Frailty Is Not Associated with Awake Craniotomy Outcomes

Introduction: Awake craniotomy allows for real time intraoperative feedback and improved extent of resection for patients with pathology in eloquent brain regions. Studies have shown frailty is a predictor of poor outcomes in glioblastoma (GBM), epilepsy, and brain metastasis surgery but has not been studied in awake craniotomy. Our study evaluates the effect of frailty on awake craniotomy outcomes and whether frailty should inform patient selection.

Methods: We performed a retrospective analysis of adult patients who underwent awake craniotomy at our institution between 2018 and 2023. Frailty was defined as a modified frailty (mFI-11) score ≥ 2. Primary outcomes were conversion to general anesthesia or failure, 24-hour neurologic deficit, 30-day readmission, and neurological deficit at first follow up. Secondary outcomes included disposition, mortality, 30-day return to the intensive care unit (ICU), 30-day operating room (OR) takeback.

Results: Of 116 patients included for analysis, 28 (24%) were frail, 10 (7.9%) were failed cases. Indications included: 51 (44%) GBM, 49% non-GBM tumors, 5 (4.3%) epilepsy, and 3 (2.6%) vascular. Frail patients were more likely to have sleep apnea (p=0.005), preoperative neurologic deficits (p=0.002), cognitive impairment (p < 0.001) and a pre-operative diagnosis of anxiety (p=0.027). There was no significant difference in failure (p=0.14), return to the ICU (p=0.40), residual deficits at first outpatient follow-up (p=0.78), 30-day readmission (p=0.28), or takeback to the OR (p=0.93). On univariate analysis, frailty was not associated with primary outcomes, however, it was associated with increased likelihood of mortality (OR 2.45; 95% CI 1.01-5.92; p=0.046) and discharge to rehabilitation facility (OR 3.00; 95% CI 1.10-8.15; p=0.034). These results did not persist after adjusted analysis.

Conclusion : In our cohort, frailty influenced preoperative considerations for awake craniotomy but it was not independently associated with failure or post-operative complications. Frailty status alone should not preclude awake craniotomy.