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Awake craniotomies in the pediatric population: a systematic review
Debarati Bhanja1, Bao Y Sciscent1, Lekhaj C Daggubati2
1Departments of1Neurosurgery and.
Insights
Awake craniotomy (AC) is a safe and tolerable procedure for children with brain pathologies. Standardized guidelines are needed to optimize outcomes and minimize risks in pediatric patients undergoing AC.
Area of Science:
- Neurosurgery
- Pediatric Anesthesiology
- Neuroscience
Background:
- Awake craniotomy (AC) is a neurosurgical technique used to maximize tumor resection while preserving neurological function.
- While common in adults, AC in children is less established due to concerns about neuropsychological differences and procedure feasibility.
- This systematic review analyzes outcomes and anesthetic protocols for pediatric AC.
Approach:
- A systematic review following PRISMA guidelines was conducted.
- Studies reporting AC in children with intracranial pathologies were extracted from Medline/PubMed, Ovid, and Embase databases (inception to 2021).
- Data included patient demographics, pathology, and anesthetic management; outcomes assessed were conversion to general anesthesia, intraoperative seizures, task completion, and postoperative complications.
Key Points:
- Thirty studies involving 130 pediatric patients (ages 7-17) undergoing AC were analyzed.
- The most common indication was tumors (77.6%).
- Complications included conversion to general anesthesia (4.1%), intraoperative seizures (7.8%), difficulty with monitoring tasks (20.6%), and postoperative complications (19.4%).
- Common anesthetic techniques involved asleep-awake-asleep protocols with propofol, remifentanil/fentanyl, local scalp blocks, and dexmedetomidine.
Conclusions:
- Pediatric AC demonstrates tolerability and safety for treating intracranial pathologies.
- Individualized risk-benefit analyses are crucial due to potential risks in children.
- Development of age-specific guidelines for AC in pediatric neurosurgery is recommended to minimize complications and improve patient care.
Objective:
Awake craniotomy (AC) is employed to maximize tumor resection while preserving neurological function in eloquent brain tissue. This technique is used frequently in adults but remains poorly established in children. Its use has been limited due to concern for children's neuropsychological differences compared with adults and how these differences may interfere with the safety and feasibility of the procedure. Among studies that have reported pediatric ACs, complication rates and anesthetic management vary. This systematic review was performed to comprehensively analyze outcomes and synthesize anesthetic protocols of pediatric ACs.
Methods:
The authors followed PRISMA guidelines to extract studies that reported AC in children with intracranial pathologies. The Medline/PubMed, Ovid, and Embase databases were searched from database inception to 2021, using the terms ("awake") AND ("Pediatric*" OR "child*") AND (("brain" AND "surgery") OR "craniotomy"). Data extracted included patient age, pathology, and anesthetic protocol. Primary outcomes assessed were premature conversion to general anesthesia, intraoperative seizures, completion of monitoring tasks, and postoperative complications.
Results:
Thirty eligible studies published from 1997 to 2020 were included that described a total of 130 children ranging in age from 7 to 17 years who had undergone AC. Of all patients reported, 59% were male and 70% had left-sided lesions. Procedure indications included the following etiologies: tumors (77.6%), epilepsy (20%), and vascular disorders (2.4%). Four (4.1%) of 98 patients required conversion to general anesthesia due to complications or discomfort during AC. In addition, 8 (7.8%) of 103 patients experienced intraoperative seizures. Furthermore, 19 (20.6%) of 92 patients had difficulty completing monitoring tasks. Postoperative complications occurred in 19 (19.4%) of 98 patients and included aphasia (n = 4), hemiparesis (n = 2), sensory deficit (n = 3), motor deficit (n = 4), or others (n = 6). The most commonly reported anesthetic techniques were asleep-awake-asleep protocols using propofol, remifentanil or fentanyl, a local scalp nerve block, and with or without dexmedetomidine.
Conclusions:
The findings of this systematic review suggest the tolerability and safety of ACs in the pediatric population. Although pediatric intracranial pathologies pose etiologies that certainly may benefit from AC, there is a need for surgeons and anesthesiologists to perform individualized risk-benefit analyses due to the risks associated with awake procedures in children. Age-specific, standardized guidelines for preoperative planning, intraoperative mapping, monitoring tasks, and anesthesia protocols will help to continue minimizing complications, while improving tolerability, and streamlining workflow in the treatment of this patient population.
