Craniotomy in sitting position: anesthesiology management

Sitting position to surgically approach posterior fossa disorder continues to be the first choice for some neurosurgical teams. We underwent a literature research for recent published studies involving neurosurgical patients operated on in this position. Preoperative evaluation, anesthetic technique, intraoperative monitoring, detection and treatment of venous or arterial air embolism episodes, and all the reported complications were recorded. A modified semisitting (lounging) position aiming to create a positive pressure in the transverse and sigmoid sinuses, with lower head and higher legs positioned above the top of the head, decreases the incidence and severity of venous air embolism. Hyperventilation, compromising cerebral blood flow, has to be avoided during a sitting position. Precordial Doppler or transesophageal echocardiography monitoring improves the detection of small venous air embolism enabling its early treatment and diminishing its consequences. Patients with known patent foramen ovale can be operated on in a sitting position, under strict protocol, with few reported clinical venous air embolism and no paradoxical air embolism. Sitting position for neurosurgical procedures may be a well tolerated approach for the patient if neurosurgeons and neuroanesthesiologists undergo a strict team protocol, including all necessary monitoring and meticulously followed.