Awake craniotomy anesthesia: A comparison between the monitored anesthesia care (MAC) versus the asleep-awake-asleep (AAA) technique

Background The commonly used sedation techniques for an awake craniotomy includes monitored anesthesia care(MAC), using an unprotected airway, or the asleep-awake-asleep(AAA) technique, using a partially or totally protected airway. We present a comparative analysis between the MAC and AAA technique evaluating anesthetic management, perioperative outcomes, and complications in a consecutive series of patients undergoing the removal of an eloquent brain lesion. Methods Eighty-one patients underwent an awake craniotomy for an intracranial lesion over a nine-year period by a single-surgeon and a team of anesthesiologists. Fifty patients underwent the MAC technique and thirty-one patients underwent the AAA technique. Retrospective analysis regarding anesthetic management, intraoperative complications, postoperative outcomes, pain management, and complications were presented. Results Similar preoperative patient and tumor characteristics were found in the two groups. Operative time was found to be shorter in the MAC group(283.5 mins) versus the AAA(313.3 mins, p=0.038). Hypertension was the most common intraoperative complication encountered(MAC: 8% vs AAA: 9.7%, p=0.794). Intraoperative seizures occurred at a rate of 4% in the MAC group and 3.2% in the AAA group(p=0.858). Awake cases were converted to general anesthesia in none of the MAC group and in 1 patient(3.2%) from the AAA cohort(p=0.201). No cases were aborted in either cohort. The mean hospital stay was 3.98 and 3.84 days in the MAC and AAA group, respectively(p=0.833). Conclusions Both the MAC and AAA sedation techniques provide efficacious and safe methods for managing awake craniotomy cases that produce similar perioperative outcomes, with the MAC technique being associated with shorter operative cases.