Hypnosis-Assisted Awake Craniotomy for Eloquent Brain Tumors: Advantages and Pitfalls

Abstract

Background: Awake craniotomy (AC) is recommended for the resection of tumors in eloquent areas. It is traditionally performed under monitored anesthesia care (MAC), which relies on hypnotics and opioids. Hypnosis-assisted AC (HAAC) is an emerging technique that aims to provide psychological support while reducing the need for pharmacological sedation and analgesia. We aimed to compare the characteristics and outcomes of patients who underwent AC under HAAC or MAC.

Methods: We retrospectively analyzed the clinical, anesthetic, surgical, and neuropsychological data of patients who underwent awake surgical resection of eloquent brain tumors under HAAC or MAC. We used Mann-Whitney U tests, Wilcoxon signed-rank tests, and repeated-measures analyses of variance to identify statistically significant differences at the 0.05 level.

Results: A total of 22 patients were analyzed, 14 in the HAAC group and 8 in the MAC group. Demographic, radiological, and surgical characteristics as well as postoperative outcomes were similar. Patients in the HAAC group received less remifentanil (p = 0.047) and propofol (p = 0.002), but more dexmedetomidine (p = 0.025). None of them received ketamine as a rescue analgesic. Although patients in the HAAC group experienced higher levels of perioperative pain (p < 0.05), they reported decreasing stress levels (p = 0.04) and greater levels of satisfaction (p = 0.02).

Conclusion: HAAC is a safe alternative to MAC as it reduces perioperative stress and increases overall satisfaction. Further research is necessary to assess whether hypnosis is clinically beneficial.

Keywords: anesthesia; awake craniotomy; brain neoplasms; brain tumor; eloquent area; hypno-sedation; hypnosis; monitored anesthesia care.

Figure 1

Surgical and procedural durations were both marginally shorter in the hypnosis-assisted awake craniotomy group (HAAC), compared to the monitored anesthesia care group (MAC). This trend was not statistically significant. Abbreviations: HAAC: hypnosis-assisted awake craniotomy; MAC: monitored anesthesia care.

Figure 2

Differences in analgesia protocols between hypnosis-assisted awake craniotomies (HAAC) and monitored anesthesia care (MAC) procedures. HAAC patients received less remifentanil (436 mcg vs. 659 mcg in the MAC group; p = 0.047), probably mainly due to a shorter surgical duration, as the average infusion rate was not significantly different between the two groups. Rescue therapy was used less frequently in the HAAC group (p = 0.02). Other opioids were used similarly in the two groups. Abbreviations: HAAC: hypnosis-assisted awake craniotomy; kg: kilogram; MAC: monitored anesthesia care; mcg: microgram.

Figure 3

Propofol was used less often (p = 0.002), and at significantly lower infusion rates (p < 0.001), in the hypnosis-assisted awake craniotomy (HAAC) group. The total dose of dexmedetomidine was similar in the two groups, but average infusion rates were higher in the HAAC group (p = 0.025). Abbreviations: HAAC: hypnosis-assisted awake craniotomy; h: hour; kg: kilogram; MAC: monitored anesthesia care.

Figure 4

Perioperative stress measured using a visual analog scale (VAS). Patients in the HAAC group showed decreasing stress levels over time (p = 0.04), as opposed to patients in the MAC group, who showed increasing stress levels over time (p = 0.09). Pain scores were higher in the HAAC group: mean perioperative pain scores were 3.8 in the HAAC group vs. 0.9 in the MAC group (p = 0.03), while maximal perioperative pain scores were 7.2 in the HAAC group vs. 2.7 in the MAC group (p = 0.009). Comfort scores were similar in both groups. Abbreviations: HAAC: hypnosis-assisted awake craniotomy; MAC: monitored anesthesia care; preop: preoperative; perop: during surgery; postop: postoperative; VAS: visual analog scale.