Outcomes following awake craniotomy for glioma resection: cohort study

Introduction: Awake craniotomy is a key technique for safe resection of intra-axial tumors involving regions of eloquent cortex, which presents unique challenges for patients and surgical teams. We report an extensive and longitudinally followed single-institution cohort retrospective study examining the outcomes of awake craniotomy for glioma resection at our institution.

Methods: 380 patients who underwent awake craniotomy surgery for glioma resection at our institution during the sampling frame 2014-2023 and were included. Data capture included demographics, tumor pathology, intraoperative neurocognitive assessments, postoperative deficits, and Karnofsky performance scale (KPS).

Results: Median age was 53 years (range, 18-87) with a male predominance (60%). Baseline KPS ranged from 40-100, and 82% were >80 at baseline (313/380; median, 90). High-grade glioblastoma (grade IV; 242/380; 63%) and diffuse astrocytoma (grade II; 57/380; 15%) were the most highly represented pathologies. Seizure incidence during intraoperative mapping was 9%; no intraoperative or early postoperative death associated with these events was reported. Following surgery, neurological deficits were improved or resolved in 48%, unchanged in 23%, or worsened in 29%, as compared to preoperative examination. New immediate postoperative motor deficits were observed in 9% (34/380); new speech/language deficits were noted in 4% (15/380) of patients. Other postoperative complications within 30 days of surgery included surgical site infection (n=34), new seizures (n=19), sepsis/pneumonia (n=14), stroke (n=7), and cerebrospinal fluid leak (n=2). Mortality referable to a postoperative complication (e.g., rather than disease progression) was very rare (n=5). Median postoperative KPS scores at one-month follow-up was 80 (range, 30-100; n=375); at one-year, median KPS among survivors was 90 (range, 20-100; n=176).

Conclusion : Awake craniotomy is a safe and useful technique for optimization of intra-axial tumor resection in eloquent brain. Key areas for future study include more nuanced assessment of the interaction between intraoperative cortical mapping, postoperative extent-of-resection, and the incidence and duration of any new postoperative neurological deficits.