Intraoperative Awakening from Endotracheal General Anesthesia for Brain Mapping with Tracheal Tube In Situ

Awake craniotomy (AC) is indicated to excise a lesion close to an eloquent area of the brain. Success of this procedure depends upon the patient’s active participation during the awake phase of the surgery, especially for brain mapping. Occasionally, a patient may refuse to remain awake during the surgical procedure and demand general anesthesia (GA). A 27-year-old male with uncontrolled seizures from recurrent brain tumor near motor area refused to consent for AC citing his past unpleasant experience; so, the decision to administer GA was taken. To avoid straining/coughing on tracheal tube, his airway was anesthetized with transtracheal xylocaine, bilateral superior laryngeal nerve block, and inflation of tracheal tube cuff with xylocaine. GA was maintained with sevoflurane, infusion of fentanyl, and rocuronium. To awaken him, anesthetics were discontinued and rocuronium antagonized with sugammadex. Intravenous lignocaine and midazolam were administered to supress cough reflex and produce amnesia, respectively. He tolerated the entire duration of 30 minutes of brain mapping with electrocorticography and neurological testing comfortably. Upon completion of brain mapping, GA was reintroduced and the lesion excised. The surgical outcome was good with no neurological deficit. When interviewed postoperatively, the patient had no recall of the awake phase