgesia, optimal surgical conditions and at the same time allows intraoperative neurological testing and brain mapping without respiratory and hemodynamic compromise.

Traditionally, neurolept analgesia has been used to provide sedation during awake craniotomy. Commonly used drugs included fentanyl, midazolam and droperidol [4],[5],[6],[7],[8],[9] . More recently, the use of propofol has become popular and is frequently administered in combination with remifentanil. Evidence suggests that low doses of propofol do not interfere substantially with intraoperative electrocorticography (ECoG) recordings if administration is suspended in advance of the electrophysiological testing. The popularity of this technique is based on the assumption that it provides more pleasant sedation that is more readily titrated to clinical circumstances than traditional neurolept technique. However, patient, surgeon, anesthesiologist satisfaction with the technique has not been systematically evaluated.

   Methods Top

After institutional Research Ethics Board approval and acquisition of a written, informed consent, all adult patients (aged 18-65 yr) scheduled for removal of intracranial tumors or vascular abnormalities or for the management of refractory seizures under local anesthesia and monitored conscious sedation at London Health Science Centre, a tertiary referral centre for neurosurgery between, December 2003 and March 2005 were enrolled in the study. Exclusion criteria included uncooperative patients, patients with drug/alcohol dependence and patients with significant cardiac, pulmonary, hepatic or renal disease.

Intraoperative monitoring included ECG, pulse oximetry, non-invasive automated blood pressure measurement, respiratory rate and End-tidal CO2. Arterial lines and urinary catheters were inserted at the discretion of the attending anesthesiologist. Regional blockade of the scalp was performed by the surgeon using lidocaine 2% and bupivacaine 0.25% with epinephrine 1:200,000. All patients were placed in a three head pins system for head stabilization.

All patients received supplemental oxygen via nasal prongs or simple face masks during surgery. Sedation and analgesia were administered as intravenous infusions of propofol (20-100 ug/kg/min) and remifentanil (0.03-0.1 ug/kg/min). Infusion rates and the depth of sedation were adjusted by the attending anesthesiologist according to patient comfort, hemodynamic and respiratory parameters. Patients were deeply sedated during regional blockade of the scalp. Propofol infusion was discontinued 15 minutes prior to brain mapping. Intraoperative data included sedation score using a 5-points sedation scale were 1 represents fully awake oriented patient, and 5 represents a patient who is unrousable to mild physical stimulation. The level of sedation was assessed at the time of regional blockade, head pin insertion, and brain mapping. Postoperatively, patient satisfaction was assessed with a questionnaire completed during an interview with a member of the anesthesia team at 1 hour, 24 hours and 6 weeks postoperatively. (Appendix 1)

Post operative recall of intraopeartive events was also evaluated during interviews conducted at 24 hours and 6 weeks postoperatively. Postopertive recall of pain, discomfort, and anxiety were evaluated using individual 10 point visual analogue scales, with responses quantified as none (0), mild (1-3), moderate (4-7), severe (8-10).

Surgeon satisfaction was evaluated at the end of each procedure using 10-point scale to assess operative conditions, brain mapping, patient cooperation, and the quality of ECoG recording if performed. (Appendix 2)

Anesthesiologist satisfaction was also assessed postoperatively using 10-point scales to evaluate brain mapping conditions and patient suitability for an awake surgical technique. (Appendix 3)

Both intraoperative and postoperative complications were reported. Hemodynamic complications were defined as SBP >150 mmHg, or SBP < 90 mmHg for more than 5 minutes, or heart rate >110 or < 45 /min. Respiratory complications were defined as oxygen saturation < 90% for more than 3 minutes or apnea. Neurological complications included intraoperative seizure. Other complications included nausea, vomiting and conversion to general anesthesia.

   Results Top

Twenty-seven adult patients scheduled for awake craniotomy were enrolled in the study.

One patient required general anesthesia and endotracheal intubation due to airway obstruction. The other patient developed intraoperative grand mal seizure and the procedure was cancelled. Hence, two patients were excluded from the satisfaction analysis and data from 25 patients were analyzed.

Demographic data and surgical variables are shown in [Table 1].

Patient satisfaction

Twenty-four patients (96%) were satisfied (score = 3/4) or very satisfied (score = 4/4) with the anesthetic technique. One patient was dissatisfied (score = 2/4) and none of the patients reported being very dissatisfied (score = 1/4) at one hour postoperatively. Similar results were obtained at 24 hours and 6 weeks postoperatively [Table 2]. Eighty- four percent of patients (n=21) indicated their willingness to use the same anesthetic technique if they have to. Interestingly, three of the four patients who said that they would not use the same anesthetic technique had a high satisfaction score but did not think that they would cope with the operative stress again. Results were similar at 1 hour, 24 hours and 6 weeks postoperatively. [Table 2]

Sedation score

During regional blockade of the scalp eighteen patients (72%) were deeply sedated, five patients (20%) mildly sedated and one patient was fully awake. During head pin insertion fifteen patients (60%) were deeply sedated, eight patients (32%) were mildly sedated and two patients (8%) were awake. During brain mapping sixteen patients (64%) were awake, nine patients (36%) were mildly sedated and none of the patients were deeply sedated.

Postoperative Recall of intraoperative Events

Seven patients (28%) did not recall any intraoperative pain, sixteen patients (64%) recalled mild pain, one patient recalled moderate pain and one patient recalled severe pain. Six patients (24%) did not recall any intraoperative discomfort, fourteen patients (56%) recalled mild discomfort, four patients (16%) recalled moderate discomfort and one patient recalled severe discomfort. Nine patients (36%) did not recall any intraoperative anxiety, nine patients (36%) recalled mild anxiety, six patients (24%) recalled moderate anxiety and one patient recalled severe anxiety. Similar results were obtained at 24 hours and 6 weeks postoperatively.

Surgeon Satisfaction

With regard to operating conditions, in twenty­three procedures (92%) the surgeon satisfaction was reported as 8 or above. In the two other procedures the surgeon reported a score of 7. No scores of six or less were reported. The results for brain mapping were similar with scores of 8 or higher reported in twenty one procedures (84%) and a score of 7 reported in the remaining 4 procedures.

Anesthesiologist Satisfaction

With regards to brain mapping, in twenty-three procedures (92%) the anesthesiologist reported a score of 8 and above. No score of 5 or less was reported. Similarly, based on postoperative assessment by the anesthesiologist, 92% (n=23) of the patients were reported to have been suitable candidates for an awake procedure.

Intraoperative complications

Intraoperative complications were reported and analyzed from the original 27 patients. Airway obstruction was the most common complication observed. This complication was reported in five patients (18.5%) and was a result of deep levels of sedation. Obstruction was typically alleviated with airway maneuvers (i.e., jaw thrust, or insertion of an airway) in combination with the administration of supplemental oxygen. Oxygen saturation was maintained above 90%. Of the five patients, one patient developed severe airway obstruction that required tracheal intubation and conversion to general anesthesia.

Hypertension was reported in three patients (11.1%) and was treated in each case pharmacologically (i.e., labetalol). One patient developed intraoperative nausea and vomiting. One patient experienced an intraoperative tonic/clonic seizure and was converted to general anesthesia.

Post operative complications

Postoperatively, hypertension was reported in three patients. No other significant postoperative complications were reported.

   Discussion Top

Awake craniotomy is well established procedure for excision of intracranial tumors, epileptogenic foci or vascular abnormalities in close proximity to eloquent areas of the brain [10],[11] . Although several anesthetic techniques have been described for awake craniotomy, the use of propofol and remifentanil is becoming popular combination [8],[12],[13] .

Remifentanil has a very short half-life, which allows rapid control of the depth of anesthesia or sedation [14],[15] . Propofol offers several potential advantages over the traditional neurolept technique.

Its short duration of action also facilitates titration of sedation, and it possesses both antiemetic and amnesic properties at sedative doses [16],[17] . Based on these advantages, it has been postulated that propofol and remifentanil provide a more " pleasant" anesthetic experience for the patients [18] . During awake craniotomy however, a formal evaluation of patient, surgeon and anesthesiologist satisfaction with this technique has not been performed.

The data from this prospective study demonstrate that the use of propofol-remifentanil sedation during awake craniotomy is associated with high patient satisfaction (96%). The majority of patients (21 out of 25) expressed willingness to use the same anesthetic technique again if they have to undergo the same surgery. Although the majority of patients were deeply sedated during regional blockade and during the insertion of head pins, most of the patients were awake during brain mapping and were able to perform neurological testing as reflected in surgeon and anesthetist satisfaction scores.

Most of the patients reported experiencing only mild intraoperative pain, discomfort or anxiety at 24 hours and 6 weeks postoperatively. Only one patient recalled severe intraoperative pain, discomfort and anxiety. This patient required awake craniotomy for excision of a tumor in close proximity to a motor area of the brain. Even though she was deeply sedated most of the procedure; she was very anxious and uncooperative during periods of neurophysiological testing. She was complaining of severe pain and discomfort and in spite all the measures (reassurance, analgesia, patient position adjustment), she was still not satisfied. It was still necessary to proceed with the awake procedure with constant testing of her motor function due to the delicate location of her tumor. Postoperatively, she was considered by the attending anesthetist as an unsuitable candidate for an awake surgery.

Respiratory complications were the most common intraoperative complication. The combination of propofol and remifentanil and the deep level of sedation established during regional blockade of the scalp were contributing factors. While most patients did not experience airway obstruction, the occurrence of airway obstruction in 18.5% of the patients in this study exemplifies the need for enhanced respiratory monitoring and vigilance when deep levels of sedation required.

The data from this prospective study indicate that propofol-remifentanil conscious sedation during awake craniotomy is associated with high patient, surgeon and anesthetist satisfaction. However, deep levels of sedation can be associated with airway obstruction in some patients, emphasizing the need for careful observation and monitoring.

   References Top

1.Black PM, Ronner SF. Cortical mapping for defining the limits of tumor resection. Neurosurgery 1987 Jun; 20:914­9.  Back to cited text no. 1    
2.Ebeling U, Schmid UD, Ying H, Reulen HJ. Safe surgery of lesions near the motor cortex using intra-operative mapping techniques: a report on 50 patients. Acta Neurochir. (Wien.) 1992; 119:23-8.  Back to cited text no. 2    
3.Haglund MM, Berger MS, Shamseldin M, Lettich E, Ojemann GA. Cortical localization of temporal lobe language sites in patients with gliomas. Neurosurgery 1994 Apr; 34:567-76.  Back to cited text no. 3    
4.Archer DP, McKenna JM, Morin L, Ravussin P. Conscious-sedation analgesia during craniotomy for intractable epilepsy: a review of 354 consecutive cases. Can.J.Anaesth. 1988 Jul; 35:338-44.  Back to cited text no. 4    
5.Sarang A, Dinsmore J. Anaesthesia for awake craniotomy evolution of a technique that facilitates awake neurological testing. Br.J.Anaesth. 2003 Feb; 90:161-5.  Back to cited text no. 5    
6.Danks RA, Rogers M, Aglio LS, Gugino LD, Black PM. Patient tolerance of craniotomy performed with the patient under local anesthesia and monitored conscious sedation. Neurosurgery 1998 Jan; 42:28-34.  Back to cited text no. 6    
7.Herrick IA, Craen RA, Gelb AW, Miller LA, Kubu CS, Girvin JP, Parrent AG, Eliasziw M, Kirkby J. Propofol sedation during awake craniotomy for seizures: patient­controlled administration versus neurolept analgesia. Anesth.Analg. 1997 Jun; 84:1285-91.  Back to cited text no. 7    
8.Johnson KB, Egan TD. Remifentanil and propofol combination for awake craniotomy: case report with pharmacokinetic simulations. J.Neurosurg.Anesthesiol. 1998 Jan; 10:25-9.  Back to cited text no. 8    
9.Berkenstadt H, Perel A, Hadani M, Unofrievich I, Ram Z. Monitored anesthesia care using remifentanil and propofol for awake craniotomy. J.Neurosurg.Anesthesiol. 2001 Jul; 13:246-9.  Back to cited text no. 9    
10.Taylor MD, Bernstein M. Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: a prospective trial of 200 cases. J.Neurosurg. 1999 Jan; 90:35-41.  Back to cited text no. 10    
11.Blanshard HJ, Chung F, Manninen PH, Taylor MD, Bernstein M. Awake craniotomy for removal of intracranial tumor: considerations for early discharge. Anesth.Analg. 2001 Jan; 92:89-94.  Back to cited text no. 11    
12.Hogue CW, Jr., Bowdle TA, O'Leary C, Duncalf D, Miguel R, Pitts M, Streisand J, Kirvassilis G, Jamerson B, McNeal S, et al. A multicenter evaluation of total intravenous anesthesia with remifentanil and propofol for elective inpatient surgery. Anesth.Analg. 1996 Aug; 83:279-85.  Back to cited text no. 12    
13.Vuyk J, Mertens MJ, Olofsen E, Burm AG, Bovill JG. Propofol anesthesia and rational opioid selection: determination of optimal EC50-EC95 propofol-opioid concentrations that assure adequate anesthesia and a rapid return of consciousness. Anesthesiology 1997 Dec; 87:1549-62.  Back to cited text no. 13    
14.Egan TD, Lemmens HJ, Fiset P, Hermann DJ, Muir KT, Stanski DR, Shafer SL. The pharmacokinetics of the new short-acting opioid remifentanil (GI87084B) in healthy adult male volunteers. Anesthesiology 1993 Nov; 79:881­92.  Back to cited text no. 14    
15.Egan TD. Remifentanil pharmacokinetics and pharmacodynamics. A preliminary appraisal. Clin.Pharmacokinet. 1995 Aug; 29:80-94.   Back to cited text no. 15    
16.Borgeat A, Wilder-Smith OH, Saiah M, Rifat K. Subhypnotic doses of propofol possess direct antiemetic properties. Anesth.Analg. 1992 Apr; 74:539-41.  Back to cited text no. 16    
17.Smith I, Monk TG, White PF, Ding Y. Propofol infusion during regional anesthesia: sedative, amnestic, and anxiolytic properties. Anesth.Analg. 1994 Aug; 79:313-9.  Back to cited text no. 17    
18.Herrick IA, Gelb AW. Anesthesia for temporal lobe epilepsy surgery. Can.J.Neurol.Sci. 2000; 27 Suppl 1:S64­7; discussion S92-6.:S64-S67.  Back to cited text no. 18    


  [Table 1], [Table 2]


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