RESUMEN
We report the case of an aborted awake craniotomy for a left frontotemporoinsular glioma due to ammonia encephalopathy on a patient taking Levetiracetam, valproic acid and clobazam. This awake mapping surgery was scheduled as a second-stage procedure following partial resection eight days earlier under general anesthesia. We planned to perform the surgery with local anesthesia and sedation with remifentanil and propofol. After removal of the bone flap all sedation was stopped and we noticed slow mentation and excessive drowsiness prompting us to stop and control the airway and proceed with general anesthesia. There were no post-operative complications but the patient continued to exhibit bradypsychia and hand tremor. His ammonia level was found to be elevated and was treated with an infusion of l-carnitine after discontinuation of the valproic acid with vast improvement. Ammonia encephalopathy should be considered in patients treated with valproic acid and mental status changes who require an awake craniotomy with patient collaboration.
Asunto(s)
Encefalopatías/etiología , Mapeo Encefálico/métodos , Neoplasias Encefálicas/cirugía , Sedación Consciente , Craneotomía/métodos , Lóbulo Frontal/cirugía , Glioma/cirugía , Hiperamonemia/complicaciones , Complicaciones Intraoperatorias/etiología , Lenguaje , Lóbulo Temporal/cirugía , Anestesia General , Anestesia Local , Anticonvulsivantes/efectos adversos , Anticonvulsivantes/uso terapéutico , Afasia/etiología , Benzodiazepinas/uso terapéutico , Neoplasias Encefálicas/complicaciones , Carnitina/uso terapéutico , Clobazam , Trastornos de la Conciencia/etiología , Dominancia Cerebral , Lóbulo Frontal/fisiopatología , Glioma/complicaciones , Humanos , Hiperamonemia/inducido químicamente , Hiperamonemia/tratamiento farmacológico , Hipnóticos y Sedantes/uso terapéutico , Complicaciones Intraoperatorias/tratamiento farmacológico , Levetiracetam , Masculino , Persona de Mediana Edad , Piperidinas/uso terapéutico , Piracetam/análogos & derivados , Piracetam/uso terapéutico , Propofol/uso terapéutico , Remifentanilo , Convulsiones/tratamiento farmacológico , Convulsiones/etiología , Lóbulo Temporal/fisiopatología , Ácido Valproico/efectos adversos , Ácido Valproico/uso terapéuticoRESUMEN
Awake craniotomy was the earliest surgical procedure known, and it has become fashionable again. In the past it was used for the surgical management of intractable epilepsy, but nowadays, its indications are increasing, and it is a widely recognized technique for the resection of mass lesions involving the eloquent cortex, and for deep brain stimulation. The procedure is safe, provides excellent results, and saves money and resources. The anesthesiologist should know the principles underlying neuroanesthesia, the technique of scalp blockade, and the sedation protocols, as well as feeling comfortable with advanced airway management. The main anesthetic aim is to keep patients cooperating when required (analgesia-based anesthesia). This review attempts to summarize the most recent evidence from the clinical literature, a long as the number of patients undergoing craniotomies in the awake state are increasing, specifically in the pediatric population.