目的:清醒开颅术(AC)用于最大程度地切除肿瘤,同时保留有意义的脑组织的神经功能。这种技术在成人中经常使用,但在儿童中仍然很少建立。由于关注儿童与成人的神经心理差异以及这些差异如何干扰手术的安全性和可行性,其使用受到限制。在报道儿科ACs的研究中,并发症发生率和麻醉管理各不相同。本系统评价旨在全面分析小儿AC的预后并综合麻醉方案。
方法:作者遵循PRISMA指南,提取报告患有颅内病变的儿童AC的研究。TheMedline/PubMed,奥维德,从数据库开始到2021年,使用术语(\“清醒\”)和(\“儿科*\”或\“儿童*\”)和((\“大脑\”和\“手术\”)或\“开颅术\”)搜索Embase数据库。提取的数据包括患者年龄,病理学,和麻醉方案。评估的主要结果是过早转换为全身麻醉,术中癫痫发作,完成监测任务,术后并发症。
结果:纳入了1997年至2020年发表的30项符合条件的研究,描述了总共130名年龄在7至17岁之间的儿童接受AC治疗。在所有报告的患者中,59%为男性,70%为左侧病变。手术适应症包括以下病因:肿瘤(77.6%),癫痫(20%),和血管疾病(2.4%)。由于AC期间的并发症或不适,98例患者中有4例(4.1%)需要转换为全身麻醉。此外,103例患者中有8例(7.8%)经历了术中癫痫发作。此外,92例患者中有19例(20.6%)难以完成监测任务。98例患者中有19例(19.4%)发生术后并发症,包括失语症(n=4),偏瘫(n=2),感觉缺陷(n=3),运动缺陷(n=4),或其他(n=6)。最常报道的麻醉技术是使用异丙酚的睡眠-清醒-睡眠方案,瑞芬太尼或芬太尼,局部头皮神经阻滞,或不使用右美托咪定。
结论:本系统评价的结果表明ACs在儿科人群中的耐受性和安全性。尽管小儿颅内病变的病因肯定可以从AC中受益,由于与儿童清醒手术相关的风险,外科医生和麻醉师需要进行个性化的风险-收益分析.特定年龄,术前计划的标准化指南,术中标测,监控任务,麻醉方案将有助于继续减少并发症,在提高耐受性的同时,并简化该患者人群的治疗工作流程。
Awake craniotomy (AC) is employed to maximize tumor resection while preserving neurological function in eloquent brain tissue. This technique is used frequently in adults but remains poorly established in children. Its use has been limited due to concern for children\'s neuropsychological differences compared with adults and how these differences may interfere with the safety and feasibility of the procedure. Among studies that have reported pediatric ACs, complication rates and anesthetic management vary. This systematic
review was performed to comprehensively analyze outcomes and synthesize anesthetic protocols of pediatric ACs.
The authors followed PRISMA guidelines to extract studies that reported AC in children with intracranial pathologies. The Medline/PubMed, Ovid, and Embase databases were searched from database inception to 2021, using the terms (\"awake\") AND (\"Pediatric*\" OR \"child*\") AND ((\"brain\" AND \"surgery\") OR \"craniotomy\"). Data extracted included patient age, pathology, and anesthetic protocol. Primary outcomes assessed were premature conversion to general anesthesia, intraoperative seizures, completion of monitoring tasks, and postoperative complications.
Thirty eligible studies published from 1997 to 2020 were included that described a total of 130 children ranging in age from 7 to 17 years who had undergone AC. Of all patients reported, 59% were male and 70% had left-sided lesions. Procedure indications included the following etiologies: tumors (77.6%), epilepsy (20%), and vascular disorders (2.4%). Four (4.1%) of 98 patients required conversion to general anesthesia due to complications or discomfort during AC. In addition, 8 (7.8%) of 103 patients experienced intraoperative seizures. Furthermore, 19 (20.6%) of 92 patients had difficulty completing monitoring tasks. Postoperative complications occurred in 19 (19.4%) of 98 patients and included aphasia (n = 4), hemiparesis (n = 2), sensory deficit (n = 3), motor deficit (n = 4), or others (n = 6). The most commonly reported anesthetic techniques were asleep-awake-asleep protocols using propofol, remifentanil or fentanyl, a local scalp nerve block, and with or without dexmedetomidine.
The findings of this systematic
review suggest the tolerability and safety of ACs in the pediatric population. Although pediatric intracranial pathologies pose etiologies that certainly may benefit from AC, there is a need for surgeons and anesthesiologists to perform individualized risk-benefit analyses due to the risks associated with awake procedures in children. Age-specific, standardized guidelines for preoperative planning, intraoperative mapping, monitoring tasks, and anesthesia protocols will help to continue minimizing complications, while improving tolerability, and streamlining workflow in the treatment of this patient population.