Awake Craniotomy in a Rare Case of Frontal Mucocele with Extradural Extension: A Case Report

Abstract Frontal sinus mucocele is a rare, benign lesion that can cause bony erosion and intracranial extension when left untreated, leading to mass effect and neurological symptoms. We report the case of a man in his late 60s presenting with progressive left frontal swelling, persistent headache, dizziness, and vomiting, without neurological deficits. Imaging revealed a large frontal bone lesion with destruction of the anterior skull base but no intraparenchymal involvement. Due to the lesion’s extradural location, brain compression, and the patient’s advanced age, awake craniotomy was selected to minimize perioperative risk while enabling neurological monitoring. Anesthesia was induced using dexmedetomidine-based sedation and a comprehensive scalp nerve block with levobupivacaine. Sedation was titrated to a Ramsay score of 3–4, and intraoperative monitoring confirmed preserved responsiveness. The mucocellic lesion and capsule were completely excised without complications. Histopathology confirmed a diagnosis of frontal sinus mucocele. Hemodynamics and oxygenation remained stable throughout the procedure. Postoperatively, the patient exhibited no new neurological deficits, required no airway support, and was mobilized early. Pain was well controlled using opioid-sparing multimodal analgesia. This case highlights the successful use of awake craniotomy in a geriatric patient for a non-eloquent extradural lesion, demonstrating the safety and feasibility of this approach beyond traditional indications. The dexmedetomidine–scalp block combination provided effective sedation and analgesia with minimal respiratory depression, aligning with enhanced recovery after surgery principles. Careful patient selection, multidisciplinary planning, and tailored anesthesia strategy were critical to the positive outcome. Awake craniotomy may be considered in select elderly patients undergoing complex cranial surgery.