Case Report: Anesthetic Considerations for Enhanced Recovery After Supratentorial Craniotomy: A Case Report

Introduction

Enhanced Recovery After Surgery (ERAS) is a recovery approach developed to minimize pain and accelerate postoperative healing. In neurosurgery, ERAS is being adapted to reduce hospital stays and enhance recovery outcomes.¹ The core components of ERAS, including intraoperative and postoperative pain management, have shown lasting benefits for patients.^1,2

The ERAS protocol involves a multidisciplinary approach—engaging surgeons, anesthetists, nutritionists, nurses, and pharmacists—to improve patient care by reducing hospitalization duration, hospital readmissions, postoperative complications, and mortality rates.³

In 2021, the American Cancer Society reported 24,530 new cases of brain and nervous system tumors, with an estimated annual incidence of 7-19.1 cases per 100,000 population.⁴ Approximately 80% of neurosurgical operations are for supratentorial tumors, with common symptoms including headache, increased intracranial pressure, epilepsy, and localized brain dysfunction. These tumors often include astrocytoma, glioblastoma, meningioma, metastatic tumors, oligodendroglioma, and primary central nervous system lymphoma. Surgical resection, typically through craniotomy, is the most effective treatment for supratentorial tumors but can cause moderate to severe pain postoperatively, often persisting for months. Consequently, robust pain management and effective postoperative analgesia are essential.³

The rising incidence of supratentorial tumors underscores the importance of advanced recovery methods like ERAS to support early postoperative recovery and reduce treatment duration and costs.⁵ This case series explores the application of ERAS protocols to achieve rapid recovery following supratentorial craniotomy surgery.

Case report

A 44-year-old female, weighing 58 kg and 154 cm tall, presented with a 6-month history of vision loss in the left eye. Symptoms began 1.5 years prior with ptosis, orbital swelling, and proptosis in the left eye, along with progressively diminished vision in that eye. She denied experiencing headaches, nausea, vomiting, seizures, or limb weakness. The patient was alert with stable vital signs: blood pressure 117/76 mmHg, pulse 74 bpm, respiratory rate 18 bpm, temperature 36.5°C, and oxygen saturation 99% on room air. Neurologically, she had a Glasgow Coma Scale (GCS) of E4V5M6, isochoric round pupils bilaterally measuring 3 mm in diameter, and reduced movement in the left eyeball. Examination for meningeal irritation revealed no rigidity, with normal Lasegue and Kernig signs and motor strength.

Laboratory tests and chest X-ray were within normal limits. MRI of the head with contrast showed a solid, strongly enhancing mass in the left parasellar region extending to the left orbital canal, prepontine cistern, and left middle cranial fossa (approximate size: AP 3.89 x LL 3.67 x CC 3.12 cm). The mass encased the internal carotid artery (C4 segment) and contacted the left intracranial optic nerve, trochlear nerve, trigeminal nerve, and left temporal lobe, resulting in left-sided proptosis ( Figure 1). The patient was diagnosed with a supratentorial mass in the left parasellar region, suspected to be a meningioma, and scheduled for craniotomy and tumor resection.

Figure 1. Contrast-enhanced MRI of the head.

Counseling regarding the ERAS-based anesthetic approach was provided. Nutritional preparation included a solid meal and 100g maltodextrin 6 hours preoperatively, followed by a glucose solution 2 hours before surgery, as she could not tolerate maltodextrin. She denied alcohol or tobacco use. Preoperative thromboprophylaxis and surgical site shaving were not conducted. Cefazolin was administered as a prophylactic antibiotic.

The patient was positioned supine with 5-lead ECG monitoring and oxygen saturation. Induction included dexmedetomidine 1 mcg/kg over 10 minutes, followed by maintenance at 0.2-0.6 mcg/kg/hour, propofol 2.5 mg/kg, rocuronium 0.8 mg/kg, fentanyl 2 mcg/kg, and lidocaine 1 mg/kg. Intubation was achieved with a 7.0 endotracheal tube. Maintenance was managed with dexmedetomidine 0.2-0.6 mcg/kg/hour, propofol 50-150 mcg/kg/min, and intermittent rocuronium and fentanyl. Following induction, a scalp block with 0.25% bupivacaine was performed, and an arterial line, central venous catheter (CVC), and urinary catheter were placed. Mannitol (1 g/kg) was administered before the dural incision.

The surgery lasted 3.5 hours with stable hemodynamics ( Figure 2) and a relaxed brain ( Figure 3). Postoperatively, paracetamol 1 g IV was given, propofol was discontinued, and dexmedetomidine was maintained at 0.2 mcg/kg/hour. Ondansetron 4 mg IV was administered before extubation. The patient regained consciousness smoothly, reporting minimal pain (VAS 2/10).

Figure 2. Patient’s hemodynamics during surgery.

Figure 3. Image of the patient’s brain during surgery.

The patient was transferred to the High Care Unit (HCU), fully conscious and breathing spontaneously. A neurological exam revealed left eyelid weakness. Postoperative analgesia included paracetamol 1 g IV every 6 hours, and dexmedetomidine was continued at 0.2 mcg/kg/hour for 24 hours. Pain was well-managed (maximum VAS 2/10), with no nausea, vomiting, chills, or respiratory depression. The urinary catheter was removed after one day in the HCU, with mobilization and oral feeding resumed. She was transferred to a general ward and discharged after a 4-day hospital stay.

Discussion

ERAS (Enhanced Recovery After Surgery) is a standardized, multidisciplinary perioperative care protocol aimed at minimizing perioperative stress and improving patient outcomes.^1,6 Effective analgesia post-craniotomy is crucial for successful ERAS implementation, as craniotomy often results in moderate to severe postoperative pain that can persist for several months. Appropriate pain management and the use of analgesia are thus necessary to support recovery.^1,3

A study by Liu et al. indicated that patient satisfaction following elective craniotomy under the ERAS protocol is significantly influenced by mild, well-tolerated postoperative pain, which supports rapid mobilization and reduces ICU stay duration.⁷ In this case, the patient’s postoperative pain was sufficiently managed, contributing to a pain-free recovery period.

The ERAS protocol encompasses a variety of care components: preoperatively (counseling, nutrition, habit management, thromboprophylaxis, surgical site preparation, and antimicrobial prophylaxis), intraoperatively (anesthesia technique and management, analgesia, fluid management, temperature regulation, and surgical technique), and postoperatively (management of postoperative nausea and vomiting, urinary drainage, nutritional intake, and early mobilization).³

Dexmedetomidine, an alpha-2 agonist with hypnotic, sedative, and analgesic properties, has been shown to reduce postoperative opioid requirements by approximately 60%.⁸ Its administration can suppress adrenergic responses and catecholamine levels triggered by surgical stress. Additionally, dexmedetomidine provides stable perioperative hemodynamics without significant respiratory depression and reduces intraoperative opioid needs.⁶

A study by Tanskanen et al. demonstrated that dexmedetomidine improved perioperative hemodynamic stability in patients undergoing brain tumor surgery, allowing faster tracheal intubation without respiratory depression compared to fentanyl.⁹ Continuous dexmedetomidine administration decreases the minimum alveolar concentration (MAC) of inhaled anesthetics and has opioid-sparing effects.¹⁰ Further, initiating dexmedetomidine infusion before surgery can maintain intraoperative hemodynamic stability and reduce cardiovascular responses during intubation, skull pin insertion, and extubation.⁹

Scalp block can mitigate hemodynamic responses to surgical stimuli, decrease intraoperative anesthetic requirements, and minimize postoperative pain and morphine use. In intracranial tumor surgery, scalp block helps prevent hemodynamic changes during scalp incision, thereby reducing stress responses such as increased blood pressure and heart rate, which may elevate intracranial pressure (ICP).⁸

This case highlights how applying ERAS principles in supratentorial craniotomy can support optimal neurologic and functional recovery. Through the use of balanced, opioid-sparing anesthesia, such as dexmedetomidine and paracetamol, combined with anticipatory antiemetic strategies and early mobilization, we demonstrate that neurosurgical patients can benefit from a smoother emergence, better pain control, and a shorter hospital stay. This approach emphasizes the growing relevance of individualized anesthetic planning in neurosurgery to minimize physiological stress and enhance postoperative outcomes.

Ethical approval

This case report did not require ethical approval according to the policy of the Health Research Ethics Committee of the Faculty of Medicine, Padjadjaran University, as it reports on a single clinical case without experimental intervention. All procedures were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments.

Consent

Written informed consent to publish this case report, including clinical details and any associated images, was obtained from the patient. The authors confirm that this consent is held securely and is available for review by the editorial office upon request.

Reporting guidelines

The reporting materials for this study are available via the Open Science Framework at: https://osf.io/8jbz7/?view_only=241d08d65923409ba4121ae0cacdacd3, under the project Anesthetic Considerations for Enhanced Recovery After Supratentorial Craniotomy: A Case Report.¹¹

All content is provided under the terms of the Creative Commons Zero (CC0 1.0) license, allowing free use without restriction.