ABSTRACT
Traumatic brain injury is one of the leading causes of morbidity and mortality worldwide and is one of the major public healthcare burdens in the US, with millions of patients suffering from the traumatic brain injury itself (approximately 1.6 million/year) or its repercussions (2-6 million patients with disabilities). The severity of traumatic brain injury can range from mild transient neurological dysfunction or impairment to severe profound disability that leaves patients completely non-functional. Indications for treatment differ based on the injury's severity, but one of the goals of early treatment is to prevent secondary brain injury. Hemodynamic stability, monitoring and treatment of intracranial pressure, maintenance of cerebral perfusion pressure, support of adequate oxygenation and ventilation, administration of hyperosmolar agents and/or sedatives, nutritional support, and seizure prophylaxis are the mainstays of medical treatment for severe traumatic brain injury. Surgical management options include decompressive craniectomy or cerebrospinal fluid drainage via the insertion of an external ventricular drain. Several emerging treatment modalities are being investigated, such as anti-excitotoxic agents, anti-ischemic and cerebral dysregulation agents, S100B protein, erythropoietin, endogenous neuroprotectors, anti-inflammatory agents, and stem cell and neuronal restoration agents, among others.
ABSTRACT
Most current awake craniotomy techniques utilize unnecessarily complicated airway management, and cause discomfort to the patients during the awake phase of the surgery. Our manuscript is written to discuss the neurosurgical and anesthetic techniques that we have developed to optimize awake craniotomy techniques at Stony Brook University Medical Center. We used the frameless Brainlab™ skull-mounted array for stereotactic navigation. Rigid fixation of the skull was avoided. General anesthesia with established airway was used during the "asleep" phase of the surgery. Following the removal of the bone flap and the opening of the dura, the patients were woken up, and the established airway was removed. Cortical mapping was performed to establish a safe entry zone for tumor removal. While the tumors were being removed, we continued motor examination and casual conversation with the patients to ensure safety. Patients were sedated during the remaining phase of the surgery until skin closure. No patient exhibited any neurological deficits or adverse anesthesia outcomes during the postoperative period. The protocol we developed avoids rigid skull fixation and emphasizes flexible intraoperative planning, thereby maximizing patient and physician comfort while allowing for successful tumor resection.
