title: Awake Surgery for Brain Vascular Malformations and Moyamoya Disease.
abstract: OBJECTIVE
  Although a significant amount of experience has accumulated for awake procedures for brain tumor, epilepsy, and carotid surgery, its utility for intracranial neurovascular indications remains largely undefined. Awake surgery for select neurovascular cases offers the advantage of precise brain mapping and robust neurologic monitoring during surgery for lesions in eloquent areas, avoidance of potential hemodynamic instability, and possible faster recovery. It also opens the window for perilesional epileptogenic tissue resection with potentially less risk for iatrogenic injury.
  
  
  METHODS
  Institutional review board approval was obtained for a retrospective review of awake surgeries for intracranial neurovascular indications over the past 36 months from a prospectively maintained quality database. We reviewed patients' clinical indications, clinical and imaging parameters, and postoperative outcomes.
  
  
  RESULTS
  Eight consecutive patients underwent 9 intracranial neurovascular awake procedures conducted by the senior author. A standardized "sedated-awake-sedated" protocol was used in all 8 patients. For the 2 patients with arteriovenous malformations and the 3 patients with cavernoma, awake brain surface and white matter mapping was performed before and during microsurgical resection. A neurological examination was obtained periodically throughout all 5 procedures. There were no intraoperative or perioperative complications. Hypotension was avoided during the 2 Moyamoya revascularization procedures in the patient with a history of labile blood pressure. Postoperative imaging confirmed complete arteriovenous malformation and cavernoma resections. No new neurologic deficits or new-onset seizures were noted on 3-month follow-up.
  
  
  CONCLUSIONS
  Awake surgery appears to be safe for select patients with intracranial neurovascular pathologies. Potential advantages include greater safety, shorter length of stay, and reduced cost.
authors.affiliation: Department of Neurological Surgery, Neurovascular and Skullbase Program, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA; Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.
authors.forename: Rami James N
authors.initials: RJN
authors.lastname: Aoun
authors.affiliation: Department of Neurological Surgery, Neurovascular and Skullbase Program, Mayo Clinic, Phoenix, Arizona, USA.
authors.forename: Mithun G
authors.initials: MG
authors.lastname: Sattur
authors.affiliation: Department of Neurological Surgery, Neurovascular and Skullbase Program, Mayo Clinic, Phoenix, Arizona, USA.
authors.forename: Chandan
authors.initials: C
authors.lastname: Krishna
authors.affiliation: Department of Neurological Surgery, Neurovascular and Skullbase Program, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA; Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.
authors.forename: Amen
authors.initials: A
authors.lastname: Gupta
authors.affiliation: Department of Neurological Surgery, Neurovascular and Skullbase Program, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA; Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Welz
authors.affiliation: Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
authors.forename: Allan D
authors.initials: AD
authors.lastname: Nanney
authors.affiliation: Department of Anesthesiology, Northwestern University Memorial Hospital, Chicago, Illinois, USA.
authors.forename: Antoun H
authors.initials: AH
authors.lastname: Koht
authors.affiliation: Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
authors.forename: Matthew C
authors.initials: MC
authors.lastname: Tate
authors.affiliation: Department of Neurology, Mayo Clinic, Phoenix, Arizona, USA.
authors.forename: Katherine H
authors.initials: KH
authors.lastname: Noe
authors.affiliation: Department of Neurology, Mayo Clinic, Phoenix, Arizona, USA.
authors.forename: Joseph I
authors.initials: JI
authors.lastname: Sirven
authors.affiliation: Department of Neurological Surgery, Neurovascular and Skullbase Program, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA; Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.
authors.forename: Barrett J
authors.initials: BJ
authors.lastname: Anderies
authors.affiliation: Department of Anesthesiology, Mayo Clinic, Phoenix, Arizona, USA.
authors.forename: Patrick B
authors.initials: PB
authors.lastname: Bolton
authors.affiliation: Department of Anesthesiology, Mayo Clinic, Phoenix, Arizona, USA.
authors.forename: Terry L
authors.initials: TL
authors.lastname: Trentman
authors.affiliation: Department of Neurological Surgery, Neurovascular and Skullbase Program, Mayo Clinic, Phoenix, Arizona, USA.
authors.forename: Richard S
authors.initials: RS
authors.lastname: Zimmerman
authors.affiliation: Department of Neurological Surgery, Neurovascular and Skullbase Program, Mayo Clinic, Phoenix, Arizona, USA.
authors.forename: Kristin R
authors.initials: KR
authors.lastname: Swanson
authors.affiliation: Department of Neurological Surgery, Neurovascular and Skullbase Program, Mayo Clinic, Phoenix, Arizona, USA; Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona, USA; Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA; Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA. Electronic address: Bendok.bernard@mayo.edu.
authors.forename: Bernard R
authors.initials: BR
authors.lastname: Bendok
mesh_terms: D000328:Adult; D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D009072:Moyamoya Disease / Q000000981:diagnostic imaging / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000379:methods*; D014851:Wakefulness; D055815:Young Adult
keywords: Arteriovenous malformation; Awake surgery; Cavernomas; Direct cortical stimulation; Moyamoya; Neurovascular surgery; fMRI