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Invited Review
Anesthesia for pediatric epilepsy surgery
Rebecca Jacob, Sanjib Das Adhikary, Roy Thomas Daniel1
Departments of Anaesthesia and 1Neurological Sciences, Christian Medical College, Vellore, India

Address for Correspondence: Prof. Rebecca Jacob, Department of Anaesthesia, Christian Medical College, Vellore - 632 004,
Tamil Nadu, India. E-mail: rebeccajacob@hotmail.com

ABSTRACT
Epilepsy surgery for the child is increasingly being offered as a management option even in infants, due
to advances in neurosurgery and pediatric neuro-anesthesia, coupled with a better understanding of
neurophysiological evaluation/monitoring. Anesthesia for children in the setting of a major surgery like epilepsy
surgery presents a variety of challenges. This article deals with the physiology of electroencephalogram and
the effects of anesthetic agents on neurophysiology, sedation and anesthesia for investigative procedures and
definitive surgery with major blood loss and fluid shifts, with special emphasis on the small child and awake
craniotomy in the older child.
Key words: Anesthesia, electrocorticogram, epilepsy surgery

Pediatric epilepsy is more common than is generally

acknowledged or perceived. The current treatment strategies
include use of conventional antiepileptic drugs (AEDs), new
AEDs, ketogenic diets, vagus nerve stimulation and epilepsy
surgery. The last is usually considered only if the epilepsy is
intractable. The commonest definition for intractable epilepsy
is when seizures continue despite maximally tolerated doses
of more than two AEDs with an occurrence of an average
of one seizure per month for approximately 18 months
with no more than a 3-month seizure-free period in these
18 months.[1] At the stage when the epilepsy is intractable
and surgery is considered, the child is examined to determine
whether he has a surgically remediable epilepsy syndrome
with good electro-clinical-radiological concordance. To this
end, he is subjected to neurological and neuropsychological
evaluation, multiple electroencephalograms (EEGs), video
telemetry and magnetic resonance imaging (MRI). If the
lesion that is producing epilepsy may be safely removed
without causing major functional deficits, he is considered
for surgery. If, however, there is no concordance in the
above investigations, he goes into Phase II studies, where
he is subjected to prolonged invasive EEG monitoring,
nuclear medicine and WADA (sodium amylobarbital)
studies. Surgery is offered if concordance is obtained and
the risk of incurring functional deterioration is considered
minimal or acceptable.[2] Surgically remediable epilepsy can
be treated by either resective or disconnective surgery. The
surgical techniques are guided either by image guidance
Online full text at
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82 / J Pediatr Neurosci / Volume 3 / Jan-Jun / 2008

or by intraoperative neurophysiological monitoring. With

the advent of newer surgical techniques and anesthetic
agents and a greater understanding of neurophysiology in
the intraoperative setting, surgery for epilepsy is now being
undertaken even in very small children.
In this article, we will deal with the physiology of EEG and
the effects of anesthetic agents on neurophysiology, sedation
and anesthesia for investigative procedures, anesthesia for
definitive surgery, along with management of major blood
loss and fluid shifts, with special emphasis on the small child
and awake craniotomy in the older child.

Physiology of Electroencephalogram
The electroencephalogram (EEG) is used to help identify
conditions like epilepsy, infarction of the brain, consciousness
and unconsciousness. However, the correlation of EEG with
anesthetic agents is less clear. The EEG signals contain three
parameters: amplitude, frequency and time. Amplitude is
the height of the wave, frequency is the number of cycles
per second the wave crosses the zero voltage line and time
is the duration of epileptic activity. In cases of deeply placed
epileptic foci, the spread of epileptiform activity is also of
significance. The usual base frequency in a normal conscious
patient is in the beta wave range (>13 Hz), and this comes to
alpha range (8-13 Hz) with closure of eyes or mild sedation.
The events that lead to the production of higher frequency
is termed activation, and the events that lead to slower
frequencies like theta or delta (<4-7 Hz) are referred to as
depression of EEG. Epilepsy is recognized by high-voltage

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Jacob et al.: Anesthesia for epilepsy surgery

spike waves, whereas conditions like cerebral infarction

appear as low voltage in EEG. These high-voltage spike waves
have certain recognizable patterns and occur in areas specific
to a particular type of epileptiform activity. However, these
activities are not seen or recorded where the cortical activity
is depressed by use of agents like antiepileptic medications or
anesthetics. Therefore, to localize the epileptic focus, spike
activity may be evoked or produced during surgery by using
different maneuvers or pharmacologic agents.

An Overview of the Anesthetic Agents and

their Impact on Electroencephalogram
Anesthetic agents
Anesthesia tends to suppress normal EEG and suppress spike
activity. However, it appears that spiking activity with volatile
anesthetics may be expressed differently according to the type
of epilepsy or location of the epileptiform focus.[3] Volatile
anesthetics have both pro- and anticonvulsive properties.
Increased spiking activity is seen with high concentrations
of isoflurane. And sevoflurane, but very high concentration
of isoflurane, sevoflurane and propofol, on the other hand,
cause burst suppression and electrical silence. Propofol
reduces spike activity in a dose-dependent manner.[4] Opioids
are used intraoperatively for analgesia and for reduction of
the dose requirements of other agents like inhalational and
intravenous agents.[5,6] Remifentanil, alfentanil and fentanyl
all increase spiking in abnormal brain this is considered
an advantage for monitoring.[7-9] The patients on prolonged
antiepileptic drug treatment require a higher dose of opioids
for effective analgesia. Hyperventilation also increases spike
count. [10] It seems preferable to use low concentrations
of anesthetic agents so as to facilitate neurophysiologic
monitoring. However, this may lead to awareness. To avoid
this, a depth-of-anesthesia monitor like a BIS monitor may
be used where possible, with enough opioids so as to provide
adequate analgesia. Agents like droperidol have been used in
adults and pediatrics during awake craniotomy, but its sedative
effects and postoperative drowsiness have been the main
disadvantages. It can also induce seizure when given along
with inhalational agents.[11] Agents like dexmedetomidine, a
selective alpha 2 adrenoreceptor agonist, also have been used
recently as an adjuvant for awake craniotomy in pediatric
patients, but doses used by different authors are varied and
no standard dosing schedule has been recommended yet.
Local anesthesia
Local anesthetics have both excitatory and depressive effects
based on their plasma concentrations. At low concentrations,
they are depressive and at higher concentrations, they are
excitatory. They are used in patients where the surgery
is planned awake or under conscious sedation and in
anesthetized patients. It often requires a very large volume,
and the maximum allowable dose of local anesthesia to block
the scalp circumferentially must be carefully calculated. If used
in higher concentration, it often can exceed the toxic dose; so,
it has to be used in more diluted concentration, with addition

of vasoconstrictors like adrenaline or phenylephrine to prevent

rapid absorption. In spite of these precautions, there are reports
of toxic adverse reactions with these agents.[12,13]
Preoperative preparation
This surgery is major and elective. It is therefore important
to do a careful and comprehensive preoperative history
and evaluation of the patient. Have a frank discussion with
the parents regarding all the procedures to be undertaken,
including blood transfusion, before obtaining informed
consent. The anesthesiologist should always try to build a
good rapport with the child. This is very important if the
child requires the procedure to be done under conscious
sedation.
Many of these children are developmentally delayed and
uncooperative. They may have carious or loose teeth,
gum hypertrophy, enlarged adenoids or tonsils, cardiac
involvement; and all of them will be on one or more
seizure medications. Chronic carbamazepine and phenytoin
usage is associated with resistance to muscle relaxants and
narcotics. [14-16] Premedication may be indicated, but the
effects of the drugs, especially benzodiazepines, on EEG
should be taken into account. Ideally, routine premedication
should be avoided. If it is planned to administer any agents
as premedication, it should be discussed with the neurologist
and the dose adjusted accordingly.
Investigations requiring sedation/anesthesia
These children are often subjected to multiple investigations.
With a little care and cooperation between departments,
EEG and MRI may be done during the same session of
sedation/anesthesia, or MRI and surgery may be done at the
same sitting.
EEG and MRI are done at sites in the hospital other than
the operation suite. Often sedation is given for EEGs by
technicians using drugs like triclofos. If that does not work,
they add on other sedatives. This may lead to dangerous
respiratory and cardiovascular depression. We advocate that
these areas be well equipped for resuscitation and the staff
trained in pediatric airway management and resuscitation in
case of over-sedation or seizures.
MRI may be done under sedation using a drug like triclofos or
an inhalational agent like sevoflurane with a laryngeal mask
airway (LMA). In this case, an anesthetic machine which
is compatible with MRI is required. Another option is an
intravenous infusion of propofol. However, the infusion pump
will have to be kept outside the magnetic range. Ketamine
should be avoided due to its epileptogenic properties. Due
to the effect of the magnetic field on ferromagnetic objects,
there are limitations on monitoring and the use of infusion
pumps and ventilators in the MRI suite.
Anesthesia monitoring
Minor procedures like MRI may be carried out under sedation
with pulse oximetry alone. If general anesthesia is required,
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Jacob et al.: Anesthesia for epilepsy surgery

then end tidal carbon dioxide (EtCO 2) and noninvasive

blood pressure (NIBP), along with pulse oximetry, should be
included in monitoring.
A child undergoing major, complex, long-duration procedures
involving massive blood loss and fluid shifts requires
meticulous monitoring of oximetry, invasive arterial pressure,
central venous pressure, temperature, expired carbon dioxide
and anesthetic gases, urine output (indwelling catheter), serial
hematocrit, arterial blood gases, electrolytes and coagulation
parameters.
The skull of a child is larger in proportion, compared to
the proportion in an adult. The scalp and skull being very
vascular, massive bleeding may be expected. Therefore,
continuous intra-arterial blood pressure and central venous
pressure monitoring becomes mandatory. These monitors
help in optimizing volume replacement. It is better to avoid
using the neck veins to gain access to central veins as there
is a potential for obstruction of veins draining the brain.
A depth-of-anesthesia monitor is helpful to measure the
level of anesthesia, prevent awareness and prevent overdose
of inhalational or narcotic agents.
It is very important to secure the endo-tracheal tube, all lines,
adding extensions to the venous access lines where necessary
and monitors meticulously as once the patient is positioned
and draped it is very difficult to access the patient. Pressure
points should be carefully padded.
Special neurological monitoring
Intraoperative electrocorticogram (ECoG) is the most
common intraoperative neurophysiological monitoring done
under anesthesia during the procedure. It is used mainly to
delineate the extent of the epileptogenic foci or to confirm
the success of the predetermined resection. The most
important prerequisite for intraoperative ECoG is sufficient
brain exposure. Usually 12-16 electrodes are used. They are
placed in such a way that postresection, ECoG is possible
with the use of the same electrodes. In most cases, they also
serve to detect the post-electric stimulation discharges caused
during mapping. Intraoperative cortical mapping is preferred
in those children where cooperation and orientation are
doubtful intraoperatively, such as those with generalized
epilepsies, lesion-related and cryptogenic epilepsies such as
Lennox-Gastaut syndrome, infantile spasms, all disorders
causing intractable and disabling seizures, early cognitive
disturbances, impaired intelligence and behavioral deficits.
This makes them unsuitable for awake craniotomy or surgery
under conscious sedation.
Another essential requirement of cortical resections is
identification of the sensory and motor strip. It is usually
done by using sensory evoked potential (phase reversal)
and/or direct cortical stimulation (looking for movement on
stimulation) under anesthesia. When surgery is planned under
local anesthesia, that is, as awake craniotomy, then, only direct
cortical stimulation is done. However, due to the possibility of
84 / J Pediatr Neurosci / Volume 3 / Jan-Jun / 2008

seizure induction during electrical stimulation, a dose of fastacting barbiturates is always kept ready to treat the seizure.
Warming
Keep the ambient temperature up, as once the scalp is retracted
temperature loss from the raw surfaces is rapid. An underbody
hot air warmer, intravenous (IV) fluid warmers and airway
heat-moisture exchangers are useful in maintaining the childs
body temperature. Hypothermia leads to increased wound
infection[17] and coagulopathy.[18,19] It may also suppress EEG
waves. Hyperthermia should also be avoided as it leads to
neuronal death. Now, air blowers are available for the underbody
blankets, which can be made to cool the baby by blowing cool
air through the blankets in case of hyperthermia.
Anesthesia goals
An ideal anesthetic regime would rapidly induce sleep without
interfering with the EEG, provide analgesia when required,
provide cerebral protection with a stable ICP, provide
hemodynamic stability and end with a rapid awakening
to a safe state when the procedure is finished. The ideal
anesthetic does not quite exist, and the choice of anesthetic
depends on the experience of the anesthetist with each agent,
the procedure contemplated and the patient himself. The
smaller the patient and the more complex the surgery, the
more difficult it is to manage the blood loss, hemodynamics
and temperature. Intracranial pressure should be maintained
normal or low to help surgical access. Though a raised ICP
is not usually a problem in these cases, increased ICP can
result from positive end expiratory pressure, poor positioning
obstructing venous drainage, lack of muscle relaxation
and elevated CO2.[10] Isoflurane and sevoflurane with mild
hyperventilation may be used.[20] Propofol will produce a
consistent reduction in cerebral blood volume and ICP.
Neuroprotection is done best by ensuring adequate cerebral
perfusion. Mild hypothermia and anesthetic drugs have also
been reported to be neuroprotective.[10]
Blood and fluid management
Some epilepsy surgeries, such as hemispherectomy, are
associated with very large blood loss. This should be
anticipated, adequate monitoring in place and large-bore
IV lines available for transfusion. The target for fluid therapy
is normovolemia. Normal saline is the commonly used
crystalloid. Large volumes of normal saline will cause acidosis.
Ringer lactate decreases osmotic pressure and can cause brain
swelling. Colloids such as voluven are an option. The child
may tolerate low hematocrit; but if transfusion is done after
filling him with colloids, then there is the risk of overfilling
the intravascular volume. If on the other hand, transfusion
is left till too late on a relatively hypovolemic child, then the
rapid transfusion could lead to hyperkalemia, acidosis and
hypocalcemia, which may result in cardiac arrest. Transfusion
should therefore be started early and volume maintained.[10]
There is also a need to check coagulation profile and get
specific blood products like FFP and cryoprecipitate, if
required, as in cases of massive transfusion.

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Jacob et al.: Anesthesia for epilepsy surgery

Awake Craniotomy
Intracranial procedures requiring a conscious patient are
challenging to the anesthesiologist, especially when the patient
is a child. The challenges associated with this technique are
to provide adequate sedation, analgesia, with respiratory and
hemodynamic control while keeping the patient conscious
and cooperative for neurological testing. Resection of lesions
near eloquent areas of brain, such as speech and language,
mandates the use of this technique for excision of the lesion.
Different types of anesthetic techniques for awake craniotomy
have been described in the literature.[21-25] However, most of
these are for adult patients. There have been few case reports
recently where these techniques have been modified for use
in children down to 11 years of age. Compared to the adult,
where the patient is fully awake and conscious throughout the
surgery, in the pediatric patient a sleep-awake-sleep technique
is usually preferred. All the reports of awake craniotomy in
children have emphasized one single point that of proper
patient selection for the procedure.[26-28]
Complications during these procedures are often related
to airway obstruction, agitation, drowsiness and respiratory
depression. These problems are very difficult to treat once
the patient is positioned for a craniotomy, the skull opened
or the procedure started. Even though different reports
suggest different agents during the management, not a single
anesthetic agent has proven ideal by randomized trial; and
every drug has its advantages and disadvantages. There
are different agents that have been tried as anesthetics in
these cases, such as sevoflurane, propofol, remifentanil,
dexmedetomidine, droperidol and fentanyl alone or in
combination. The most commonly used for sleep-awakesleep technique, as reported in the literature, are propofol
with fentanyl. The advantage of propofol is that if used
properly, the patient can breathe spontaneously and no active
airway management is necessary. However, in higher doses,
respiratory depression and hypotension are seen. Sevoflurane,
on the other hand, has to be administered through an
LMA or ETT, which requires manipulation of the airway
during the procedure. Dexmedetomidine has recently been
introduced. It is an effective sedative, but it has a propensity
for bradycardia and hypotension even though it does not
have depressive effects on the respiratory system. There are
no large clinical trials to date comparing different anesthetic
agents in children during awake craniotomy; so it is left to
the neuroanesthesiologists to decide on the technique and
agents with which they are most familiar and which will suit
the specific patient. We describe here, broadly, the steps
of an awake (conscious) craniotomy with advantages and
disadvantages of the particular agent or technique.
Awake craniotomy with intraoperative cortical stimulation
is most commonly done in patients where the lesions affect
the eloquent areas of the brain. This technique allows the
excision of the lesion without significant neurological deficits
such as aphasia. The prerequisite on the part of the patient
is his/her psychological stability. The patient should be old

enough to understand that it is very important to cooperate

during the procedure. If there is any doubt regarding his
cooperation, he should not be considered as a candidate for
awake craniotomy. The preoperative visits and consultations
with the patient and his parents are very important. Various
means of description and explanations of the procedure, like
videos, slides or photographs of previous surgeries, may have
a role in helping him imagine, understand and accept his role
intraoperatively. The task which is expected to be evaluated
during the procedure has to be rehearsed preoperatively. It
is very important to obtain the confidence of the patient
irrespective of the number of visits required preoperatively.
On the day of the surgery, the patient is usually not given
any premedications except for steroids and H2 blockers and
is kept nil per oral. The doses of anticonvulsants are decided
after discussion with the attending neurologist. If the child is
apprehensive, a small bolus of short-acting benzodiazepine like
midazolam is administered after securing an intravenous line.
All the personnel in the operating room should be aware that
the patient is conscious and so unnecessary noise or verbal
exchanges should be kept to a minimum. The temperature of
the operating room should be made comfortable for the patient.
All emergency drugs and equipment should be available and
checked. An appropriate-size laryngeal mask airway (LMA)
is kept ready. The bladder is not usually catheterized as it is
uncomfortable and can aggravate the patients anxiety. After
positioning the patient on a well-padded table, a nasal cannula
is placed to administer oxygen and to monitor end-tidal
carbon dioxide during the procedure. A depth-of-anesthesia
monitor can be placed to monitor the depth of anesthesia
during the procedure. We now describe the most commonly
used technique described in the literature with drugs that
are available in India. Fentanyl 1 g.kg-1 along with propofol
in increments from 0.5 to 2 mg.kg-1 is administered slowly
until the patient goes to sleep.[26] An infusion of propofol
150-200 g.kg-1.min-1 is then started, and an arterial cannula
is inserted under local anesthesia to measure continuous
arterial pressure. The maximum amount of local anesthetic
is decided on the basis of the body weight and divided into
three volumes for blockade of scalp nerves, the pin sites and
for infiltration of the surgical incision site along with dural
infiltration. The concentration of bupivicaine used varies
from 0.1 to 0.25% depending on the requirement and body
weight of the patient. Sometimes, if the requirement is more
than the allowable dose of bupivicaine, an additional amount
of lignocaine in varying concentration (1-2%) is added to
bupivicaine to make up the adequate volume required for the
procedure. After application of the three-pin Mayfield head
holder and positioning of the patient, the surgeons are allowed
to drape the patient in such a way that the anesthesiologists
have a clear view of the patients face, have access to the
patient and monitoring and have enough space for any
airway management if required. The planned incision site
is then infiltrated with the local anesthetic mixture. During
infiltration if the patient responds, up to 0.5 g.kg-1 of fentanyl
is given incrementally. Mannitol (0.5 g.kg-1) is administered
slowly during the flap removal. After raising the skin and
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Jacob et al.: Anesthesia for epilepsy surgery

bone flap, the outer layer of dura is usually infiltrated with

local anesthetic mixture and an incision is made to expose
the cortex. Once the dura is incised, the anesthetic agent
is usually stopped and over a period of 10 to 15 minutes,
the patient usually wakes up. This correlates well with the
depth-of-anesthesia monitoring. Direct electrical stimulation
is done on the cortex to localize motor and speech areas. The
patient is usually kept awake and continuously evaluated by
the neurophysiologist during the time of resection, ensuring
that no disturbances to patient language and other higher
functions occur. There is a chance of seizure occurring at
this time. It usually gets resolved on stoppage of stimulation.
However, if clinical seizure occurs, then it has to be treated
with boluses of propofol or thiopentone. The patient can lose
his ability to maintain his airway in these conditions; so an
LMA may be used to intervene if required. An intubating
laryngeal mask (ILMA) or proseal LMA is easier to place
than an LMA classic. Once the mapping is complete, the
anesthetic agent (propofol) infusion is restarted as per
requirement. Ondansetron 0.15 mg.kg-1 is administered
prophylactically. Propofol or anesthetic agents are stopped
once the scalp wound is closed. The patient is allowed to
regain consciousness slowly. The patient is shifted to the
recovery room once he becomes oriented and obeys verbal
commands.

Conclusion
It is now increasingly being recognized that the treatment of
epilepsy in the child needs to be prioritized in order to not lose
the crucial phase of brain development when the plasticity of
the brain is maximal. Allowing a child to grow to adulthood
with normal cognition and capability to earn a livelihood
contributes immensely to the family and society. Thus younger
children are now presenting for major surgery on the brain in
the hope that early treatment will ameliorate their epilepsy
without increasing morbidity and enhance brain development.
The anesthetic management of these cases is widely different
and challenging in its own right. The anesthetist is thus called
upon to play a major role in the management of the very young
child who presents for epilepsy surgery or the older child who
undergoes an awake craniotomy. With marked improvement
in the understanding of neurophysiology, newer techniques of
surgery and anesthesia, more children with epilepsy can now
be offered the benefit of a curative surgery.

3.

4.

5.

6.

7.

8.

9.

10.
11.
12.

13.

14.

15.

16.

17.

18.

Acknowledgement
19.

Dr. K. Srinivasa Babu, Neurophysiologist, Christian Medical College,

Vellore, for his invaluable help in understanding neurophysiology.

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Source of Support: Nil, Conflict of Interest: None declared.

2008 / Jan-Jun / Volume 3 / J Pediatr Neurosci / 87