Awake versus non-awake surgery for brain surgery

Awake craniotomies (ACs) have become more widely used for glioma patients. In this chapter we will discuss the most recent available data for ACs performed with local anesthesia in comparison with craniotomies under general anesthesia (GA). Originally, ACs were used for epilepsy surgery, but it is now being used in the neuro-oncology field for glioma resection. As with every surgical technique, advantages and disadvantages coexist. Therefore it is imperative to select the most beneficial technique for each patient. Recent evidence suggests that glioma patients tend to benefit from awake procedures. This is due to the surgeon’s ability to perform more accurate cortical and subcortical stimulation, obtain a higher extent of resection, achieve better overall postoperative outcomes, achieve lower rates of postoperative complications which directly impact the patient’s quality of life (QoL), provide a shorter hospital stay, and lower overall health-care costs. However, during awake procedures, breathing rate cannot be controlled, making it difficult to have a controlled CO₂ to reduce brain swelling. Awake procedures may also have a big impact on the psyche of the patient, and some of them are not able to tolerate the procedure. In these cases, GA is advantageous, and this technique is still widely used around the globe. Deep sedation is a good alternative for failed procedures, as well as for interventions in which patient positioning does not allow for an awake procedure. Even though GA has its benefits, in the right patient, craniotomies with local anesthesia tend to be more advantageous and provide a better postoperative outcome with a better QoL for the patient.