Journal of Neurosurgical Anesthesiology

Vol. 15, No. 3, pp. 263–266

© 2003 Lippincott Williams & Wilkins, Inc., Philadelphia

Case Report

Awake Craniotomy with Dexmedetomidine in Pediatric Patients

*John Ard, †Werner Doyle, and *Alex Bekker

Departments of *Anesthesiology and †Neurosurgery, New York University Medical Center, New York, New York

Summary: We present our experience with the use of dexmedetomidine, an ␣2 agonist,

in two children undergoing awake craniotomy. General anesthesia with the laryngeal
mask airway was used for parts of the procedure not requiring patient cooperation to
reduce the duration of wakefulness and abolish the discomfort of surgical stimulation.
Dexmedetomidine was used as a primary anesthetic for brain mapping of the cortical
speech area. The asleep–awake–sleep technique provided adequate sedation and anal-
gesia throughout the surgery and allowed the patient to complete the necessary neuro-
psychological tests. To our knowledge, ours is the first description of the use of dexme-
detomidine in pediatric neurosurgery. Key Words: temporal lobe epilepsy, craniotomy,
awake, dexmedetomidine

Resection of lesions located near eloquent areas of the
brain, such as the speech center or motor cortex, requires
patient cooperation for functional assessment. Designing a
safe anesthetic that provides sedation, anxiolysis, and an-
algesia yet leaves the patient able to perform neurologic
tests is a challenge, especially in children. Numerous
drugs and anesthetic techniques have been used in adults
with varying success.1–3 Reported intraoperative compli-
cations include respiratory depression, airway obstruction,
hemodynamic instability, vomiting, disinhibition, and
pain.4,5 Only a limited number of reports describe anes-
thetic management of pediatric patients.6,7 In these case
reports, we describe the use of dexmedetomidine (Dex), a
highly selective ␣2 adrenoreceptor agonist, for a sleep–
awake–sleep craniotomy in children. Dex provides seda-
tion, analgesia, and an anesthetic-sparing effect, with
minimal respiratory depression.8 Low-dose infusion of
this drug in healthy volunteers provided sedation that
could be easily reversed with verbal stimulation.9 Al-
Address correspondence and reprint requests to Alex Bekker, MD,
PhD, Department of Anesthesiology, New York University Medical, 550
First Avenue, New York, NY, 10016 (e-mail: alex.bekker@med.
nyu.edu).
Accepted for publication on February 11, 2003.
though the use of Dex for awake craniotomy in adults has
been reported,10 to date there are no reports concerning its
use in children.
CASE REPORTS
Case 1
A 12-year-old girl (weight 52 kg) was scheduled for
removal of subdural electrodes and partial left temporal
lobectomy. The patient’s overall level of intellectual func-
tioning was in the low average range. Her medical history
was otherwise unremarkable. Red blood cell, white blood
cell, platelet counts, and prothrombin/activated partial
thromboplastin times were within normal limits.
This was a second of the planned two-stage procedure.
Video- and invasive EEG monitoring conducted after sub-
dural grid placement was consistent with left temporal
localization of the epileptogenic foci. Language changes
were seen during the stimulation of various contacts in the
epileptogenic area. Wada test had revealed left hemi-
sphere language dominance. Based on the results of these
studies, the epilepsy multidisciplinary team concluded that
an awake craniotomy with intraoperative direct brain
stimulation mapping for language was the most appropri-
ate option to allow for epileptogenic foci excision without
postoperative language deficit.

263
264
The awake craniotomy requires a cooperative, under-
standing patient. Prior to surgery, the surgeon, neuropsy-
chologist, and anesthesiologist extensively counseled the
patient and family. A series of tests that simulated the
intraoperative neuropsychologic examination were con-
ducted at the bedside. The patient received no preoperative
medication.
Anesthesia was induced with 150 mg propofol and 100
␮g fentanyl intravenously. A laryngeal mask airway
(LMA 3) was then placed. The usual ASA recommended
monitors were used for induction and throughout the case.
End-tidal CO2 was monitored via nasal cannula with fe-
male luer connector for sampling during the awake phase
of the procedure. An arterial line, second intravenous line,
and Foley catheter were inserted after induction of anes-
thesia. The patient was then placed comfortably on the
donut head support, positioned supine with a left shoulder
roll. The head was turned to the right about 25° from the
full lateral position with vertex slightly down for the left
craniotomy. The drapes were appropriately tented using
“ether” screen to allow a clear view of the patient’s face
and to prevent rebreathing of CO2. During the procedure,
the anesthesiologist had access to the airway if needed.
The scalp nerves were blocked with 0.25% bupivacaine.
In addition, the surgeon infiltrated the area along the old
incision with the mixture of lidocaine 0.5% and bupiva-
caine 0.25%. Anesthesia was maintained with 60% nitrous
oxide, remifentanil (0.1 ␮g · kg−1 · min−1), and sevoflu-
rane (0.3%–0.7%). Dex infusion was initiated at a rate of
0.5 ␮g · kg−1 · h−1 for 30 minutes followed by the con-
tinuous infusion at 0.2 ␮g · kg−1 · h−1. The level of anes-
thesia was adjusted to maintain a bispectral index close to
60 to prevent oversedation and, consequently, minimize
awakening time. The patient was breathing spontaneously
throughout the procedure. We did not notice any signifi-
cant changes in heart rate (80 ± 10 beats/min) or in blood
pressure (100–120/50–70 mm Hg) with the initiation of
Dex infusion.
Skin incision, bone flap removal, and dissection of the
dura were uneventful. Sevoflurane and nitrous oxide were
discontinued approximately 20 minutes prior to the in-
tended awakening. Antiemetics (4 mg ondansetron and 5
mg metoclopramide) were administered prior to awaken-
ing. Dex infusion rate was reduced to 0.1 ␮g · kg−1 · h−1.
The LMA was removed and oxygen was administered via
nasal canula.
Approximately 30 minutes after discontinuation of
sevoflurane, the patient was awake and able to follow
commands and assist in the phase of operation requiring
functional mapping of complex motor and speech func-
Journal of Neurosurgical Anesthesiology, Vol. 15, No. 3, 2003
Ard et al
tion. Direct brain stimulation was used to further define
and confirm the extraoperative functional map. The pa-
tient was kept awake and evaluated by the neuropsychol-
ogist during the actual resection ensure that no disturbance
in the patient’s language was encountered as the brain was
removed. Focal seizures occurred several times with cor-
tical stimulation and resolved with discontinuation of the
stimulation.
Dex infusion was maintained at 0.1 ␮g · kg−1 · h−1
during cortical speech mapping and brain resection that
lasted 130 minutes. An additional dose of 4 mg ondanse-
tron and 0.625 mg droperidol was administered as the
patient complained of nausea during the resection. No
other sedatives or analgesics were administered. The
bispectral index was fluctuating from approximately 95
during the neuropsychological evaluation to approxi-
mately 65 during quiet periods. The patient was hemody-
namically stable throughout the testing.
Once the brain resection was completed, the patient was
anesthetized with 150 mg propofol and an LMA was re-
inserted. Dex infusion was discontinued and anesthesia
maintained with nitrous oxide, remifentanil, and low-dose
sevoflurane until the conclusion of the operation. At the
end of the operation, the patient was without any gross
motor/sensory pathofocality, and the language appeared to
be without injury or deficit. The total duration of the case
was 8 hours.
Case 2
A 12-year-old boy (45 kg) with medically refractory
seizures was scheduled for left craniotomy, subdural elec-
trode removal, and resection of a seizure focus. This was
the second stage of a two-stage procedure. Video- and
invasive EEG monitoring with subdural grid, strip, and
depth electrode captures a partial seizure arising from the
left temporal-parietal region and left frontal-temporal re-
gions. MRI revealed abnormal pathoanatomy of the left
hippocampal formation. Because of the close proximity of
the seizure focus to the language center, the surgical team
wanted the child awake during the procedure for mapping
of the language area to avoid injury during resection. We
first discussed this option with the patient and his parents,
as full cooperation is necessary for a successful procedure.
The child was of average intelligence, had a distant history
of asthma, and had a class II airway. His medications
included oxcarbazepine, dexamethasone, phenytoin, and
proventil. We thought the child was mature enough to
attempt an awake procedure.
We induced general anesthesia with 120 mg propofol
and 75 ␮g fentanyl. An LMA 3 was placed and the patient
 Awake Craniotomy with Dexmedetomidine
began breathing spontaneously. Metoclopramide 5 mg and
ondansetron 4 mg were given to prevent nausea. An A-
line, BIS monitor, and Foley catheter were placed after
induction of anesthesia. The surgeon performed a field
block with a total of 20 mL bupivacaine 0.25%, 20 mL
lidocaine 0.5% mixed with epinephrine 1:200,000 parts.
The patient was positioned supine with a left shoulder roll.
The head was placed on a cushioned donut and turned
further right to facilitate surgical exposure.
Anesthesia was maintained with N2O 60%, O2 40%,
and sevoflurane 0.7% to 1.5% for the bone flap removal
and dural opening. A Dex infusion was started shortly
after induction. The patient was loaded with 0.5 ␮g/kg
over 1 hour and then maintained with 0.15 to 0.3 ␮g · kg−1
· h−1. There was minimal change in heart rate and blood
pressure with the addition of Dex. Approximately 90 min-
utes after induction, we turned off the N2O and sevoflu-
rane and allowed the patient to wake up. In approximately
10 minutes, the LMA was removed and the patient was
able to communicate without difficulty. Dex was the pri-
mary agent during the awake portion of the procedure.
The patient complained of a mild headache that was
treated with small boluses of fentanyl (total of 100 ␮g).
The neuropsychologist and surgeon performed the func-
tional testing and seizure focus resection over the next 140
minutes. This was done to ensure that no disturbance in
the patient’s language ability was encountered as the sei-
zure focus was removed. We reinduced anesthesia with
100 mg propofol and reinserted LMA after the surgeon
completed the resection and documented that no injury to
language had occurred. The Dex infusion was discontin-
ued. At the end of the surgery, the LMA was removed and
the patient’s neurologic examination was intact.
DISCUSSION
Intraoperative speech mapping requires an awake pa-
tient with an exposed cerebral cortex that can be electri-
cally stimulated at critical language sites to disrupt per-
formance of various tasks, such as counting and
confrontation naming. The aim of anesthesia is to have the
patient comfortable enough to remain immobile during a
long procedure, yet alert and cooperative to comply with
testing. Awake craniotomy in a child presents a challenge
to the anesthesiologist, and there are only limited number
of reports describing anesthetic care of an awake pediatric
patient.6,7
Tobias and Jimenez6 successfully used a sleep–awake–
sleep technique on a 12-year-old undergoing a craniotomy
for a frontal lobe tumor. A propofol infusion provided
265
maintenance anesthesia during the sleep portions, and the
authors were able to manage the airway without an LMA
or any other airway devices. The propofol infusion was
discontinued after dura opening, and the patient was able
to communicate within 10 minutes. The duration of the
awake portion of the operation is not specified in the re-
port. The authors emphasized that careful patient selection
and preparation are required to tolerate intraoperative
mapping using this technique.
Welling and Donegan7 used a combination of droperi-
dol and alfentanil to conduct cortical mapping on a 14-
year-old boy undergoing excision of a right parietal lesion.
“Tight” brain was the only problem reported by the au-
thors. Other reported intraoperative complications associ-
ated with the “neuroleptanesthesia” technique include
drowsiness, pain, respiratory depression, and seizures.
Postoperative delirium is often associated with high doses
of droperidol (12.5 mg in this case).2,4 In view of these
complications, propofol sedation supplemented with opi-
oid is a technique recommended by most current au-
thors.2,3,11
Our case reports describe the successful use of Dex
infusion for awake language mapping and temporal lobe
resection in two 12-year-old children. We used a sleep–
awake–sleep technique with the Dex infusion starting
shortly after induction and continued through the awake
portion of the procedure. Dex is a selective ␣2 adrenocep-
tor agonist with centrally mediated sympatholytic effects.
It significantly reduces the intraoperative and postopera-
tive anesthetic requirements for various surgical proce-
dures.12,13 A lack of respiratory depression offers a dis-
tinct advantage over other anesthetic techniques for an
awake craniotomy. Moreover, Dex possesses unique phar-
macologic characteristics that render it desirable as an
agent for awake craniotomy: patients are sedated but re-
main rousable and able to cooperate when stimulated.9,14
Despite Dex’s theoretical advantages for procedures
that require functional testing, Bustillo et al.16 reported an
inability to perform cognitive testing in 5 patients receiv-
ing Dex for sedation during endovascular embolization for
a cerebral arteriovenous malformation. It is not clear why
they experienced difficulty with cognitive testing and we
have not. The most likely explanation involves drug dos-
ing and level of stimulation. It seems likely that patients
undergoing procedures with little surgical stimulus (ie,
embolization) do not require a loading dose of 1 ␮g/kg
and/or elevated infusion rates. Our cases involved continu-
ous surgical stimulation, and we used low infusion rates
(0.1–0.2 ␮g · kg−1 · h−1). It’s also possible that there was a
difference in how the cognitive testing was carried out.
Journal of Neurosurgical Anesthesiology, Vol. 15, No. 3, 2003
266
Dex produces dose-dependent decreases in blood pres-
sure and heart rate as a result of its agonistic effect on the
␣2 adrenoreceptors.8 Our patients experienced minimal
hemodynamic changes, and no vasopressor was adminis-
tered in either case. The observed minimal hemodynamic
changes in our cases are consistent with the reported effect
of low-dose Dex infusion on cardiovascular function.
During the awake portion of the procedure, one of the
patients complained of headache. Dex provides some an-
algesia, but it seems to be insufficient in some. We added
small doses of fentanyl, and this led to some oversedation
that improved with time. It is possible that a very low-dose
remifentanyl infusion would be easier to titrate than fen-
tanyl and improve comfort without causing oversedation.
The preanesthetic preparation of the pediatric patient
scheduled for awake craniotomy is of paramount impor-
tance irrespective of the chosen sedation technique. We
usually exclude a patient if we think that the child is
unable to understand and follow instructions. During the
preoperative visit, the specifics of the intraoperative awak-
ening were described to the patients and their parents. It
was explained that most painful episodes occur during the
initial and final parts of the procedure. We stressed that the
patient would be asleep during these phases of the opera-
tion and be awake for intraoperative testing only. It was
emphasized that the anesthesiologist will be at bedside
throughout the procedure and will administer analgesics
and sedative if required. Both patients were well moti-
vated and understood the logistics of the procedure. The
epileptology team simulated planned intraoperative tests
with electrical stimulation of motor cortex to elicit move-
ment and the speech area and to experience inhibitory
response during counting.
CONCLUSION
We report the first successful application of Dex in an
awake pediatric craniotomy. The pharmacology of Dex
allowed us to achieve a level of sedation and analgesia
sufficient to complete the neuropsychiatric testing re-
quired for the mapping of the cortical language area, as
well as to perform an awake resection of the epileptogenic
foci. The patients remained hemodynamically stable and
Journal of Neurosurgical Anesthesiology, Vol. 15, No. 3, 2003
Ard et al
cooperative during the “awake” portion of the procedure.
Dex infusion at low rate (0.1–0.3 ␮g · kg−1 · h−1) may be
helpful for intraoperative functional testing in procedures
in which sedation and mild analgesia are the only anes-
thetic requirements.
REFERENCES
1. Gignac E, Manninen PH, Gelb AW. Comparison of fentanyl, sufen-
tanil and alfentanil during awake craniotomy for epilepsy. Can J
Anaesth. 1993;40:421–4.
2. Herrick IA, Craen RA, Gelb AW, et al. Propofol sedation during
awake craniotomy for seizures: patient controlled administration
versus neurolept analgesia. Anesth Analg. 1997;84:285–91.
3. Berkenstadt H, Perel A, Hadani M, et al. Monitored anesthesia care
using remifentanil and propofol for awake craniotomy. J Neurosurg
Anesthesiol. 2001;13:246–50.
4. Archer DP, McKenna JM, Morin L, et al. Conscious-sedation anal-
gesia during craniotomy for intractable epilepsy: a review of 354
consecutive cases. Can J Anaesth. 1988;35:338–44.
5. Danks RA. Rogers M, Aglio LS, et al. Patient tolerance of craniot-
omy performed with the patient under local anesthesia and moni-
tored conscious sedation. Neurosurgery. 1998;42:28–36.
6. Tobias JD, Jimenez D. Anaesthetic management during awake cra-
niotomy in a 12-year-old boy. Paediatr Anaesth. 1997;7:341–4.
7. Welling E, Donegan J. Neuroleptanalgesia using alfentanil for
awake craniotomy. Anesth Analg 1989;68:57–60.
8. Belleville JP, Ward DS, Bloor BC, et al. Effects of intravenous
dexmedetomidine in humans: I. Sedation, ventilation, and metabolic
rate. Anesthesiology. 1992;77:1125–33.
9. Hall EJ, Uhrich TD, Barney JA, et al. Sedative, amnestic, and an-
algesic properties of small-dose dexmedetomidine infusions. Anesth
Analg. 2000;90:699–705.
10. Bekker A, Kaufman B, Samir H, et al. The use of Dexmedetomidine
infusion for awake craniotomy. Anesth Analg. 2001;92:1251–3.
11. Silbergeld DL, Mueller WM, Colley PS, et al. Use of propofol
(Diprivan) for awake craniotomies: technical note. Surg Neurol.
1992;38:271–2.
12. Aho M, Lehtinen AM, Erkola O, et al. The effect of intravenously
administered dexmedetomidine on perioperative hemodynamics and
isoflurane requirements in patients undergoing abdominal hysterec-
tomy. Anesthesiology. 1991;74:997–1002.
13. Aho MS, Erkola OA, Scheinen H, et al. Effect of intravenously
administered dexmedetomidine on pain after laparoscopic tubal li-
gation. Anesth Analg. 1991;73:112–8.
14. Ebert TJ, Hall JE, Barney JA, et al. The effects of increasing plasma
concentrations of dexmedetomidine in humans. Anesthesiology.
2000;93:382–94.
15. Bustillo M, Lazar R, Finck A, et al. Dexmedetomidine may impair
cognitive testing during endovascular embolization of cerebral arte-
riovenous malformations: a retrospective case reports series. J Neu-
rosurg Anesthesiol. 2002;14:209–12.