Awake Craniotomy: Lessons Learned

Awake craniotomy is still in its evolutionary stage and is generally successful in a highly motivated patient. The attending anesthesiologist must ensure that patient is optimally sedated and pain free yet readily arousable. In addition, it is essential to have a Plan B and C ready in case the first one fails. We adopted awake craniotomy technique in a 33 yr old male patient undergoing excision of frontal glioneuronal tumor that produced recurrent convulsions. Despite blockade of six nerves in the scalp bilaterally and sedation with combination of dexmedetomidine-fentanyl, patient felt sharp pain when scalp pins were placed. Despite assurance that he would not feel pain any further, patient refused to proceed any further. However, activating Plan B using supraglottic device and sedation with propofol resulted in successful completion of the surgery in which patient was briefly woken up to perform neurocognitive testing before putting back to sleep till the end of surgery. Lessons learned from this case report were that inadequate motivation and a hasty placement of scalp pins should be avoided to make awake craniotomy successful.