Reply to the commentary. Risks and tasks of awake craniotomy under conscious sedation

Dear Editor,
We are responding to the questions raised by our colleagues from Warsaw (commentary by Surówka et al.) [1] following the publication of our study “Awake craniotomy with dexmedetomidine during resection of brain tumours located in eloquent regions” [2]. We appreciate this discussion, as it could enhance the ma­nagement of patients undergoing the awake craniotomy procedure.
The proper patient selection for awake craniotomy (AC) under conscious sedation (CS) is an important factor that influences possible adverse events during the procedure. Therefore, in our study, a psychologist carefully evaluated each patient at least one day before the procedure to identify the risk factors of uncooperativeness, overwhelming stress, and an inability to understand and follow commands or answer questions. Patients with significant intellectual or psychiatric disorders were disqualified from AC. Some patients with somnolence, aphasia or motor impairment were recognised as candidates for AC under CS because they could cooperate and answer questions once aroused, which was confirmed by the psychologist. In our study, we defined patients as having a “good neurological status” if they passed all psychological tests preoperatively. Additionally, in our group, only one patient had a Glasgow Coma Scale (GCS) of 14 points, and the rest had a GCS of 15 points (Table 1 should show GCS 14–15: n = 26, and GCS 8–13, n = 0). However, in our opinion, GCS is not appropriate and sufficient to describe a patient’s psychological and intellectual condition in the context of selection for AC, although commonly used to define neurological status [3, 4].
It may be surprising that even patients with previous psychiatric diseases, as well as those with a poor performance status (Karnofsky scale: < 70 points), were selected for AC and CS in other centres. A significant correlation between an increase in intraoperative emotional intolerance, and further complications (uncooperativeness, respiratory insufficiency, conversion to general anaesthesia with intubation, or other instrumental upper airway support) during AC and CS, below 70 points of the Karnofsky scale has been noted [5]. This issue was addressed in other studies, which included patients with various neurosurgical procedures of AC/CS, based on dexmedetomidine sedation [5–7].
AC under dexmedetomidine-based CS is routinely performed in our centre. To date, we have operated on about 70...


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