Feasibility and safety of awake craniotomy in adult patients with drug-resistant focal epilepsy.

Abstract

Objective: Although awake craniotomy can guide functional brain mapping and resection, its feasibility and safety have been poorly studied in large series of patients with drug-resistant focal epilepsy surgery.

Methods: We conducted an observational, retrospective, single-center cohort study of 588 consecutive awake craniotomies (2010-2024). Patients with drug-resistant focal epilepsy were compared to controls, with a focus on subgroup analysis of patients with low-grade, developmental, epilepsy-associated brain tumor and an associated nontumoral epileptogenic brain lesion group (46/558 patients, 8.2%), patients with ≥2 years of uncontrolled epileptic seizures (32/558 patients, 5.6%), and patients on ≥2 antiseizure medications (77/588 patients, 13.1%). Feasibility outcomes included time to awakening, intraoperative cooperation, and procedure abortion. Safety outcomes included surgery-related risks and intraoperative and early postoperative epileptic seizures.

Results: Compared to controls, patients with medically drug-resistant focal epilepsy (1) did not present higher rates of late awakening (6.5%-14.3% vs. 8.7%-9.8%, p = .450, p = .972, p = .143) or of insufficient intraoperative cooperation (0%-9.1% vs. 5.0%-6.1%, p = .019, p = .345, p = .173), (2) did not require abortion of the awake procedure because of epilepsy (0% vs. 0%, p = 1.0), (3) did not present a higher rate of intraoperative epileptic seizures (4.3%-9.1% vs. 2.7%-5.0%, p = .226, p = .529), (4) presented a higher rate of intraoperative epileptic seizures when presenting a ≥2-year history of uncontrolled epileptic seizures (12.9% vs. 2.3%, p < .001), and (5) did not exhibit a higher rate of early postoperative epileptic seizures (13.0%-19.3% vs. 9.8%-10.6%, p = .613, p = .143, p = .078). In multivariable analysis, drug-resistant focal epilepsy was not independently associated with time to awakening, intraoperative cooperation, procedure abortion, or occurrence of intraoperative or early postoperative epileptic seizures.

Significance: Awake craniotomy appears feasible and safe in patients with medically drug-resistant focal epilepsy, with similar and low rates of adverse events, including intraoperative epileptic seizures.