Neuroanesthesia in Evolution: A Comprehensive Review of Anaesthetic Approaches in Craniotomy

Monitored anaesthesia care (MAC) is a preferred approach for craniotomy, particularly in awake procedures involving tumors near eloquent brain regions. Awake craniotomy (AC), practiced for over a century, is now the gold standard for resecting tumors in sensorimotor and language areas. It facilitates maximal tumor removal while preserving critical functions through intraoperative neurophysiological monitoring and cortical mapping. Techniques such as MAC, sedation-awake-sedation (SAS), and awake-awake-awake (AAA) demand skilled neuroanesthesia, patient cooperation, and precise sedation. The study by Carella et al. demonstrated that spinal block offered improved hemodynamic stability, reduced anesthetic and analgesic requirements, and lower postoperative pain scores. Jiang et al. conducted a randomized trial comparing desflurane and total intravenous anaesthesia (TIVA), finding no difference in brain relaxation but shorter emergence and extubation times, better early cognitive scores, and reduced remifentanil use in the desflurane group. Yang et al. found that scalp nerve block (SNB) significantly reduced intraoperative hemodynamic fluctuations, inflammatory markers, postoperative pain, and opioid consumption. In pediatric craniotomy, Xing et al. reported that morphine provided the most effective pain control, followed by tramadol and fentanyl. These studies collectively highlight the importance of anesthetic and analgesic strategy selection in optimizing perioperative outcomes, including hemodynamic response, pain management, and recovery profiles in adult and pediatric craniotomy patients.