Anesthesia for Awake Craniotomy

In recent years, performing awake craniotomy has become increasingly popular and widespread. This can be attributed to recent reports that describe the many advantages of awake craniotomy over craniotomy under general anesthesia, including its low rate of complications, greater extent of tumor resection, less postoperative pain, considerable reductions in cost and resource utilization, reduction in intensive care and total hospital stay, and improved outcomes (Gruenbaum et al. Curr Opin Anaesthesiol 29(5):552–557, 2016; Flexman et al. Can J Anaesth 63:205–211, 2015). Although awake craniotomy is typically well-tolerated, the anesthetic management requires extensive knowledge and training in providing local anesthetic scalp blockade, advanced airway management, a dedicated sedation–analgesia protocol, and skillful management of systemic and cerebral hemodynamics. Moreover, the anesthesiologist should be able to recognize and prepare for common intraoperative complications, including respiratory depression, local anesthetic toxicity, an uncooperative patient, and acute changes in cerebral or systemic hemodynamics. Most importantly, anesthesia for the patient undergoing awake craniotomy requires vigilance and the ability to quickly adapt should unanticipated complications ensue.