Is awake craniotomy (surgical procedure where the patient remains awake) an effective treatment option?

Awake Craniotomy Effectiveness

Awake craniotomy with intraoperative brain mapping is highly effective and superior to surgery under general anesthesia for resecting supratentorial lesions near eloquent cortex, achieving better neurological outcomes, higher quality resection rates, and excellent patient satisfaction. 1

Evidence for Effectiveness

Superior Outcomes Compared to General Anesthesia

• Awake craniotomy with brain mapping demonstrates significantly better neurological outcomes and quality of resection (P < .001) compared to craniotomy under general anesthesia for lesions in eloquent areas. 1

• The procedure allows maximal removal of lesions close to functional areas with low neurological complication rates, providing an excellent alternative to craniotomy under general anesthesia. 1

• Most patients achieve functional preservation, with only rare permanent neurological complications (1/26 patients in one series). 2

Patient Safety and Tolerability

• Awake craniotomy using the "asleep-awake-asleep" anesthetic protocol is generally safe and well-tolerated, with 92% patient satisfaction rates. 2

• Intraoperative complications are manageable: only 8% experience more than slight pain, 12% more than slight discomfort, 15% fear, and 4% claustrophobia during the procedure. 2

• Surgery is typically uneventful with shorter hospital stays compared to general anesthesia approaches. 1

Specific Clinical Outcomes

For epilepsy patients: 7 of 8 patients (87.5%) achieved Engel class I seizure freedom at 1-year follow-up, with 6 maintaining this status at latest follow-up. 3

For tumor resection: The procedure enables precise localization of functional neural networks through intraoperative brain mapping and real-time monitoring, decreasing postoperative morbidities. 4

Patient Selection Criteria

Appropriate candidates include patients with:

• Supratentorial lesions in close proximity to eloquent cortex requiring elective surgery 1
• Intact verbal ability and cognitive profile 3
• No considerable anxiety concerns during neuropsychology assessment 3
• Successful completion of preoperative functional MRI testing paradigms 3

Anesthetic Management

Conscious sedation is the technique of choice, primarily using:

• Propofol (81.5% of cases) - associated with lower incidence of intraoperative seizures (P = 0.03) 5
• Dexmedetomidine (18.5% of cases) 5
• Remifentanil infusions for analgesia 4

The asleep-awake-asleep protocol is preferred by patients and clinically appropriate. 2

Intraoperative Complications and Management

Most common complications during awake craniotomy:

• Hypertension (16.7%) - most frequent complication 5
• Seizures (9.3%) 5
• Desaturation (7.4%) 5
• Tight brain/brain bulge (7.4%) 5
• Shivering (5.6%) 5

Conversion to general anesthesia is rarely required (approximately 2% of cases due to refractory brain bulge). 5

Postoperative Course

• 20% of patients develop new motor deficits postoperatively, though most are temporary 5
• Mean ICU stay: 2.8 ± 1.9 days 5
• Mean hospital stay: 7.0 ± 5.0 days 5
• Most patients return to or maintain baseline motor and speech functions by latest follow-up 3

Pediatric Considerations

Awake craniotomy is safe, feasible, and effective in carefully selected children as young as 11.5 years old. 3

Success requires:

• Intact verbal ability and cognitive profile 3
• Successful completion of preoperative functional MRI 3
• No significant anxiety concerns 3

Outcomes in pediatric patients mirror adult success rates, with all patients maintaining or returning to baseline function. 3

Critical Success Factors

The key elements for successful awake craniotomy include:

• Appropriate patient selection based on lesion location, cognitive ability, and psychological readiness 5
• Thorough preoperative preparation by the surgical team, which significantly increases patient confidence and preparedness 2
• Understanding the surgical procedure and judicious use of sedatives/anesthetic agents 5
• Real-time intraoperative brain mapping to preserve eloquent cortex 1

Common Pitfalls to Avoid

• Do not use hypotonic fluids postoperatively - these are contraindicated and can worsen cerebral edema 6
• Avoid inadequate patient preparation - thorough preoperative counseling is essential for patient confidence 2
• Do not select patients with significant anxiety or cognitive impairment 3
• Avoid excessive sedation that compromises patient cooperation during neurological testing 5