Author Affiliations
Abstract
Monitored anaesthesia care (MAC) is a preferred approach for craniotomy, particularly in awake procedures involving tumors near eloquent brain regions. Awake craniotomy (AC), practiced for over a century, is now the gold standard for resecting tumors in sensorimotor and language areas. It facilitates maximal tumor removal while preserving critical functions through intraoperative neurophysiological monitoring and cortical mapping. Techniques such as MAC, sedation-awake-sedation (SAS), and awake-awake-awake (AAA) demand skilled neuroanesthesia, patient cooperation, and precise sedation. The study by Carella et al. demonstrated that spinal block offered improved hemodynamic stability, reduced anesthetic and analgesic requirements, and lower postoperative pain scores. Jiang et al. conducted a randomized trial comparing desflurane and total intravenous anaesthesia (TIVA), finding no difference in brain relaxation but shorter emergence and extubation times, better early cognitive scores, and reduced remifentanil use in the desflurane group. Yang et al. found that scalp nerve block (SNB) significantly reduced intraoperative hemodynamic fluctuations, inflammatory markers, postoperative pain, and opioid consumption. In pediatric craniotomy, Xing et al. reported that morphine provided the most effective pain control, followed by tramadol and fentanyl. These studies collectively highlight the importance of anesthetic and analgesic strategy selection in optimizing perioperative outcomes, including hemodynamic response, pain management, and recovery profiles in adult and pediatric craniotomy patients.
Keywords
Awake craniotomy, Monitored anaesthesia care, Total intravenous anaesthesia, Perioperative outcomes, Analgesics, Total intravenous anaesthesia.
Introduction
MAC is a suitable anaesthetic approach for craniotomy, especially in awake procedures where patients perform tasks during surgery. While this technique offers better surgical outcomes and cost-effectiveness compared to general anaesthesia (GA), it poses significant psychological and technical challenges. AC under MAC requires the patient’s cooperation and minimal-to-moderate sedation, demanding precise monitoring to maintain safety and responsiveness. Effective implementation relies on institutional strategies, staff training, and clear communication.[1-6]
AC, practiced for over a century, is now the gold standard for resecting tumors near eloquent brain areas such as sensorimotor or language regions. This technique, combined with intraoperative neurophysiological monitoring, enables cortical mapping to preserve critical functions while maximizing tumor removal.[7-10] Compared to GA, AC allows greater tumor resection with fewer neurological deficits and improved patient outcomes. Performed under MAC, it presents challenges in maintaining patient cooperation and safe sedation. Success relies on institutional protocols, skilled staff, and clear communication, making it a vital option in the neurosurgical management of eloquent-area brain tumors.[11-15]
AC, established over a century ago, is now the gold standard for tumor resection near eloquent brain areas and is also used in functional neurosurgery for conditions like Parkinson’s disease and obsessive-compulsive disorder (OCD).[16,17] AC enables maximal tumor removal with fewer neurological deficits compared to GA, owing to intraoperative neurophysiological monitoring and cortical mapping. Modern techniques include SAS, MAC, and AAA, each with distinct strategies. Successful AC requires deep neuroanesthesia expertise, including scalp blocks, sedation protocols, airway management, and hemodynamic control.[18-22]
AC is a widely accepted neurosurgical approach, especially for tumors near eloquent brain areas and functional surgeries like deep brain stimulation. Tumors infiltrating neural tissue, e.g., gliomas, cannot be completely cured, but maximal resection improves survival. AC allows real-time mapping to optimize tumor removal while preserving function. Techniques include SAS, MAC, and AAA, each requiring local anaesthesia and tailored sedation strategies.[23-26]
Methodology
A structured literature search was conducted in PubMed, Scopus, and Google Scholar databases covering articles published from January 2015 to December 2023. Keywords used included: awake craniotomy, scalp block, desflurane, TIVA, neuroanesthesia, and perioperative outcomes.
The initial search yielded 127 articles. After removing duplicates and screening abstracts, 22 full-text articles were assessed. Based on inclusion criteria (original clinical studies, RCTs, or trials on pediatric craniotomy under different anesthetic techniques), and exclusion criteria (non-English, reviews, case reports), four studies were included in the final review. Parameters assessed included hemodynamic response, postoperative pain, anesthetic consumption, and recovery profiles.
Results
Perioperative outcomes: Hemodynamic response, anesthetic requirements, and postoperative pain
In a study by Carella M., a prospective, randomized, placebo-controlled, blinded study was approved by the Ethics Review Board of the University of Liège (Committee No. 707; Study No. 2016/235-B707201629458) and registered under NCT02880566 on August 1, 2016. Conducted at the University Hospital of Liège between October 21, 2016, and December 18, 2019, it followed the Helsinki Declaration and CONSORT guidelines. Informed consent was obtained prior to inclusion.
Sixty-four American Society of Anesthesiologists (ASA) I–III patients scheduled for elective supratentorial intracranial surgery under GA in the supine position (90-360 minutes duration) were screened. Exclusions included patient refusal, contraindications to spinal block, age <18 or >75 years, obesity, emergency surgeries, chronic pain, substance abuse, corticosteroid use >6 months, severe systemic illness, or major psychiatric or cardiac conditions. Four patients were excluded, leaving 60 randomized participants.
Intraoperative management included ephedrine (3 mg intravenous (IV)) or nicardipine (1 mg IV) for hemodynamic control and atropine (0.5 mg IV) for bradycardia (<40 bpm). Recovery occurred immediately post-surgery for early neurological evaluation.
Primary outcome was mean arterial pressure (MAP) changes across time points. Secondary outcomes included heart rate, pain scores, opioid, propofol, and remifentanil use. Statistical analysis employed intention-to-treat design using Statistical Package for the Social Sciences (SPSS) v26 and Datasim v1.1. Normality, sphericity, and variance equality were tested. Two-way mixed-design analysis of variance (ANOVA) and Tukey’s honestly significant difference (HSD) were used for repeated measures. Significance was set at p<0.01 for primary and p<0.05 for secondary outcomes. Sample size (n=52) ensured 80% power to detect medium effect size (f=0.2).
Out of 64 patients assessed, four were excluded (two declined, two did not meet criteria), leaving 60 participants randomized into two equal groups (n=30). Data loss occurred due to technical issues (n=4), incomplete morphine data (n=4), prolonged surgery (n=1), and postoperative complications (n=1). Available data from these cases were still included in the analysis.
Group control (CO) had significantly higher increases in MAP than Group SB at 1-, 3-, and 5-minutes following skin incision (SI) and skull pinning (SP) (mean differences (MD) ranging from 14.5–20.5 mmHg; p<0.0001). At cranial reduction (CR), MAP remained higher in Group CO (MDs 6.1–8.9 mmHg; p=0.0014), but not significantly over time. No significant differences were observed at dura mater manipulation (DM).
Propofol Ce was higher in Group CO during SP (t+5: MD=0.3 µg/mL) and throughout SI, CR, and DM (MD=0.2–0.3 µg/mL). Remifentanil Ce was significantly greater in Group CO at all noxious events (MD=1.0–1.6 ng/mL). Total propofol and remifentanil consumption were also higher (MD=0.02 mg/kg/min and 0.05 µg/kg/min, respectively).
State entropy (SE) was higher in Group CO during SP and SI (MD up to 5.7), though differences were not clinically meaningful (<10 units). No differences were noted at CR and DM. Ephedrine (n=7) and nicardipine (n=4) were used sparingly, with no atropine administered. Postoperative visual analog scale (VAS) scores were significantly higher in Group CO across all time points (MD=2–3; p<0.0001). Morphine consumption at 48 hours was also higher (MD=12 mg; p<0.001).[27]
Comparison of desflurane and TIVA in elective supratentorial craniotomy: Intraoperative Stability, brain relaxation, and recovery profiles
In a study by Jiang Z., a single-center, randomized, controlled, patient- and assessor-blinded trial was conducted at Beijing Tiantan Hospital, Capital Medical University, from January to August 2021 (ethics approval: KY2020-150-02; ClinicalTrials.gov: NCT04691128). Patients aged 18-60 years with ASA physical status I–III undergoing craniotomy for supratentorial tumors were enrolled. Exclusion criteria included midline brain shift >5 mm, planned electrophysiological monitoring, anesthetic allergies, GCS <15, cerebrovascular or cardiopulmonary disease, body mass index (BMI) >30 kg/m², postoperative tracheal intubation, and inability to cooperate.
Participants were randomized 1:1 to either the desflurane or TIVA group using sealed opaque envelopes. Patients, outcome assessors, and nursing staff were blinded; anaesthesiologists were not. Standard ASA monitoring was used. Anaesthesia was induced with sufentanil (0.3-0.5 µg/kg), propofol (1-3 mg/kg), and cisatracurium (0.2 mg/kg), followed by tracheal intubation and mechanical ventilation. Maintenance differed by group: desflurane (0.8-1.0 MAC) + remifentanil (0.05-0.2 µg/kg/min) or propofol (6-8 mg/kg/h) + remifentanil. Bispectral index (BIS) was maintained at 40-55; MAP within ±20% of baseline. Rescue therapy included sufentanil boluses and intraoperative adjustments. Primary outcome was satisfactory brain relaxation at dura opening, assessed using a 4-point scale. Secondary outcomes included emergence/extubation time, cognitive recovery (SOMCT), and postoperative complications.
Sample size (n=55/group) was calculated to detect a 25% difference in satisfactory brain relaxation (power 80%, α=0.05). Analyses followed modified intention-to-treat and per-protocol principles. Data were analysed using SPSS v25. Logistic regression identified predictors of brain relaxation, with desflurane/TIVA forced into the model.
Between January and August 2021, 369 patients scheduled for elective supratentorial craniotomy were screened, and 111 were enrolled and randomized into either the desflurane (n=56) or TIVA (n=55) groups. One patient in the desflurane group was excluded due to severe bronchospasm, resulting in 110 patients included in the modified intention-to-treat analysis (55 per group). Baseline demographics, tumor characteristics, and comorbidities were well balanced between the groups.
Intraoperative factors were largely similar, although MAP at dura opening was significantly lower in the desflurane group (76 ± 7 mmHg vs. 84 ± 15 mmHg, p=0.002). This group also required more vasopressors (20% vs. 7%), while the TIVA group required more vasodilators (31% vs. 0%, p<0.0001). Remifentanil consumption was lower in the desflurane group (1.1 ± 0.5 mg vs. 2.4 ± 0.9 mg, p<0.0001).
Primary outcomes showed no significant difference in the proportion of satisfactory brain relaxation (69% vs. 73%, p=0.675). Multivariate analysis identified peritumoral edema (OR: 0.328, p=0.002) and occipital tumor location (OR: 0.067, p=0.004) as predictors of poor brain relaxation, not the anesthetic technique.
Regarding secondary outcomes, emergence and extubation times were significantly shorter in the desflurane group (10 vs. 13 minutes and 13 vs. 17 minutes, both p<0.001). Short orientation memory concentration test (SOMCT) scores were higher 15 minutes post-extubation in the desflurane group (16 vs. 0, p=0.003).[28]
Comparative perioperative outcomes of SNB, local anesthetic infiltration, and control in craniotomy patients
Study by Yang X et al., Fifty-seven adult patients (ASA I or II, aged 18–65) scheduled for elective craniotomy for anterior cerebral aneurysm clipping were enrolled after informed consent. Patients with complex aneurysms, prior craniotomy, drug allergies, substance abuse, or inability to communicate/VAS comprehension were excluded. The same anaesthesiologist and surgeon managed all patients.
BIS electrodes were placed on the forehead, and values were accepted only if the signal quality index (SQI) exceeded 50%. Anesthesia was induced with propofol (1.5-2 mg/kg), sufentanil (0.5-0.8 µg/kg), and cis-atracurium (0.2 mg/kg). Post-intubation, MAP and venous access were secured. Propofol (4-9 mg/kg/h) and remifentanil (0.1-0.5 µg/kg/min) were titrated to maintain BIS between 40-60. Hemodynamic responses were managed with supplemental remifentanil or nicardipine/esmolol. No additional muscle relaxants were used intraoperatively. Fluids included normal saline and hydroxyethyl starch. All patients received oxycodone (0.1 mg/kg) 30 min before closure and as rescue analgesia postoperatively.
Patients were randomized into three groups: Group S received SNB; Group I, local infiltration; and Group C, no regional anaesthesia. The second author, blinded to group assignment, recorded hemodynamic data, pain scores, and analgesic use. Inflammatory markers were measured at baseline, and 6, 12, 24, 48, and 72 h postoperatively. MAP and HR were recorded at seven time points. Pain and side effects were assessed at 2-48 h post-op. Primary endpoint: postoperative inflammatory response; secondary: pain, opioid consumption, and hemodynamics.
Out of 57 randomized patients, six were excluded (5 due to delayed extubation and one due to reoperation), leaving 51 patients analysed (Group S: 18, Group I: 16, Group C: 17). Baseline characteristics were similar among the three groups, except for remifentanil consumption and nicardipine use. Group C had the highest cumulative remifentanil dose (4.59 ± 0.64 mg), significantly more than Group I (3.67 ± 0.38 mg, p< 0.001) and Group S (1.40 ± 0.38 mg, p< 0.001). Group I also used more remifentanil than Group S (p< 0.001). Nicardipine was more frequently required in Group C (47.1%) compared to Group I (18.8%) and Group S (5.6%), with statistically significant differences (p=0.017).
Plasma CRP and interleukin (IL)-6 levels increased postoperatively, peaking at 24 hours and then declining. Group S showed a tendency toward lower CRP and significantly lower IL-6 levels at 6 hours compared to Groups C (p=0.001) and I (p=0.009). IL-10 levels peaked at 12 hours, with Group S showing significantly higher levels than Groups C and I at both 12 and 24 hours (p<0.05).
Heart rate (HR) and mean arterial pressure (MAP) were significantly lower in Groups I and S compared to Group C during incision and dura opening. Group S had the lowest MAP among all groups during key surgical times.
Postoperative pain scores were significantly lower in Group S at all measured intervals, and oxycodone use was substantially less (5.01 ± 4.3 mg) compared to Groups C (27 ± 9.6 mg) and I (22.06 ± 12.24 mg) (p< 0.001). The time to first oxycodone use was longest in Group S. No severe adverse effects were observed. Postoperative nausea and vomiting (PONV) incidence was lowest in Group S (11.1%) compared to Groups C and I (p=0.012).[29]
Comparative analysis of analgesic regimens in pediatric craniotomy: Pain control and predictive factors
Study by Xing F., randomized controlled clinical trial was conducted at Beijing Tiantan Hospital (ChiCTR-IOC-15007676) after ethical approval (KY2015–009-01) and informed parental consent. Children aged 1-12 years, ASA I–III, undergoing open craniotomy for tumors, craniofacial reconstruction, or vascular malformations were included. Exclusion criteria comprised mental disorders, postoperative hematomas/edema requiring reoperation, anesthetic allergies, or substance abuse.
Standard monitoring included non-invasive blood pressure (BP), HR, pulse oximetry (SpO₂), invasive arterial pressure, end-tidal carbon dioxide partial pressure (PETCO₂), and MAC. Premedication included midazolam (0.025-0.075 mg/kg), methylprednisolone (1-2 mg/kg), and oral midazolam (0.5 mg/kg) if needed. Anaesthesia was induced with propofol (2 mg/kg), cisatracurium (0.2 mg/kg), and sufentanil (0.3 μg/kg) or fentanyl (3 μg/kg). In younger or uncooperative patients, 6-8% sevoflurane was used for induction. Anaesthesia maintenance included sevoflurane (0.5 MAC), remifentanil (0.1-0.2 μg/kg/min), and propofol (3-5 mg/kg/h). Analgesics were given 30 min pre-end.
Postoperative analgesia used nurse-controlled intravenous analgesia (NCIA) (ages 1-6) or patient-controlled intravenous analgesia (PCIA) (ages 7-12). Group C received saline; Group F, fentanyl; Group M, morphine; and Group T, tramadol, all adjusted to 100 ml with ondansetron. Rescue analgesia included oral ibuprofen (0.3 ml/kg) and IV morphine (0.02 mg/kg) if pain was ≥7.
Randomization was 1:1:1:1; investigators were blinded. Primary outcome was pain intensity; secondary outcomes included adverse effects and rescue medication use. Statistical analysis used analysis of variance (ANOVA), chi-square, Kruskal-Wallis, and logistic regression. A sample size of 40 ensured 80% power and 5% significance level.
Between January 2016 and June 2018, 387 pediatric patients undergoing major craniotomy were screened. In the 1-6-year-old group (n=192), 32 patients were excluded (12 declined consent, 18 remained intubated, two required reoperation), resulting in 160 participants. Similarly, in the 7-12-year-old group (n=195), 35 were excluded (11 declined consent, 21 intubated, three reoperated), also leaving 160 patients (91 males, 69 females) for final analysis.
Pain scores measured using Wong-Baker Faces Scale/ Faces, Legs, Activity, Cry, and Consolability (WBFS/FLACC) (younger group) and WBFS/ numeric rating scale (NRS) (older group) showed significant differences among the four analgesia groups (Control, Tramadol, Fentanyl, Morphine) at early time points. In younger children, Morphine significantly reduced pain scores at 1 and 8 hours postoperatively compared to Tramadol, Fentanyl, and Control (p<0.05). Tramadol and Fentanyl were both superior to Control (p<0.05), with no significant difference between them (p>0.05). In older children, similar trends were observed, with Morphine providing the most effective analgesia from 1-16 hours (p<0.05), followed by Tramadol and Fentanyl (both better than Control, p<0.05).
Postoperative analgesic consumption, converted to morphine milligram equivalents (MME), was similar between Morphine and Fentanyl groups. The tramadol group had slightly higher MME. The Control group required significantly more rescue medication (ibuprofen and morphine) across both age groups. Moderate-to-severe postoperative pain intensity (POPI) occurred in 17.5% of all patients: 16.25% in the younger group and 18.75% in the older group. Severe pain was reported in a few patients, mostly from the Control group. Univariate and multivariate regression identified younger age (OR = 1.161, p=0.017), occipital craniotomy (OR = 0.374, p=0.029), and use of fentanyl (OR = 0.355, p=0.017) or morphine (OR = 0.077, p<0.001) as significant factors associated with moderate-to-severe POPI.[30]
| Study | Sample size and intervention | Primary outcome | Key findings |
| Carella M. | 60 adults Spinal block vs. GA |
Hemodynamics, pain, opioid use | Spinal block had better MAP stability and lower VAS scores & morphine use. |
| Jiang et al. | 110 adults Desflurane vs. TIVA |
Brain relaxation, recovery | No difference in brain relaxation; desflurane had shorter emergence and lower remifentanil use |
| Yang et al. | 51 adults SNB vs. Infiltration vs. Control |
Pain, IL-6/CRP, opioid use | SNB group showed lower IL-6, better MAP, less pain, and opioid requirement |
| Xing F. | 320 children Morphine vs. Tramadol vs. Fentanyl vs. Control |
Pain intensity, rescue analgesia | Morphine is most effective, especially early post-op, across all age groups. |
Table 1: Comparative analysis of anaesthetic and analgesic strategies in craniotomy
Discussion
MAC for AC has emerged as a valuable technique, especially for tumors near eloquent brain areas. While it ensures superior surgical outcomes and functional preservation, it demands rigorous patient cooperation, precise sedation strategies, and robust institutional protocols. AC combined with intraoperative neurophysiological monitoring facilitates cortical mapping and maximizes tumor resection while minimizing neurological deficits. The integration of MAC with neurophysiological monitoring has transformed the surgical landscape for tumors near eloquent brain regions. The reviewed studies demonstrate how tailored anaesthetic strategies impact perioperative outcomes.
Carella et al. revealed spinal block offers more stable intraoperative hemodynamic and better pain control than GA, emphasizing its value in select patients. Jiang et al. compared desflurane and TIVA, showing similar efficacy for brain relaxation but with desflurane offering quicker emergence and reduced opioid use, an advantage in settings prioritizing rapid neurological assessment.
Yang et al. highlighted the benefits of SNB in lowering IL-6 and CRP inflammatory markers, as well as reducing opioid requirements and hemodynamic variability. These findings support incorporating SNB in aneurysm surgeries. In pediatric populations, Xing et al. showed morphine as the most effective analgesic in reducing early postoperative pain, especially in younger children.
When viewed collectively, these studies support a tailored anesthetic approach based on patient demographics, tumor location, and surgery type. A combination of regional blocks, optimized agent selection (e.g., desflurane for faster recovery), and structured intraoperative monitoring enhances safety and recovery. However, variability in protocols and patient selection highlights the need for standardization and further comparative trials.
Conclusion
MAC is an effective and increasingly preferred anaesthetic approach for craniotomy, particularly in awake procedures involving tumors near eloquent brain regions. It enables maximal tumor resection with minimal neurological deficits, supported by intraoperative neurophysiological monitoring and cortical mapping. Although technically and psychologically demanding, MAC offers enhanced surgical precision, cost-effectiveness, and improved recovery when executed within structured institutional protocols and with skilled personnel.
Comparative studies further clarify perioperative outcomes across different anaesthetic and analgesic strategies. These findings reinforce that anaesthetic and analgesic choices significantly impact surgical conditions, recovery, and long-term outcomes. Tailoring techniques such as MAC, regional blocks, and optimized pharmacological regimens are crucial for enhancing perioperative care in craniotomy patients.
References
- Özlü O. Anaesthesiologist’s approach to awake craniotomy. Turk J Anaesthesiol Reanim. 2018;46(4):250–256. doi:10.5152/TJAR.2018.56255
PubMed | Crossref | Google Scholar - Kim SH, Choi SH. Anesthetic considerations for awake craniotomy. Anesth Pain Med (Seoul). 2020;15(3):269–274. doi:10.17085/apm.20050
PubMed | Crossref | Google Scholar - Rylova A, Maze M. Protecting the brain with xenon anesthesia for neurosurgical procedures. J Neurosurg Anesthesiol. 2019;31(1):18–29. doi:10.1097/ANA.0000000000000494
PubMed | Crossref | Google Scholar - Piccioni F, Fanzio M. Management of anesthesia in awake craniotomy. Minerva Anestesiol. 2008;74(7-8):393–408.
Management of anesthesia in awake craniotomy - Meng L, Berger MS, Gelb AW. The potential benefits of awake craniotomy for brain tumor resection: An anesthesiologist’s perspective. J Neurosurg Anesthesiol. 2015;27(4):310–317. doi:10.1097/ANA.0000000000000179
PubMed | Crossref | Google Scholar - Potters JW, Klimek M. Local anesthetics for brain tumor resection: Current perspectives. Local Reg Anesth. 2018;11:1–8. doi:10.2147/LRA.S135413
PubMed | Crossref | Google Scholar - Hans P, Bonhomme V. Anesthetic management for neurosurgery in awake patients. Minerva Anestesiol. 2007;73(10):507–512.
Anesthetic management for neurosurgery in awake patients - Li J, Gelb AW, Flexman AM, Ji F, Meng L. Definition, evaluation, and management of brain relaxation during craniotomy. Br J Anaesth. 2016;116(6):759–769. doi:10.1093/bja/aew096
PubMed | Crossref | Google Scholar - Conte V, Baratta P, Tomaselli P, Songa V, Magni L, Stocchetti N. Awake neurosurgery: An update. Minerva Anestesiol. 2008;74(6):289–292.
Awake neurosurgery: An update - Min KT. Practical guidance for monitored anesthesia care during awake craniotomy. Anesth Pain Med (Seoul). 2025;20(1):23–33. doi:10.17085/apm.24183
PubMed | Crossref | Google Scholar - Murselović T, Makovšek A. Airway management in neuroanesthesia. Acta Clin Croat. 2023;62(Suppl 1):119–124. doi:10.20471/acc.2023.62.s1.15
PubMed | Crossref | Google Scholar - Davy A, Fessler J, Fischler M, Le Guen M. Dexmedetomidine and general anesthesia: A narrative literature review of its major indications for use in adults undergoing non-cardiac surgery. Minerva Anestesiol. 2017;83(12):1294–1308. doi:10.23736/S0375-9393.17.12040-7
PubMed | Crossref | Google Scholar - Fiani B, Reardon T, Selvage J, et al. Awake spine surgery: An eye-opening movement. Surg Neurol Int. 2021;12:222. doi:10.25259/SNI_153_2021
PubMed | Crossref | Google Scholar - Uribe AA, Stoicea N, Echeverria-Villalobos M, et al. Postoperative nausea and vomiting after craniotomy: An evidence-based review of general considerations, risk factors, and management. J Neurosurg Anesthesiol. 2021;33(3):212–220. doi:10.1097/ANA.0000000000000667
PubMed | Crossref | Google Scholar - Kolias AG, Adams H, Timofeev I, et al. Decompressive craniectomy following traumatic brain injury: Developing the evidence base. Br J Neurosurg. 2016;30(2):246–250. doi:10.3109/02688697.2016.1159655
PubMed | Crossref | Google Scholar - Ayrian E, Kaye AD, Varner CL, et al. Effects of anesthetic management on early postoperative recovery, hemodynamics and pain after supratentorial craniotomy. J Clin Med Res. 2015;7(10):731–741 doi:10.14740/jocmr2256w
PubMed | Crossref | Google Scholar - Lee KS, Yordanov S, Stubbs D, et al. Integrated care pathways in neurosurgery: A systematic review. PLoS One. 2021;16(8):e0255628. doi:10.1371/journal.pone.0255628
PubMed | Crossref | Google Scholar - Syrous NS, Sundstrøm T, Søfteland E, Jammer I. Effects of intraoperative dexmedetomidine infusion on postoperative pain after craniotomy: A narrative review. Brain Sci. 2021;11(12):1636. doi:10.3390/brainsci11121636
PubMed | Crossref | Google Scholar - de Gray LC, Matta BF. Acute and chronic pain following craniotomy: A review. Anaesthesia. 2005;60(7):693–704. doi:10.1111/j.1365-2044.2005.03997.x
PubMed | Crossref | Google Scholar - Gandhe RU, Bhave CP. Intraoperative magnetic resonance imaging for neurosurgery—An anaesthesiologist’s challenge. Indian J Anaesth. 2018;62(6):411–417. doi:10.4103/ija.IJA_29_18
PubMed | Crossref | Google Scholar - Mofatteh M, Mashayekhi MS, Arfaie S, et al. Awake craniotomy in Africa: A scoping review of literature and proposed solutions to tackle challenges. Neurosurgery. 2023;93(2):274–291. doi:10.1227/neu.0000000000002453
PubMed | Crossref | Google Scholar - McPhaden E, Tobias JD, Smith A. Clinical experience with remimazolam in neuroanesthesiology and neurocritical care: An educational focused review. J Clin Med Res. 2025;17(3):125–135. doi:10.14740/jocmr6193
PubMed | Crossref | Google Scholar - Shen L, Zhou Y, Xu J, Su Z. Malignant cerebral swelling after cranioplasty: Case report and literature review. World Neurosurg. 2018;110:4–10. doi:10.1016/j.wneu.2017.10.102
PubMed | Crossref | Google Scholar - Dinsmore J. Anaesthesia for elective neurosurgery. Br J Anaesth. 2007;99(1):68–74. doi:10.1093/bja/aem132
PubMed | Crossref | Google Scholar - Galvin IM, Levy R, Boyd JG, Day AG, Wallace MC. Cooling for cerebral protection during brain surgery. Cochrane Database Syst Rev. 2015;2015(1):CD006638. doi:10.1002/14651858.CD006638
PubMed | Crossref | Google Scholar - Tariq R, Siddiqui UA, Bajwa MH, et al. Feasibility of awake craniotomy for brain arteriovenous malformations: A scoping review. World Neurosurg X. 2024;22:100321. doi:10.1016/j.wnsx.2024.100321
PubMed | Crossref | Google Scholar - Carella M, Tran G, Bonhomme VL, Franssen C. Influence of Levobupivacaine Regional Scalp Block on Hemodynamic Stability, Intra- and Postoperative Opioid Consumption in Supratentorial Craniotomies: A Randomized Controlled Trial. Anesth Analg. 2021;132(2):500-511. doi:10.1213/ANE.0000000000005230
PubMed | Crossref | Google Scholar - Jiang Z, Wu Y, Liang F, et al. Brain relaxation using desflurane anesthesia and total intravenous anesthesia in patients undergoing craniotomy for supratentorial tumors: A randomized controlled study. BMC Anesthesiol. 2023;23(1):15. doi:10.1186/s12871-023-01970-z
PubMed | Crossref | Google Scholar - Yang X, Ma J, Li K, et al. A comparison of effects of scalp nerve block and local anesthetic infiltration on inflammatory response, hemodynamic response, and postoperative pain in patients undergoing craniotomy for cerebral aneurysms: a randomized controlled trial. BMC Anesthesiol. 2019;19(1):91. doi:10.1186/s12871-019-0760-4
PubMed | Crossref | Google Scholar - Xing F, An LX, Xue FS, Zhao CM, Bai YF. Postoperative analgesia for pediatric craniotomy patients: A randomized controlled trial. BMC Anesthesiol. 2019;19(1):53. doi:10.1186/s12871-019-0722-x
PubMed | Crossref | Google Scholar
Acknowledgments
Not applicable
Funding
No funding
Author Information
Corresponding Author:
Samatha Ampeti
Department of Pharmacology
Kakatiya University, University College of Pharmaceutical Sciences, Warangal, TS, India
Email: ampetisamatha9@gmail.com
Co-Authors:
Shubham Ravindra Sali, Mansi Srivastava, Raziya Begum Sheikh, Sonam Shashikala B V, Patel Nirali Kirankumar
Independent Researcher
Department of Content, medtigo India Pvt Ltd, Pune, India
Authors Contributions
All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation and writing-review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.
Ethical Approval
Not applicable
Conflict of Interest Statement
None
Guarantor
None
