Upward Herniation in Awake Craniotomy: A Case Report

Awake craniotomy has been gaining popularity for the last decade. It allowed maximum tumor resection while avoiding neurological morbidity. However, this technique presents several challenges to both the neurosurgeon and anesthesiologist. In this case, we present a 33-year-old male who was diagnosed with low-grade glioma in the left parieto-occipital, which required surgical resection. Anatomically, the tumor was located in the language area. Hence, it was decided to perform an awake craniotomy excision of the tumor to allow intraoperative cortical mapping to preserve language functions. Intraoperative, a subdural hematoma was noted, and severe pain occurred. Eventually, this leads to an upward herniation of the brain parenchyma. The crisis was addressed promptly with maneuvers to decrease intracranial pressure. Awake craniotomy was abandoned, and the procedure was converted to general anesthesia without the benefit of intraoperative cortical mapping. It is important to note that complications may arise during the procedure, leading to significant harm and debilitation for the patient. Prompt crisis management is necessary to address these potential issues and ensure the highest level of care is provided.