Opioid-Free Anesthesia Technique in Craniotomy Arteriovenous Malformation (AVM) Resection (Anesthetic Management)

Abstract

Intracranial arteriovenous malformation (AVM) is a rare cerebrovascular abnormality that may cause bleeding, seizures, or neurological deficits. Treatment options, including surgery, embolization, and radiosurgery, are based on lesion size, location, and symptoms. In neurosurgery, Enhanced Recovery After Surgery (ERAS) aims to reduce pain, accelerate recovery, and shorten hospitalization. Opioid-Free Anesthesia (OFA), as part of ERAS, minimizes opioid-related complications and supports faster postoperative recovery. A 43-year-old woman presented with seizures and decreased consciousness. Angiography revealed an AVM in the right lateral parietooccipital region, classified as Spetzler Martin Supplementary Grade VI. She underwent craniotomy and AVM resection under OFA. Induction included dexmedetomidine loading at 0.7 mcg/kg for 10 minutes, followed by 0.2–0.5 mcg/kg/h maintenance. Anesthesia was maintained with target-controlled infusion (TCI) propofol in Schnider mode, effect-site concentration 3–5 mcg/mL. Lidocaine 90 mg and rocuronium 30 mg were also administered. Postoperative analgesia consisted of paracetamol 500 mg every 6 hours, ibuprofen, and dexmedetomidine infusion 0.2 mcg/kg/h. Multimodal anesthesia using dexmedetomidine, propofol, rocuronium, and lidocaine effectively replaced opioids, maintaining stable hemodynamics and adequate anesthesia. The combination of propofol and dexmedetomidine provided sedation, hypnosis, and analgesia, facilitating early extubation. The patient experienced rapid recovery without postoperative nausea or vomiting. AVM resection in a 43-year-old woman was successfully performed under OFA, with stable intraoperative conditions and no postoperative complications or neurological deficits. This case demonstrates the feasibility and effectiveness of OFA in complex neurosurgical procedures, supporting its broader application in clinical anesthesia practice.