Awake craniotomy: Controversies, indications and techniques in the surgical treatment of temporal lobe epilepsy

In 1886, Victor Horsley excised an epileptogenic posttraumatic cortical sca r in a 23-year-old man under general anaesthesia and discussed his choice o f anaesthesia: "I have not employed ether in operations on man, fearing tha t it would tend to cause cerebral excitement; chloroform, of course, produc ing on the contrary, well-marked depression." His concerns regarding anaest hesia are reiterated 100 years later as evidenced by the ongoing controvers y over the choice of anaesthetic in surgical procedures for epilepsy. The c urrent controversies regarding the necessity for local anaesthesia in tempo ral lobe epilepsy operations concern the utility of electrocorticography in surgical decision making, its relationship to seizure outcome and the valu e of intraoperative language mapping in dominant temporal lobe resections. The increasing sophistication of pre-operative investigation and localizati on of both areas of epileptogenesis and normal brain function and the intro duction of minimally invasive surgical techniques and smaller focal resecti ons are changing the indications for local anaesthesia in temporal lobe epi lepsy. Thus, indications which were previously absolute are now perhaps rel ative. This article reviews the current indications for craniotomy under lo cal anaesthesia in the surgical treatment of temporal lobe epilepsy.