Successful Second Awake Craniotomy Reoperation With Dexmedetomidine After an Initial Abandonment Case Due to Restlessness

Abstract

Awake craniotomy (AC) is sometimes aborted due to poor arousal and restlessness. Dexmedetomidine (DEX), an α2-adrenoreceptor agonist, has sedative, analgesic, and anesthetic-sparing effects, with a low risk of respiratory depression, making it effective for intraoperative pain and agitation during the awake phase. We report a case in which AC was successfully performed in combination with low-dose continuous administration of DEX during reoperation in a patient who experienced poor arousal and restlessness during their first surgery, leading to the abandonment of AC. The patient is a 48-year-old male who is scheduled for AC reoperation. Two years ago, the first AC was scheduled and performed under anesthesia with propofol and remifentanil. However, AC was abandoned due to poor intraoperative arousal and restlessness. At reoperation, general anesthesia was induced with propofol and continuous administration of remifentanil (0.1 µg/kg/min); following anesthesia induction (continuous infusion of propofol, remifentanil, and a bolus infusion of fentanyl), DEX was also administered (0.2 µg/kg/hour). We performed a scalp nerve block. Before the awake phase, the propofol dose was decreased as was DEX to 0.1 µg/kg/hour, and propofol and remifentanil were discontinued. The patient gradually awoke without any agitation and restlessness 24 min after stopping propofol and remifentanil and could perform language tasks without any complications. In this case, AC was successfully performed in combination with continuous low-dose administration of DEX at the time of reoperation in a patient who experienced poor arousal and restlessness during their first operation and had to discontinue AC.

Keywords: asleep-awake-awake methods; awake craniotomy; dexmedetomidine; propofol; restlessness.

Figure 1. Anesthesia record of reoperation.

X, start of anesthesia time; ◎, start of the operation; HR, heart rate; ABP, arterial blood pressure; NIBP, non-invasive blood pressure; EtCO₂, end-tidal carbon dioxide; RR, respiratory rate; DEX, dexmedetomidine; RASS, Richmond agitation-sedation scale; BIS, bispectral index; B, regional nerve block; T, intubation; E, extubation