B Awake craniotomy
In a small percentage of patients (those in whom a seizure focus may be suppressed during general anesthesia or may be adjacent to an area of eloquent cortical function), awake craniotomy may be necessary. Awake craniotomy is the most reliable method to ensure neurologic integrity in cerebral gliomas that infiltrate or come close to the eloquent areas of the brain. It allows for the localization of eloquent cortical areas by electrical stimulation and epileptic foci through cortical recordings. Continuous monitoring of the functional integrity of the brain in awake patients is inherently protective while surgical removal of the gliomatous tissue is performed.
2. Patient preparation
a) Patient selection: To minimize the risk of intraoperative complications, contraindications for awake craniotomy include developmental delay, lack of maturity, an exaggerated or unacceptable response to pain, a significant communication barrier, and a failure to obtain patient consent. Only patients who have the ability to clearly understand risks and benefits and, in the opinion of the neurosurgeon, will cooperate during surgery should be considered as candidates for an awake craniotomy. Seizure management should be optimized with acceptable levels of antiepileptic medications verified.
b) Patient teaching: The single most important element in successful awake craniotomy is a highly motivated, well-informed patient. Each step of the procedure is discussed with the patient and family. Special emphasis is paid to prolonged surgical procedure, positioning, head immobility, pain anxiety, monitoring, noise, seizure management, and any individual considerations.
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