AXON VOLUME 28 ❖ NUMBER 1 ❖ FALL 2006 15 By Sharon Hoosein, RN, MN/ACNP, CNN(C) Abstract The awake craniotomy procedure has become the gold standard for tumour resection in eligible patients. In this paper, the awake craniotomy procedure is reviewed, including the advantages of the procedure over the standard craniotomy procedure. The role of the neuroscience nurse in awake craniotomies is highlighted. Introduction The use of the awake craniotomy procedure for brain mapping began in the 1950s at the Montreal Neurological Institute by the Canadian pioneer, Dr. Wilder Penfield. His work, in mapping the brain, led to understanding the function of the areas of the cerebral cortex, known today as the Somatosensory Map (Bulsara, Johnson, & Villavicencio, 2005). Today, awake craniotomy is used for tumour resection, allowing patients a faster recovery, a shortened length of hospital stay, a decline in post-operative complications, and a higher satisfaction rate (Bernstein, 2001; Berkenstadt, 2001; Bhardwaj, 2002). In this paper, the awake craniotomy procedure is described. A detailed account of the operative phase will be given and the nursing care of the patient undergoing the awake craniotomy will be discussed. Very little information currently exists in the literature regarding nursing care during and after this procedure. Review of the literature Penfield’s work with intractable epilepsy led him to the discovery of the “asleep-awake-asleep” technique (Berkenstadt, 2001; Blanshard, 2001; Meyers, 2001; Taylor & Bernstein, 1999) that is now used in anesthesia to enable the surgeon to speak with an alert patient during cortical mapping. It was essential that Penfield’s patients be alert so that, as an electrical stimulant was applied to specific areas on the cerebral cortex, he could elicit a reaction or aura in his patients. This response indicated the area of the cortex responsible for the seizure and, thus, it could be removed or destroyed. Penfield used this simple technique to map the brain into its corresponding body parts. A diagrammatical figure or homunculus was created to demonstrate that the face, lips, tongue and hands have far more innervation on the cerebral cortex than any other parts of the body. Penfield also discovered that the human brain’s surface cortex corresponds to physical anatomy and is influenced by the motor and sensory experiences of the individual (Bulsara, Johnson, & Villavicencio, 2005). For example, an artist’s motor cortex would be highly evolved and reorganized to reflect the practices of a musician, painter, or dancer. The eloquent areas of the cortex such as the motor strip, Broca’s area (receptive speech) in the dominant hemisphere, and Wernicke’s area (expressive speech) were also defined and could be avoided during surgery in order to prevent impairment of these functions. With a trend in health care towards a shorter length of stay (LOS), use of less-invasive treatments, and the evolution of imaging technology, the awake craniotomy procedure has gained favour not only in epilepsy treatment, but also brain tumour resection from eloquent areas, Parkinson’s dystonia, and even heroin addiction (Bernstein, 2001; Bhardwaj, 2002). The basic advantage of keeping a patient awake while performing intricate neurosurgery is obvious. Mapping prior to cutting can prevent unnecessary damage to the functionally important or eloquent areas of the brain. When compared to the standard craniotomy procedure, the awake procedure also reduces the intensive care unit (ICU) stay and shortens total LOS to about two to three days (Bhardwaj, 2002; Bernstein, 2001; Blanshard, 2001; Meyers, 2001; Taylor & Bernstein, 1999). During an awake craniotomy, patients do not require intubation or ventilation and are free of an indwelling urinary catheter. In contrast, the standard craniotomy procedure requires a longer LOS of about five to seven days, and patients require monitoring in the ICU because of the risk of developing a post- operative hematoma. A longer ICU stay was often necessary as patients had to be weaned from the ventilator or were intubated to protect their airway or manage secretions. A longer ICU stay was characterized by a decreased level of consciousness (LOC), increased intracranial pressure (ICP), and greater incidence of motor deficits, seizures, and infection (Sarkissian, 1995). In addition, patients with an indwelling urinary catheter were more likely to suffer a urinary tract infection (UTI), with risk of infection rising as much as 10% each day. UTIs are associated with prolonged hospital stay, use of antibiotics, increased mortality, and increased costs associated with hospital stay (Kunin, 2001; Saint & Lipsky, 1999; Parkin & Keeley, 2003). Intravascular devices such as intravenous (IV), or central venous pressure lines (CVP) placed patients at risk for infections and colonization with resistant micro-organisms (Struelens, 1998). Immobility coupled with malignancy potentiates hypercoagulability and the development of deep vein thrombosis (DVT) and pulmonary embolus for the post- operative brain tumour patients (Goldhaber, 2002; Warbel, 1999). Early mobility and discharge reduces the incidence of these nosocomial complications (Bernstein, 2001). It is, however, important to note that not every brain tumour patient is eligible for an awake craniotomy. Bosek (2004) and Taylor and Bernstein (1999) described patients with acute increases in ICP, sleep apnea, obesity, emotional instability, decreased LOC, or a difficult airway as ineligible for this procedure. Tumours in the low occiput also were excluded as operative positioning limited patient interaction. Additionally, patients who were dysphasic or had a language barrier could not be properly assessed during the mapping and were also ineligible. Eyes wide open: The awake craniotomy for tumour resection: A review
Transcript
AXON VOLUME 28 � NUMBER 1 � FALL 2006 15
By Sharon Hoosein, RN, MN/ACNP, CNN(C)
AbstractThe awake craniotomy procedure has become the goldstandard for tumour resection in eligible patients. In thispaper, the awake craniotomy procedure is reviewed, includingthe advantages of the procedure over the standard craniotomyprocedure. The role of the neuroscience nurse in awakecraniotomies is highlighted.
IntroductionThe use of the awake craniotomy procedure for brain mappingbegan in the 1950s at the Montreal Neurological Institute bythe Canadian pioneer, Dr. Wilder Penfield. His work, inmapping the brain, led to understanding the function of theareas of the cerebral cortex, known today as theSomatosensory Map (Bulsara, Johnson, & Villavicencio,2005). Today, awake craniotomy is used for tumour resection,allowing patients a faster recovery, a shortened length ofhospital stay, a decline in post-operative complications, and ahigher satisfaction rate (Bernstein, 2001; Berkenstadt, 2001;Bhardwaj, 2002). In this paper, the awake craniotomyprocedure is described. A detailed account of the operativephase will be given and the nursing care of the patientundergoing the awake craniotomy will be discussed. Very littleinformation currently exists in the literature regarding nursingcare during and after this procedure.
Review of the literaturePenfield’s work with intractable epilepsy led him to thediscovery of the “asleep-awake-asleep” technique (Berkenstadt,2001; Blanshard, 2001; Meyers, 2001; Taylor & Bernstein,1999) that is now used in anesthesia to enable the surgeon tospeak with an alert patient during cortical mapping. It wasessential that Penfield’s patients be alert so that, as an electricalstimulant was applied to specific areas on the cerebral cortex, hecould elicit a reaction or aura in his patients. This responseindicated the area of the cortex responsible for the seizure and,thus, it could be removed or destroyed. Penfield used this simpletechnique to map the brain into its corresponding body parts. Adiagrammatical figure or homunculus was created todemonstrate that the face, lips, tongue and hands have far moreinnervation on the cerebral cortex than any other parts of thebody. Penfield also discovered that the human brain’s surfacecortex corresponds to physical anatomy and is influenced by themotor and sensory experiences of the individual (Bulsara,Johnson, & Villavicencio, 2005). For example, an artist’s motorcortex would be highly evolved and reorganized to reflect thepractices of a musician, painter, or dancer. The eloquent areas ofthe cortex such as the motor strip, Broca’s area (receptivespeech) in the dominant hemisphere, and Wernicke’s area(expressive speech) were also defined and could be avoidedduring surgery in order to prevent impairment of thesefunctions.
With a trend in health care towards a shorter length of stay(LOS), use of less-invasive treatments, and the evolution ofimaging technology, the awake craniotomy procedure hasgained favour not only in epilepsy treatment, but also braintumour resection from eloquent areas, Parkinson’s dystonia,and even heroin addiction (Bernstein, 2001; Bhardwaj, 2002).
The basic advantage of keeping a patient awake whileperforming intricate neurosurgery is obvious. Mapping prior tocutting can prevent unnecessary damage to the functionallyimportant or eloquent areas of the brain. When compared tothe standard craniotomy procedure, the awake procedure alsoreduces the intensive care unit (ICU) stay and shortens totalLOS to about two to three days (Bhardwaj, 2002; Bernstein,2001; Blanshard, 2001; Meyers, 2001; Taylor & Bernstein,1999). During an awake craniotomy, patients do not requireintubation or ventilation and are free of an indwelling urinarycatheter.
In contrast, the standard craniotomy procedure requires alonger LOS of about five to seven days, and patients requiremonitoring in the ICU because of the risk of developing a post-operative hematoma. A longer ICU stay was often necessary aspatients had to be weaned from the ventilator or were intubatedto protect their airway or manage secretions. A longer ICU staywas characterized by a decreased level of consciousness(LOC), increased intracranial pressure (ICP), and greaterincidence of motor deficits, seizures, and infection (Sarkissian,1995). In addition, patients with an indwelling urinary catheterwere more likely to suffer a urinary tract infection (UTI), withrisk of infection rising as much as 10% each day. UTIs areassociated with prolonged hospital stay, use of antibiotics,increased mortality, and increased costs associated withhospital stay (Kunin, 2001; Saint & Lipsky, 1999; Parkin &Keeley, 2003). Intravascular devices such as intravenous (IV),or central venous pressure lines (CVP) placed patients at riskfor infections and colonization with resistant micro-organisms(Struelens, 1998). Immobility coupled with malignancypotentiates hypercoagulability and the development of deepvein thrombosis (DVT) and pulmonary embolus for the post-operative brain tumour patients (Goldhaber, 2002; Warbel,1999). Early mobility and discharge reduces the incidence ofthese nosocomial complications (Bernstein, 2001).
It is, however, important to note that not every brain tumourpatient is eligible for an awake craniotomy. Bosek (2004) andTaylor and Bernstein (1999) described patients with acuteincreases in ICP, sleep apnea, obesity, emotional instability,decreased LOC, or a difficult airway as ineligible for thisprocedure. Tumours in the low occiput also were excluded asoperative positioning limited patient interaction. Additionally,patients who were dysphasic or had a language barrier couldnot be properly assessed during the mapping and were alsoineligible.
Eyes wide open: The awake craniotomy for tumour resection: A review
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Pre-operative preparationWhile informed consent requires the neurosurgeon topsychologically prepare the patient for this procedure,anesthesiology’s challenge is to provide suitable conditions forsurgery by keeping the patient calm and cooperative withoutjeopardizing their safety and comfort during surgery. A pre-operative meeting between patient and anesthesia allows adegree of rapport to evolve. Nurses’ contributions to the pre-operative preparation of the patient, including allaying anxietyand providing useful discharge information, are not yet widelyutilized in the pre-admission education or screening of eligiblepatients (Zanchetta & Bernstein, 2004). Since the LOS forpatients is greatly shortened, a supportive and attentive familymember was needed to supervise the patient after dischargefollowing an awake craniotomy.
A stealth magnetic resonance imaging (MRI) is a necessityimmediately before the surgical resection (Bernstein, 2001;Blanshard, 2001; Meyers, 2001; Taylor & Bernstein, 1999).Stealth technology allows the surgeon a three-dimensionalview of the lesion using MRI imaging and intra-operativecameras. Fiducial markers are placed on the patient’s head priorto imaging. After the MRI imaging is obtained, the fiducialpoints are registered with an intra-operative camera and thenautomatically calibrated by stealth technology to produce the 3-Dimage coordinates for the surgeon (Bosek, 2004).
Intra-operative careThe surgical procedure of an awake craniotomy lasts from threeto six hours, somewhat longer than a standard craniotomy.However, as the surgeon’s expertise develops, this time maybe reduced (Taylor & Bernstein, 1999). Patients are positionedin a “beach chair” position, which allows them to be supineand lateral, with head of the bed at 20 degrees and facing theanesthesiologist. Elevation of the head promotes gravitationaldrainage of blood and cerebrospinal fluid (CSF) whileminimizing bleeding. This position also provides excellentoperative access for the surgeon (Bosek, 2004; Taylor &Bernstein, 1999). Draping of operative linen is done is such a wayas to allow for eye contact between patient and anesthesiologist.This allows for constant communication between the two, sothat the patient is aware of the progress of the surgery and toallow reactions to stimulation of the cortex to be observed.
The anesthesiologist’s role with a patient undergoing an awakecraniotomy is to advocate for the patient, as well asadministering all medications, monitoring vital signs andassessing patient comfort throughout the procedure. Antibiotics,antiemetics and steroids are given at the start of the surgery. Theasleep-awake-asleep anesthesia technique (Huncke, 1998) isused to begin the process of opening the skull. Additionally,local anesthesia may be injected along the incision lines and intothe dura leaflets. Soft music may lend to a more relaxedatmosphere for the patient and operating room staff. In mostcases, no indwelling urinary catheter is used during theprocedure and the patient is encouraged to void before surgery(Taylor & Bernstein, 1999). In other cases, the indwellingcatheter is inserted immediately before surgery and removed inthe recovery room (Meyer, 2001). The catheter is conjectured tocause irritation and restlessness in patients who are awake. Thepatient may be offered sips of water during the procedure and
male patients can be offered a urinal for voiding for comfort. Afull bladder may necessitate catheterization in a female patient.Further comfort measures for the patient, such as warmblankets, decreasing conversation between staff and reductionof noise in the operating room, results in a less stressfulexperience for the patient (Berkenstadt & Ram, 2001).
Asleep-awake-asleep anesthesiaPrior to surgery, the patient is commonly given propofol,Versed, and remifentanil through an intravenous line. Thissedates the patient to allow the surgeon to begin the supra-orbital nerve blocks, which are very painful, and theapplication of the Mayfield pins and frame that will hold thehead in position throughout the procedure. The patient is thenawakened by adjusting the propofol infusion. The skull is thenopened. Although this procedure is somewhat noisy, it ispainless. The dura is sensitive in some patients and openingthe dura may require increased propofol to delicately balancecomfort, sedation and responsiveness. Brain mapping andtumour resection is performed while the patient is awake sincethe brain itself has no nociceptors for pain. The patient is thenput back to sleep with neurolept, propofol and opioid sedationwhile closure of the dura and skull is undertaken (Huncke, vander Wiele, Fried & Rubinstein, 1998; Bernstein, 2001;Blanshard, 2001; Meyers & Bates, 2001, Berkenstadt & Ram,2001; Taylor & Bernstein, 1999).
Anticipating intra-operative complicationsVarious problems can be encountered during the awakecraniotomy procedure. Anticipating the complications allows theanesthesiologist, the neurosurgeon, and the neuroscience nurse tomanage the intra-operative phase of this procedure smoothly, andprovide comfort and safety for the patient (Bosek, 2004). Theprovision of antiemetics on induction prevents nausea andvomiting. Propofol, given intravenously, allows a restless patientto be given more sedation easily. While an intra-operative focalseizure is a possibility given the cortical stimulation that occursduring the procedure, cold water applied to the cortex has beenshown to alleviate seizures. Cerebral edema or a “tight brain” canbe treated with hyperventilation or diuretics. Airway difficultiesare always a possibility with an unprotected airway, supine patientand heavy sedation with increasing ICP. An awake patient posesanother challenge to the surgical team, as the need for conversionto general anesthesia could arise. Venous air embolism is apotentially fatal complication. Venous air embolism may occurwhen the head is above the heart, creating negative pressure inthe dural venous sinuses and veins draining the brain. Air isthen quickly carried to the heart, resulting in cyanosis,respiratory distress, tachycardia or circulatory shock (AANN,2006; Balki, 2003). A sitting position has been associated withincreased risk of venous air embolism. Venous air embolismcan be managed by immediately flooding the cerebral cortexwith normal saline and placing the patient in a Trendelenburgposition (Balki, 2003; Blanshard, 2001; Berkenstadt, 2001).
Disadvantages of the awake craniotomyTo summarize, an awake craniotomy may take longer toperform and is associated with a higher incidence of seizures,nausea or vomiting and emotional distress. Additionally,
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although rare, venous air embolism due to positioning has alsobeen reported (Taylor & Bernstein, 1999; Bernstein, 2001;Bosek, 1999).
Post-operative managementBhardwaj and Bernstein (2002) effectively demonstrated thatclinically and radiographically significant complications occurwithin the first four hours or after 24 hours post-stereotacticbrain biopsy. This finding lays the groundwork for a same-daydischarge for the awake craniotomy as described by Zanchettaand Bernstein (2004), Blanshard (2001) and Bernstein (2001),who routinely discharge patients as early as six hours post-operatively. Despite the evidence their reports provide, to thisauthor’s knowledge, Toronto’s University Health Network,Toronto Western Hospital site, is the only hospital in the worldfollowing this practice of early discharge. Most sites,including this author’s, employ conservative post-operativecare, with patients usually managed in the ICU for 24 hours toobserve for any neurological deterioration due to cerebraledema, intracranial hemorrhage, hematoma or seizures.Nausea and vomiting occur less often in the awake craniotomypopulation when compared to the standard craniotomyprocedure, especially so in the first four hours (Manninen,2002; Verchere, 2002). Observation for changes in bloodpressure and pain control is also important. Typically, patientsspend 24 to 48 hours in hospital prior to discharge.
Implications for nursing careThe brevity of the length of stay for awake craniotomy patientsrequires nursing assessment for changes in level of
consciousness, development of hematoma, intra-cerebralhemorrhage or seizures in the post-operative phase so thatpatients are safely discharged with the least risk for developingcomplications at home. Pain at the surgical site and headachecan be managed successfully following the awake craniotomywith oral analgesics. Zanchetta and Bernstein (2004)established that nursing played an integral role in this patientgroup’s successful recovery. They identified nursing’s role inexplaining, interpreting and reinforcing information forpatients. Health teaching is a necessary prelude to discharge,effective pre-procedure and pre-discharge teaching, decreasedcomplication rates and re-admission. Post-operative careshould include written material and, for the same-daydischarge group, access to after-hour resources.
Care of the surgical wound and signs and symptoms ofinfection and medications are key areas of discharge teaching.Staples are used in the standard closure of craniotomy woundsand are typically removed seven to 10 days post-operativelyby the patient’s family doctor. If a subgleal drain is used tocollect CSF located under the skin near the craniotomy flap, itis generally removed on the first to second day post-operatively by the surgeon. Incision sites are assessed for thedevelopment of complications by observations of drainage,subgleal fluid characteristics and incisional redness, swellingand warmth, as well as patient’s temperature.
Additionally, if medications upon discharge include thesteroid dexamethasone, warn patients that this drug must notbe stopped suddenly and to follow the tapering regimen if it isto be discontinued. Ensure that follow-up appointments with
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neuro-oncology or radiation oncology (as necessary) and theirneurosurgeon (six to eight weeks post-operatively) are inplace as this demographical group may move on to furthertreatment with radiation and/or chemotherapy. In many cases,a post-operative film (CT or MRI) will be booked prior to theneurosurgeon’s follow-up appointment. Other patientconcerns regarding driving, return to work and travellingfollowing craniotomy may be addressed at this time.Generally, patients who have experienced a seizure may notdrive for up to one year following the last seizure. Thesurgeon makes this determination and is required to report thepatient’s medical condition to the Ministry of Transportation(CMA, 2000).
Referral to support groups and resources should include theBrain Tumor Foundation of Canada (www.btfc.org), theCanadian Cancer Society, Wellspring, local support groupsand American counterparts (e.g. American Brain TumourAssociation) as necessary.
In summaryThe advent of ultra-short-acting hypnotic agents allowedanesthesiologists to monitor patients’ pain and sedation moreeffectively, thus allowing them to rapidly return patients toconsciousness. This has brought the awake craniotomyprocedure into favour over the last 15 years. The awakecraniotomy procedure has been shown to be efficacious inreducing length of stay, complications and costs, andpromoting a faster recovery, especially in the same-daydischarge patient group. The nurse’s role in the peri-operativepreparation has not been previously well-described in theliterature. Patient satisfaction with the awake craniotomyprocedure will be addressed in a future publication.
About the authorSharon Hoosein, RN, MN/ACNP, CNN(C), is a neurosurgeryNurse Practitioner at Trillium Health Centre. Comments orrequests for further information about this paper may be directedto Sharon Hoosein, [email protected], Trillium Health Centre,100 Queensway West, Rm A3156, Mississauga, ON L5B 1B5.
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