Failed awake craniotomy: a retrospective analysis in 424 patients undergoing craniotomy for brain tumor

Clinical article

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Awake craniotomy for removal of intraaxial tumors within or adjacent to eloquent brain regions is a well-established procedure. However, awake craniotomy failures have not been well characterized. In the present study, the authors aimed to analyze and assess the incidence and causes for failed awake craniotomy.


The database of awake craniotomies performed at Tel Aviv Medical Center between 2003 and 2010 was reviewed. Awake craniotomy was considered a failure if conversion to general anesthesia was required, or if adequate mapping or monitoring could not have been achieved.


Of 488 patients undergoing awake craniotomy, 424 were identified as having complete medical, operative, and anesthesiology records. The awake craniotomies performed in 27 (6.4%) of these 424 patients were considered failures. The main causes of failure were lack of intraoperative communication with the patient (n = 18 [4.2%]) and/or intraoperative seizures (n = 9 [2.1%]). Preoperative mixed dysphasia (p < 0.001) and treatment with phenytoin (p = 0.0019) were related to failure due to lack of communication. History of seizures (p = 0.03) and treatment with multiple antiepileptic drugs (p = 0.0012) were found to be related to failure due to intraoperative seizures. Compared with the successful awake craniotomy group, a significantly lower rate of gross-total resection was achieved (83% vs 54%, p = 0.008), there was a higher incidence of short-term speech deterioration postoperatively (6.1% vs 23.5%, p = 0.0017) as well as at 3 months postoperatively (2.3% vs 15.4%, p = 0.0002), and the hospitalization period was longer (4.9 ± 6.2 days vs 8.0 ± 10.1 days, p < 0.001). Significantly more major complications occurred in the failure group (4 [14.8%] of 27) than in the successful group (16 [4%] of 397) (p = 0.037).


Failures of awake craniotomy were associated with a lower incidence of gross-total resection and increased postoperative morbidity. The majority of awake craniotomy failures were preventable by adequate patient selection and avoiding side effects of drugs administered during surgery.

Abbreviations used in this paper:AED = antiepileptic drug; EEG = electroencephalography; GTR = gross-total resection; KPS = Karnofsky Performance Scale.

Article Information

Address correspondence to: Zvi Ram, M.D., Department of Neurosurgery, Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizman Street, Tel Aviv 64239, Israel. email:

Please include this information when citing this paper: published online November 2, 2012; DOI: 10.3171/2012.10.JNS12511.

© AANS, except where prohibited by US copyright law.



  • 1

    Balki MManninen PHMcGuire GPEl-Beheiry HBernstein M: Venous air embolism during awake craniotomy in a supine patient. Can J Anaesth 50:8358382003

  • 2

    Beck ATSteer RABrown GK: Manual for the Beck Depression Inventory-II San Antonio, TXPsychological Corporation1996

  • 3

    Berger MSOjemann GA: Intraoperative brain mapping techniques in neuro-oncology. Stereotact Funct Neurosurg 58:1531611992

  • 4

    Berkenstadt HPerel AHadani MUnofrievich IRam Z: Monitored anesthesia care using remifentanil and propofol for awake craniotomy. J Neurosurg Anesthesiol 13:2462492001

  • 5

    Bilotta FRosa G: ‘Anesthesia’ for awake neurosurgery. Curr Opin Anaesthesiol 22:5605652009

  • 6

    Blanshard HJChung FManninen PHTaylor MDBernstein M: Awake craniotomy for removal of intracranial tumor: considerations for early discharge. Anesth Analg 92:89942001

  • 7

    Bonhomme VFranssen CHans P: Awake craniotomy. Eur J Anaesthesiol 26:9069122009

  • 8

    Bulsara KRJohnson JVillavicencio AT: Improvements in brain tumor surgery: the modern history of awake craniotomies. Neurosurg Focus 18:4e52005

  • 9

    Carrabba GVenkatraghavan LBernstein M: Day surgery awake craniotomy for removing brain tumours: technical note describing a simple protocol. Minim Invasive Neurosurg 51:2082102008

  • 10

    Conte VBaratta PTomaselli PSonga VMagni LStocchetti N: Awake neurosurgery: an update. Minerva Anestesiol 74:2892922008

  • 11

    Conte VMagni LSonga VTomaselli PGhisoni LMagnoni S: Analysis of propofol/remifentanil infusion protocol for tumor surgery with intraoperative brain mapping. J Neurosurg Anesthesiol 22:1191272010

  • 12

    Corwin JBylsma FW: Translations of excerpts from André Rey's “Psychological examination of traumatic encephalopathy” and P.A. Osterrieth's “The complex figure copy test. Clin Neuropsychol 7:3151939

  • 13

    Craig S: Phenytoin poisoning. Neurocrit Care 3:1611702005

  • 14

    Danks RARogers MAglio LSGugino LDBlack PM: Patient tolerance of craniotomy performed with the patient under local anesthesia and monitored conscious sedation. Neurosurgery 42:28361998

  • 15

    De Benedictis AMoritz-Gasser SDuffau H: Awake mapping optimizes the extent of resection for low-grade gliomas in eloquent areas. Neurosurgery 66:107410842010

  • 16

    Gupta DKChandra PSOjha BKSharma BSMahapatra AKMehta VS: Awake craniotomy versus surgery under general anesthesia for resection of intrinsic lesions of eloquent cortex—a prospective randomised study. Clin Neurol Neurosurg 109:3353432007

  • 17

    Gupta VYadav TPYadav A: Phenytoin toxicity presenting as acute meningo-encephalitis in children. Neurol India 59:66672011

  • 18

    Kavé G: Phonemic fluency, semantic fluency, and difference scores: normative data for adult Hebrew speakers. J Clin Exp Neuropsychol 27:6906992005

  • 19

    Kavé G: Standardization and norms for a Hebrew naming test. Brain Lang 92:2042112005

  • 20

    Keifer JCDentchev DLittle KWarner DSFriedman AHBorel CO: A retrospective analysis of a remifentanil/propofol general anesthetic for craniotomy before awake functional brain mapping. Anesth Analg 101:5025082005

  • 21

    Khu KJDoglietto FRadovanovic ITaleb FMendelsohn DZadeh G: Patients' perceptions of awake and outpatient craniotomy for brain tumor: a qualitative study. Clinical article. J Neurosurg 112:105610602010

  • 22

    Khu KJNg WH: Intraoperative swelling leading to neurological deterioration: an argument for large craniotomy in awake surgery for glioma resection. J Clin Neurosci 16:8868882009

  • 23

    Kim SSMcCutcheon IESuki DWeinberg JSSawaya RLang FF: Awake craniotomy for brain tumors near eloquent cortex: correlation of intraoperative cortical mapping with neurological outcomes in 309 consecutive patients. Neurosurgery 64:8368452009

  • 24

    Larsen JRLarsen LS: Clinical features and management of poisoning due to phenytoin. Med Toxicol 4:2292451989

  • 25

    Manninen PHTan TK: Postoperative nausea and vomiting after craniotomy for tumor surgery: a comparison between awake craniotomy and general anesthesia. J Clin Anesth 14:2792832002

  • 26

    Marín LLGarcía-Peñas JJHerguedas JLGutiérrez-Solana LGRuiz-Falcó MRodriguez AD: Phenytoin-induced visual disturbances mimicking delirium tremens in a child. Eur J Paediatr Neurol 14:4604632010

  • 27

    Murata HNagaishi CTsuda ASumikawa K: Laryngeal mask airway Supreme for asleep-awake-asleep craniotomy. Br J Anaesth 104:3893902010

  • 28

    Murphy JMMotiwala RDevinsky O: Phenytoin intoxication. South Med J 84:119912041991

  • 29

    Nasreddine ZSPhillips NABédirian VCharbonneau SWhitehead VCollin I: The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 53:6956992005

  • 30

    Olsen KS: The asleep-awake technique using propofol-remifentanil anaesthesia for awake craniotomy for cerebral tumours. Eur J Anaesthesiol 25:6626692008

  • 31

    Palese ASkrap MFachin MVisioli SZannini L: The experience of patients undergoing awake craniotomy: in the patients' own words. A qualitative study. Cancer Nurs 31:1661722008

  • 32

    Patton JHStanford MSBarratt ES: Factor structure of the Barratt impulsiveness scale. J Clin Psychol 51:7687741995

  • 33

    Pereira LCOliveira KML'Abbate GLSugai RFerreira JAda Motta LA: Outcome of fully awake craniotomy for lesions near the eloquent cortex: analysis of a prospective surgical series of 79 supratentorial primary brain tumors with long follow-up. Acta Neurochir (Wien) 151:121512302009

  • 34

    Peruzzi PBergese SDViloria APuente EGAbdel-Rasoul MChiocca EA: A retrospective cohort-matched comparison of conscious sedation versus general anesthesia for supratentorial glioma resection. Clinical article. J Neurosurg 114:6336392011

  • 35

    Piccioni FFanzio M: Management of anesthesia in awake craniotomy. Minerva Anestesiol 74:3934082008

  • 36

    Prabhu VCBamber NIShea JFJellish WS: Avoidance and management of trigeminocardiac reflex complicating awake-craniotomy. Clin Neurol Neurosurg 110:106410672008

  • 37

    Rey A: L'Examen Clinique en Psychologia ParisPresses Universitaires de France1964

  • 38

    Sacko OLauwers-Cances VBrauge DSesay MBrenner ARoux FE: Awake craniotomy vs surgery under general anesthesia for resection of supratentorial lesions. Neurosurgery 68:119211992011

  • 39

    Sanai NBerger MS: Operative techniques for gliomas and the value of extent of resection. Neurotherapeutics 6:4784862009

  • 40

    Sartorius CJBerger MS: Rapid termination of intraoperative stimulation-evoked seizures with application of cold Ringer's lactate to the cortex. Technical note. J Neurosurg 88:3493511998

  • 41

    Sartorius CJWright G: Intraoperative brain mapping in a community setting—technical considerations. Surg Neurol 47:3803881997

  • 42

    Schulz UKeh DFritz GBarner CKerner TSchneider GH: [“Asleep-awake-asleep”-anaesthetic technique for awake craniotomy. Anaesthesist 55:5855982006. (Ger)

  • 43

    Scuplak SMSmith MHarkness WF: Air embolism during awake craniotomy. Anaesthesia 50:3383401995

  • 44

    Serletis DBernstein M: Prospective study of awake craniotomy used routinely and nonselectively for supratentorial tumors. J Neurosurg 107:162007

  • 45

    Spielberger CDGorsuch RLLushene RE: Manual for the State-Trait Anxiety Inventor Palo Alto, CAConsulting Psychologists Press1970

  • 46

    Stroop JR: Studies of interference in serial verbal reactions. J Exp Psychol 18:6436621935

  • 47

    Szelényi ABello LDuffau HFava EFeigl GCGalanda M: Intraoperative electrical stimulation in awake craniotomy: methodological aspects of current practice. Neurosurg Focus 28:2E72010

  • 48

    Taylor MDBernstein M: Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: a prospective trial of 200 cases. J Neurosurg 90:35411999

  • 49

    Thakral AShenoy RDeleu D: Acute visual dysfunction following phenytoin-induced toxicity. Acta Neurol Belg 103:2182202003

  • 50

    Torrubia RÁvila CMoltó JCaseras X: The sensitivity to punishment and sensitivity to reward questionnaire (SPSRQ) as a measure of Gray's anxiety and impulsivity dimensions. Pers Individ Dif 31:8378622001

  • 51

    Wechsler D: The Measurement of Adult Intelligence BaltimoreWilliams and Wilkins1939

  • 52

    Wechsler D: A standardized memory scale for clinical use. J Psychol 19:87951945

  • 53

    Wolff DLNaruse RGold M: Nonopioid anesthesia for awake craniotomy: a case report. AANA J 78:29322010


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