Journal of Clinical Neuroscience 67 (2019) 221–225

Contents lists available at ScienceDirect

Journal of Clinical Neuroscience

journal homepage: www.elsevier.com/locate/jocn

Tools and techniques

The Stony Brook awake craniotomy protocol: A technical note

Erica Shen a, Colleen Calandra b, Sofia Geralemou c, Christopher Page c, Raphael Davis b,
Wesam Andraous c, Charles Mikell b,⇑
a
Stony Brook University School of Medicine, United States
b
Department of Neurosurgery, Stony Brook University Hospital, United States
c
Department of Anesthesiology, Stony Brook University Hospital, United States

a r t i c l e i n f o a b s t r a c t

Article history: Most current awake craniotomy techniques utilize unnecessarily complicated airway management, and
Received 16 December 2018 cause discomfort to the patients during the awake phase of the surgery. Our manuscript is written to dis-
Accepted 21 June 2019 cuss the neurosurgical and anesthetic techniques that we have developed to optimize awake craniotomy
techniques at Stony Brook University Medical Center.
We used the frameless BrainlabTM skull-mounted array for stereotactic navigation. Rigid fixation of the
Keywords: skull was avoided. General anesthesia with established airway was used during the ‘‘asleep” phase of the
Awake craniotomy
surgery. Following the removal of the bone flap and the opening of the dura, the patients were woken up,
Cortical mapping
Functional testing
and the established airway was removed. Cortical mapping was performed to establish a safe entry zone
Anesthesiology techniques for tumor removal. While the tumors were being removed, we continued motor examination and casual
conversation with the patients to ensure safety. Patients were sedated during the remaining phase of the
surgery until skin closure. No patient exhibited any neurological deficits or adverse anesthesia outcomes
during the postoperative period. The protocol we developed avoids rigid skull fixation and emphasizes
flexible intraoperative planning, thereby maximizing patient and physician comfort while allowing for
successful tumor resection.
Ó 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Primary and metastatic brain tumors are a significant public
health burden in the United States. Many gliomas and metastatic
tumors are located within or near an eloquent region of the brain,
such as functional areas involved in motor or speech processes.
Awake craniotomy, a technique that allows for intraoperative cor-
tical mapping and functional testing, has emerged as the current
treatment of choice for resection of brain tumors that involve an
eloquent region of the brain [6,13]. The technique, which allows
for an interdisciplinary team’s interaction with an awake patient
during the operation, has been shown to aid a larger extent of
tumor resection while minimizing the risk of causing or worsening
a new or a pre-existing neurological deficit during the surgery
[7,18,24,25].
Most anesthetic and surgical methods that have been described
in the literature separate the awake craniotomy procedure into
three phases [1]. Craniotomy and opening of the dura under
⇑ Corresponding author at: Stony Brook Medicine, Department of Neurosurgery,
101 Nicolls Rd, Stony Brook, NY 11794, United States.
E-mail address: charles.mikell@stonybrookmedicine.edu (C. Mikell).
general anesthesia take place during the first phase. During the
second phase, patient is awakened and extubated, electrical stim-
ulation of the cortex is performed to plan the corticectomy, and
functional testing is conducted during resection of the tumor. Dur-
ing the third phase, closure of the cranium and scalp is performed.
Among the published protocols, patients are uniformly awake
during the second phase of the procedure to allow for interactions
with the interdisciplinary team. Published protocols differ in anes-
thetic strategies applied during the first phase and the last phase of
an awake craniotomy, with two types of protocols being the most
well-known [21]. The ‘‘asleep-awake-asleep” protocol calls for the
placement of the patient under general anesthesia with a sup-
ported airway during the first phase, has the patient awaken with
removal of the supported airway in order to attend to functional
testing during the second phase, and then has the patient re-
anesthetized with an re-established airway during the final phase
[9,11,14,23]. The ‘‘conscious sedation” protocol calls for a deep-
ened sedation with spontaneous respiration during the initial
and final phase of the surgery, and has the patient awaken during
the second phase to allow for functional testing [4,8,9].
A substantial minority of patients report moderate to severe
discomfort during awake craniotomies, with some pain and

https://doi.org/10.1016/j.jocn.2019.06.042
0967-5868/Ó 2019 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
222 E. Shen et al. / Journal of Clinical Neuroscience 67 (2019) 221–225

anxiety that can be directly attributed to the rigid pinning of the

head to a three-point Mayfield head frame, initial local anesthesia
injection, and scalp opening [8,15,30]. Almost all published proto-
cols employ the use of a Mayfield head frame. To reduce patient-
reported anxiety, we established a protocol to locate and resect
the brain lesion without head pinning by carefully positioning a
patient’s head at the start of an operation and by utilizing the
Brainlab cranial navigation system.
Airway management during different phases of surgery can be
challenging, especially if different levels of arousal are required from
the patient. Non-rigid positioning of the head on a donut or horse-
shoe headrest allows the patient to move his or her neck as needed
to maximize comfort and allows the anesthesiologist extensive
access to the airway during transitional phases of the surgery.
General anesthesia offers a number of potential advantages
over sedation for the initial phase of the surgery. Mechanical ven-
tilation under general anesthesia helps to regulate brain volume to
a certain extent, which can be helpful in a clinical situation where
intracranial pressure may be increased due to a tumor mass [11].
Furthermore, because the airway is secured at the beginning of Fig. 1. Operation Room Set-Up. Instruments have been labeled in the figure. The
the surgery, our protocol allows us to make a ‘‘game-time” decision brown hexagon represents the patient’s head position. The two red circles represent
the operating surgeon and his or her assistant. The two green triangles represent
on whether the patient requires extubation and functional testing. the anesthesiologists. The purple pentagon represents the circulating nurse.
The flexibility to make an impromptu decision intraoperatively can
be beneficial, for instance, if the tumor clearly comes to the surface
or a Styrofoam donut. The patient’s ‘‘down” arm, which was wearing
upon opening the dura. In that case, the step of extubation and
the blood pressure cuff, was extended towards the anesthesiologists
functional testing is no longer essential and can be easily avoided,
(Fig. 2). Three-point rigid fixation of the skull was not used. We
as it is safe to maintain the patient under general anesthesia with a
draped using a single ‘‘hip drape” from 3 M, which made a large
protected airway.
space for the anesthesiologist and the patient to be face-to-face
At Stony Brook University Hospital, we have developed a protocol
and to talk.
that avoids rigid skull fixation and simplifies airway management.
We believe that our protocol can help to maximize patient and
physician comfort while allowing for successful tumor resection. 2.4. Surgical and anesthetic procedure

After careful positioning of the patient and general monitoring,

2. Methods
2.1. Patient selection and preoperative preparation
Patients were in good general health to tolerate surgery and had
reasonable airway mechanics. To minimize anxiety, we gave
patients 2 mg of midazolam prior to departing for the operating
room.
2.2. Operation room setup
Each patient was positioned in the operation room with his or
her head facing the instruments. We arranged the anesthesiologist,
the vital sign monitors (indicating electrocardiography (ECG), non-
invasive blood pressure, pulse oximetry and capnography), and the
Brainlab cranial navigation apparatus (BrainLAB AG, Munich,
Germany) to the side of the patient. We attached the Brainlab
skull-mounted reference array (52121B/52129) to the patient’s
forehead, away from the site of the planned craniotomy. The
operating microscope was placed near the patient’s head, but the
ultrasound, the Mayo stand, the Sonopet ultrasonic aspirator, and
the ceiling-mounted boom containing cautery generators and suc-
tion were at the patient’s feet. The details of the operation setup
are depicted in Fig. 1.
2.3. Patient positioning
We positioned patients who underwent frontal craniotomy in
the supine position. The head of the patient was placed on a Styro-
foam donut, in a neutral position. We positioned patients who
underwent temporal craniotomy in the lateral decubitus position.
The head of the patient was elevated with either multiple blankets
patients received IV propofol (2 mg
kg 1), remifentanil infusion
(0.05 lg 1
kg 1
min 1 in 5 min) and rocuronium (1 mg
kg 1). We
inserted a laryngeal mask airway (LMA) or endotracheal (ET) tube
to secure the airway. Anesthesia was maintained with IV propofol
(50–75 lg 1
kg 1
min 1) and remifentanil (0.05 lg 1
kg 1
min 1)
infusions until awakening. For the awake portion of the surgeries,
patients received dexmedetomidine infusions starting at 0.2 lg 1

kg 1
h 1 with the dose titrated up 0.7 lg 1
kg 1
h 1, as needed for
anxiolysis.
The location of tumor(s) was confirmed with the Brainlab cra-
nial navigation system prior to the planning of the incision site.
We then shaved, prepped, and draped the surgical area in a sterile
fashion. Our usual perioperative medications included 0.5–1 g of
levetiracetam (anticonvulsant), 10 mg of dexamethasone (corticos-
teroid), 0.5 g/kg of mannitol, and 2 g of cefazolin IV for skin flora
prophylaxis.
We used a combination of sharp dissection and Bovie cautery to
elevate the scalp. The neuronavigation system was again used to
confirm that the surgical field provided enough exposure for tumor
resection. We discontinued propofol and remifentanil fifteen min-
utes prior to the planned wakeup of the patient for cortical map-
ping and functional testing. IV sugammadex (2 mg
kg 1) was
given to the patient to reverse the effect of rocuronium. Once the
patient began to follow commands, we removed the LMA or endo-
tracheal tube. Dexmedetomidine was reduced to a level (0.2 lg 1

kg 1
h 1) at which the patient was awake and conversational, with
minimum achievable discomfort and anxiety.
2.5. General cortical mapping techniques
We conducted cortical mapping and functional testing when
the patient was awake and conversational. Specifically, we used a
 E. Shen et al. / Journal of Clinical Neuroscience 67 (2019) 221–225 223

areas that were negative for language function were resected dur-
ing corticectomy.

2.8. Tumor resection and skin closure

We resected tumors using a combination of blunt dissection,

bipolar electrocautery, and the Sonopet ultrasonic aspirator. The
extent of tumor resection confirmed with intraoperative ultra-
sound. After meticulous hemostasis, we closed the dura, skull,
and skin. During this phase of the surgery, we either re-intubated
the patients or sedated them with a combination of remifentanil
(0.05 lg 1
kg 1
min 1) and dexmedetomidine (0.2–0.7 lg 1

kg 1
h 1).

3. Results & illustrative cases:

3.1. Case 1: awake motor mapping

A 49-year-old man presented with focal seizures and was found

to a frontal mass adjacent to the precentral gyrus measuring
2.5 cm  1.7 cm with moderate surrounding edema. He had some

Fig. 2. Lateral patient positioning for language mapping. Top Left: a patient who
underwent temporal craniotomy was positioned in the lateral decubitus position.
The patient’s head was elevated with blankets and a Styrofoam donut, with his
‘‘down” arm extended towards the anesthesiologist. Top Right: the incision site was
marked for temporal craniotomy. Bottom Left: patient was draped with a single
‘‘hip drape” from 3 M, which allows for anethesiologists and neurologists to interact
with the patient during the procedure. Bottom Right: the surgical site after the dura
is opened.

hand-held bipolar stimulator for direct cortical electrical stimula-

tion, and a six-contact recording electrode over the surface of the
cortex close to the location of stimulation for electrocorticography
(ECoG) recording. Prior to mapping, we administered a series of
stimuli to the cortex, each for five seconds, increasing the ampli-
tude by 1 mA each time, until an afterdischarge was obtained on
ECoG recording [16,29].

2.6. Motor mapping

We obtained a baseline neurological exam of hand, arm, and leg

strength prior to resection of the tumor. Areas that are near elo-
quent motor regions were stimulated, and a positive stimulation
site was identified if a patient began to develop contralateral motor
movement during stimulation. Only tumor-containing areas that
were negative for motor function were resected during
corticectomy.

2.7. Language mapping

We established baseline language function prior to resection of

the tumor. We used a series of tasks including word repetition,
object identification, and comprehension during cortical mapping
to identify critical sites. Areas that are near eloquent speech
Fig. 3. T2-weighted axial MRI images demonstrating pre-operative vs. post-
regions were mapped, and a positive stimulation site was identi- operative changes a. Left frontal craniotomy with awake motor mapping; b. Left
fied if the stimulated patient began to develop difficulties in any temporal craniotomy with awake language mapping; c. Left temporal craniotomy
of the language tests during stimulation. Only tumor-containing under general anesthesia where the tumor was easily identifiable.
224 E. Shen et al. / Journal of Clinical Neuroscience 67 (2019) 221–225
subtle hand weakness on neurological examination. During resec-
tion of tumor, the patient developed subjective hand weakness,
tumor resection was halted as a result. Subtotal tumor resection
was obtained (Fig. 3a). At the two-month follow-up visit, the
patient was found to have full motor and sensory function in his
hand. The patient stated that he was able to use his computer with-
out difficulty.
3.2. Case 2: awake language mapping
A 43-year-old woman with a history of breast cancer presented
with a seizure and word-finding difficulties and was found to have
a left posterior temporal lesion (measuring 1.7 cm  1.7 cm 
1.4 cm, Fig. 3b). Left temporal craniotomy was performed with
total tumor resection obtained. At the one-month follow-up visit,
the patient’s language level was found to be near baseline. She
was able to name objects without difficulty and to correctly inter-
pret the meaning of a proverb (intact abstract reasoning). The
patient stated that she had some subjective word-finding difficulty
during speech, and when sending text messages, but was other-
wise intact.
4. Discussion
The protocol developed at Stony Brook departs from prior
reported techniques in one primary aspect. We emphasize the
careful initial positioning of the patient to avoid rigid head pinning
during the initial phase of surgery. We believe that our avoidance
of rigid head pinning in conjunction with the use of general anes-
thesia in Phase 1 of awake craniotomies may help to increase
patients’ safety and comfort during the procedure.
Avoidance of cranial pinning during the first phase of the sur-
gery not only helps to alleviate feelings of discomfort and anxiety
associated with the use of the Mayfield headholder [8,29], but also
may help to prevent related complications from the procedure.
Previous reports show that a substantial minority of patients
express discomfort and anxiety, which we believe can be attribu-
ted partially to the first phase of the surgery, including rigid head
pinning to the Mayfield stand [18,20]. Furthermore, seizure is a
known possible complication in any craniotomy (occurring in 3–
18% cases) [26]. Complications such as dislocation of the head from
the Mayfield headholder can occur as a result of patient agitation,
uncoordinated movement, or seizure when emerging from general
anesthesia to being awake or during cortical stimulation [5,12].
Although intraoperative seizures can generally be controlled with
ice-cold saline, propofol, or midazolam [27], when such complica-
tions occur the operation is usually resumed under general anes-
thesia rather than in an awake setting [27]. Such intraoperative
disruption can result in unnecessary distress on both the patient
and the medical staff. With careful initial positioning of patients
and with utilization of the Brainlab cranial navigation system, we
were able to locate and resect the brain lesions without the rigid
pinning of the patient’s head. We thus found that the use of a May-
field head frame was unnecessary. The key to this flexible approach
is having the airway fully secured and the head appropriately posi-
tioned without the use of rigid fixation. One potential disadvantage
to our approach is that without rigid fixation of the head there is a
theoretical risk that the patient’s head may move during tumor
resection that may result in unwanted intraoperative complica-
tions. However, because the patient is awake during the tumor
resection portion of the operation, continuous verbal communica-
tion with the patient has been enough to maintain the patient’s
head in place during surgery.
We are in support of placing patients under general anesthesia
with a secured airway rather than sedating patients without a
secured airway during the first phase of the surgery for the follow-
ing reasons. First, mechanical ventilation using an advanced airway
in the asleep-awake protocol helps to avoid hypercapnia and regu-
late brain volume to a certain extent, which can be helpful and
safer in a clinical situation where an increased intracranial pres-
sure can often result from a tumor mass [11]. Mechanical ventila-
tion under general anesthesia can also help to minimize alterations
in intracranial pressure caused by compromised cerebral autoreg-
ulation or insufficient pain control [22]. Tight control of brain vol-
ume through respiratory regulation may be less crucial after tumor
resection during the last phase of the surgery, when mass effects
resulting from a tumor are no longer present. Second, general anes-
thesia used in the asleep-awake technique helps to better control
for patients’ pain and anxiety. Third, it has been suggested the
asleep-awake technique may help patients to be cooperate longer
during the awake phase if they are unconscious during Phase 1 of
surgery, especially when the procedure is expected to be long [17].
Last, optimal sedation is required in the monitored anesthesia care
(MAC) technique to maintain the patient during surgery, which
may be a delicate balance to accomplish. Too much sedation can
lead to hypoxia, hypercarbia, respiratory depression, and non-
cooperation during intraoperative mapping. Too little sedation
can result in patients experiencing significant anxiety and pain
[10].
Because patients were under general anesthesia with an estab-
lished airway during the first phase of the surgery, an impromptu
decision regarding whether to wake up the patient for cortical
mapping could be made based on the intraoperative appearance
of the lesion. An established airway during the first phase allows
for the patient to be maintained under general anesthesia in a rel-
atively stress-free manner during tumor resection without the risk
of respiratory desaturation that is sometimes associated with seda-
tion without a secured airway [18,26]. We feel strongly that this
flexible approach that provides options for intraoperative surgical
decisions that can best suit a patient’s needs. For instance, in a
patient where the tumor is in the margin of the cortex and can
be easily identified and distinguished from the remaining cortex
upon opening the dura, resecting the tumor while keeping the
patient under general anesthesia helps to maximize the patient’s
comfort and safety. One such situation occurred during one of
our planned awake craniotomies. A patient with brain metastasis
from lung adenocarcinoma required a left temporal craniotomy.
Upon opening the dura, the patient’s tumor was bulging out in
the surgical site. Because the tumor was easily identified, we
elected to keep the patient under general anesthesia during tumor
resection to minimize any unnecessary procedure and discomfort
for the patient. In this case, we successfully achieved gross total
resection of the tumor, as shown in Fig. 3c. Postoperatively and
at the three-month follow-up visit, the patient revealed no notable
cognitive dysfunction.
Remifentanil, an opioid with a short half-life that is indepen-
dent of rate of infusion allowing for rapid emergence from anesthe-
sia, has been the drug of choice at many medical centers. However,
the medication causes respiratory depression making it less ideal
to use during sedation without respiratory support [28].
Dexmedetomidine, a highly specific a2-agonist with analgesic
effects, has become popular in recent years [3]. Dexmedetomidine
does not suppress ventilation and has been shown to decrease the
amount of other sedative and opioid agents, thus reducing their
adverse effects [2,19]. We have incorporated the recent develop-
ment of co-usage of dexmedetomidine with remifentanil here at
Stony Brook, which helps to decrease the amount of remifentanil
used, thereby reducing remifentanil-induced respiratory-
depressive effects during the third phase of awake craniotomy.
A recently published article describes an ‘‘awake-awake-awake”
craniotomy technique that does not require any sedation. The arti-
 E. Shen et al. / Journal of Clinical Neuroscience 67 (2019) 221–225
cle emphasizes on a hand-in-hand/shoulder physical contact for
emotional support from health providers to patients and on alter-
native relaxation techniques such listening to music and imaging
mental images of vacationing elsewhere to reduce patients’ stress
and anxiety that are evoked during the surgery [12]. Although this
protocol took a very different approach from what we have
described here at Stony Brook Medical Center, we may adopt some
of methods described in their protocol such as increased physical
contact between health providers and patients to further maximiz-
ing patient comfort during our awake craniotomy in the future.
We did not include a large number of patients in our technical
report. This is a limitation of the current protocol. A larger patient
population should be included in a future study to allow a more
detailed discussion of the benefits and drawbacks of our procedure
compared to prior described procedures.
5. Conclusion
At Stony Brook University Medical Center, we have developed a
simple protocol for craniotomy under general anesthesia, with
subsequent ‘‘wake-up” testing. The protocol avoids rigid skull fix-
ation and emphasizes prompt intraoperative decisions based on
clinical scenarios, helping to maximize patient and physician com-
fort while allowing for successful tumor resection.
Ethics statement
The current study received a formal exemption from the Stony
Brook University Office of Research Compliance indicating that it
did not require IRB approval. Activities included in the manuscript
were conducted in compliance with applicable regulations.
Informed written consent was obtained from the patient whose
photos were used in the manuscript.
Acknowledgement
The authors would like to thank the Department of Neuro-
surgery at the Stony Brook University School of Medicine for the
departmental funding that made the current project possible.
References
[1] Andersen JH, Olsen KS. Anesthesia for awake craniotomy is safe and well-
tolerated. Dan Med Bull 2010;10:A4194.
[2] Ard Jr JL, Bekker AY, Doyle WK. Dexmedetomidine in awake craniotomy: a
technical note. Surg Neurol 2005;63:114–7.
[3] Bekker AY, Kaufman B, Samir H, Doyle W. The use of Dexmedetomidine
infusion for awake craniotomy. Anesth Analog 2001;92:1251–3.
[4] Berkenstadt H, Perel A, Hadani M, Unofrievich I, Ram Z. Monitored anesthesia
care using remifentanil and propofol for awake craniotomy. J Neurosurg
Anesthesiol 2001;13:246–9.
[5] Bilotta F, Rosa G. ‘‘Anesthesia” for awake neurosurgery. Curr Opin Anaesthesiol
2009;22:560–5.
[6] Brown T, Shah AH, Bregy A, Shah NH, Thambuswamy M, Barbarite E, et al.
Awake or craniotomy for brain tumor resection: the rule rather than the
exception? J Neurosurg Anesthesiol 2013;25:240–7.
225
[7] Chacko AG, Thomas SG, Babu KS, Daniel RT, Chacko G, Prabhu K, et al. Awake
craniotomy and electrophysiological mapping for eloquent area tumors. Clin
Neurol Neurosurg 2013;115:329–34.
[8] Danks RA, Rogers M, Aglio LS, Gugino LD, Black PM. Patient tolerance of
craniotomy performed with the patient under local anesthesia and monitored
conscious sedation. Neurosurgery 1998;42:28–36.
[9] Dilmen OK, Akcil EF, Oguz A, Vehid H, Tunali Y. Comparison of conscious
sedation and asleep-awake-asleep techniques for awake craniotomy. J Clin
Neurosci 2017;35:30–4.
[10] Frost EA, Booij LH. Anesthesia in the patient for awake craniotomy. Curr Opin
Anaesthesiol 2007;20:331–5.
[11] Fukaya C, Katayama Y, Yoshino A, Kobayashi K, Kasai M, Yamamoto T.
Intraoperative wake-up procedure with propofol and laryngeal mask for
optimal excision of brain tumor in eloquent areas. J Clin Neurosci
2001;8:253–5.
[12] Hansen E, Seemann M, Zech N, Doenitz C, Luerding R, Brawanski A. Awake
craniotomies without any sedation: the awake-awake-awake technique. Acta
Neurochir 2013;155:1417–24.
[13] Hervey-Jumper SL, Li J, Lau D, Molinaro AM, Perry DW, Meng L, et al. Awake
craniotomy to maximize glioma resection: methods and technical nuances
over a 27-year period. J Neurosurg 2015;123:325–9.
[14] Huncke K, Van de Wiele B, Fried I, Rubinstein EH. The asleep-awake-asleep
anesthetic technique for intraoperative language mapping. Neurosurgery
1998;42:1312–7.
[15] Joswig H, Bratelj D, Brunner T, Jacomet A, Hildebrandt G, Surbeck W. Awake
craniotomy: first-year experiences and patient perception. World Neurosurg
2016;90:588–96.
[16] Kim SS, McCutcheon IE, Suki D, Weinberg JS, Sawaya R, Lang FF, et al. Awake
craniotomy for brain tumors near eloquent cortex: correlation of
intraoperative cortical mapping with neurological outcomes in 309
consecutive patients. Neurosurgery 2009;64:836–45.
[17] Lobo FA, Wagemakers M, Absalom AR. Anaesthesia for awake craniotomy. Br J
Anaesth 2016;116:740–4.
[18] Manninen PH, Balki M, Lukitto K, Bernstein M. Patient satisfaction with awake
craniotomy for tumor surgery: a comparison of remifentanil and fentanyl in
conjunction with propofol. Anesth Analog 2006;102:237–42.
[19] Mantz J, Josserand J, Hamada S. Dexmedetomidine: new insights. Eur J
Anaesthesiol 2011;28:3–6.
[20] Ostrom QT, Gittleman H, Farah P, Ondracek A, Chen Y, Wolinsky Y, et al.
CBTRUS statistical report: primary brain and central nervous system tumors
diagnosed in the United Sates in 2006-2010. Neuro Oncol 2013;15(Suppl. 2):
ii1–ii56.
[21] Paldor I, Drummond KJ, Awad M, Sufaro YZ, Kaye AH. Is a wake-up call in
order? Review of the evidence for awake craniotomy. J Clin Neurosci
2016;23:1–7.
[22] Quiney N, Cooper R, Stoneham M, Walters F. Pain after craniotomy. A time for
reappraisal? Br J Neurosurg 1996;10:295–9.
[23] Rajan S, Cata JP, Nada E, Weil R, Pal R, Avitsian R. Asleep-awake-asleep
craniotomy: a comparison with general anesthesia for resection of
supratentorial tumors. J Clin Neurosci 2013;20:1068–73.
[24] Sacko O, Lauwers-Cances V, Brauge D, Sesay M, Brenner A, Roux FE. Awake
craniotomy vs. surgery under general anesthesia for resection of
supratentorial lesions. Neurosurgery 2011;68:1192–8.
[25] Sanai N, Mirzadeh Z, Berger MS. Functional outcome after language mapping
for glioma resection. N Engl J Med 2008;358:18–27.
[26] Sarang A, Dinsmore J. Anesthesia for awake craniotomy-evolution of a
technique that facilities awake neurological testing. Br J Anaesth
2003;90:161–5.
[27] Sartorious CJ, Berger MS. Rapid termination of intraoperative stimulation-
evoked seizures with application of cold Ringer’s lactate to the cortex.
Technical note. J Neurosurg 1988;88:349–51.
[28] Sidaras G, Hunter JM. Is it safe to artificially ventilate a paralyzed patient
through the laryngeal mask? The jury is still out. Br J Anaesth 2001;86:749–53.
[29] Whittle IR, Borthwick S, Haq N. Brain dysfunction following ‘‘awake”
craniotomy, brain mapping and resection of glioma. Br J Neurosurg
2003;17:130–7.
[30] Whittle IR, Midgley S, Georges H, Pringle AM, Taylor R. Patient perceptions of
‘‘awake” brain tumor surgery. Acta Neurochir 2005;147:275–7.