Efficacy and safety of awake craniotomy versus general anesthesia for glioma resection: A systematic review.

Abstract

<h4>Background</h4>Gliomas frequently arise in eloquent cortical regions, where achieving maximal resection while preserving neurological function poses a major challenge. Awake craniotomy (AC) with intraoperative mapping is increasingly employed for this purpose, but its comparative effectiveness against general anesthesia (GA) remains unclear.<h4>Methods</h4>This systematic review conducted under Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in PROSPERO, searched PubMed, Embase, Cochrane Library, and Scopus for English-language studies published from 2015 to 2025. Eligible studies compared AC and GA in adults with supratentorial gliomas and reported outcomes on extent of resection, neurological preservation, survival, safety, quality of life, or cost-effectiveness. Data extraction was performed independently by three reviewers, and study quality was assessed with Risk of Bias 2, Newcastle-Ottawa Scale, or AMSTAR 2. Due to heterogeneity, findings were synthesized narratively.<h4>Results</h4>Six studies were included (4 primary, 2 reviews); only two directly compared approaches. Extent of resection (<i>P</i> = 0.657, <i>P</i> = 0.17), overall survival (adjusted hazard ratio [HR] 0.84, <i>P</i> = 0.48), and progression-free survival (adjusted HR 0.9, <i>P</i> = 0.66) showed no significant differences. AC cost $2,175 more per case (<i>P</i> < 0.001). Neurocognitive function was generally preserved; psychomotor speed declined most.<h4>Conclusion</h4>Neither approach demonstrated superiority. AC enables functional monitoring but offers no survival benefit and increases costs. Surgical decisions should be individualized. High-quality randomized trials are needed.