Awake craniotomy versus general anesthesia for resection of intra-axial brain tumors: A systematic review and meta-analysis

Background: Awake craniotomy (AC) for intra-axial brain tumors is useful for preserving cortical and subcortical white matter tracts that may have tumor invasion. No specific guideline or concrete evidence exists regarding the superiority of AC over surgery under general anesthesia (GA), with many surgeons preferring resection under GA for benefits of potentially better extent of resection. Methods: A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines and registered on PROSPERO(CRD42022311131). A comprehensive search was conducted using specific keywords and MeSH terms with Boolean operators, from PubMED and Cochrane databases. Pooled effect size was estimated using a Mantel-Haenszel random-effects model, with evaluation of heterogeneity using Higgins I² statistic. Results: Of 929 articles, ten were included for quantitative analysis. Selected studies included 1974 patients (681 in the AC group, 1293 in the GA group). No significant differences were seen between GA and AC groups in terms of extent of resection (MD: 3.77, p = 0.38, I2 = 91 %), rates of gross total resection (OR: 1.20, p = 0.69, I2 = 74 %), OR time (MD: 5.96, p = 0.15, I2 = 0 %), or length of stay (MD: −3.39, p = 0.21, I2 = 92 %). Conclusion: AC is not inferior to surgery under GA for extent of resection of intra-axial brain tumors, with comparable rates of GTR and EOR. While non-significant, current data trends towards shorter operating time and length of stay as well for AC group patients.