Anesthetic Selection for an Awake Craniotomy for a Glioma With Wernicke's Aphasia: A Case Report

Abstract

Awake craniotomies for tumor resections allow for the preservation of eloquent cortex; however, they are high-risk surgeries that require careful patient selection and meticulous anesthetic management. Patients with significant preoperative language deficits may be unable to participate in intraoperative language mapping, increasing the risk of a failed surgery. Furthermore, anesthetic agents given for sedation and analgesia during the initial portion of the surgery may exacerbate existing language deficits. We present a case of an asleep-awake-asleep craniotomy for a left temporal lobe glioma using intraoperative neuronavigation, 5-aminolevulinic acid fluorescence, and awake speech mapping for a patient with a significant preoperative language deficit, for whom sedation had to be meticulously titrated to optimize intraoperative language testing. Anesthetic titration was aided by bispectral index monitoring, ultimately allowing successful awake speech mapping and tumor resection.

Keywords: 5-aminolevulinic acid fluorescence; awake craniotomy; bispectral index; gleolan; neuroanesthesiology; neuromonitoring.

Figure 1. Preoperative MRI of the brain.

Axial images of the brain showing a left temporal lobe glioma in close proximity to Wernicke’s area and the arcuate fasciculus, with significant vasogenic edema, and a 3-4 mm left to right midline shift. (A) T1 without contrast, (B) T1 with contrast, and (C) fluid-attenuated inversion recovery (FLAIR).