Challenges of Awake Craniotomy in a Patient with Severe COPD and Pulmonary Bullae for Excision of Frontal Glioma-A Case Report.

Awake craniotomy (AC) is primarily performed for specific surgical indications; however, medical conditions requiring AC are rarely reported. Anesthetic challenges of a patient with severe chronic obstructive pulmonary disease (COPD) and pulmonary bullae who underwent craniotomy and tumor excision are reported here. A 65-year-old diabetic woman presented with acute right-sided weakness, fever, altered mental status, and COPD exacerbation. The investigation revealed a left frontal lesion with significant perilesional edema, right lung bullae, bronchopneumonia, and hyponatremia due to the syndrome of inappropriate antidiuretic hormone (SIADH). After optimization by a multidisciplinary team, she was scheduled for craniotomy and partial excision. Given her pulmonary and neurological conditions, several anesthetic options were considered: general anesthesia (GA) with intermittent positive pressure ventilation (IPPV) utilizing low tidal volume, single-lung ventilation using a double-lumen tube/bronchial blocker, and AC using monitored anesthesia care (MAC). The potential risks and benefits of each technique were discussed, and it was decided to proceed with AC under MAC, using scalp block, dexmedetomidine infusion, intermittent propofol, and fentanyl boluses. A backup plan for conversion to GA was established in the event of severe coughing or seizure, and the equipment and personnel for emergency intercostal drainage (ICD) were on standby to address potential bullae rupture during IPPV. The family was informed of the complications associated with GA, including the risk of pneumothorax, ICD insertion, prolonged mechanical ventilation, and extended intensive care and hospital stay. A coordinated perioperative care strategy, facilitated by a multidisciplinary team, prevented morbidity in this case.