The continuous awake craniotomy (CAC) protocol: a novel protocol for awake craniotomies

Abstract Objective: The generally used asleep-awake-asleep protocol makes reliable intra-operative testing difficult as patients are frequently disoriented when woken-up from sedation. Furthermore, this protocol carries potential risks for the patient, the most common among them being respiratory complications. In an effort to eliminate potential risks for the patient during awake craniotomies, and in order to improve reliability of intra-operative test results, we implemented a new protocol for awake craniotomies, the continuous awake craniotomy protocol, where the patient is not sedated during the entire procedure. We present first results of this new protocol. Methods: In a prospective study we analyzed awake craniotomies that were performed between September 2006 and June 2008. Data included OR-records, anesthesiological protocols, patient charts, and neuropsychological records. Results: Data of 12 consecutive primary brain tumor patients (six men/six women) with a mean age of 46 years who underwent 13 awake craniotomies were analyzed. A gross total resection was achieved in ten patients (83.3%), of which one patient (8.3%) suffered from a new neurological deficit postoperatively. One patient suffered a generalized seizure and one a focal seizure triggered by direct cortical stimulation. There were no anesthesiological or surgical complications in this study. Conclusion: This study shows that the continuous awake craniotomy protocol is safe, was tolerated well by all patients, and created a very controllable situation during all surgeries. Applying this method, sedation related complications, such as respiratory complications and hemodynamic dysregulation, can be avoided, as are potential risks during an intra-operative wake-up phase. Furthermore, intra-operative neuropsychological test results become more reliable.