Awake versus asleep craniotomy for eloquent glioblastoma: a systematic review and meta-analysis.

Abstract

Awake craniotomy (AC) can aid in preserving neurological function through intraoperative mapping of sensorimotor and language functions. It has been associated with increased extent of resection (EOR) and reduced neurological deficits in glioma patients. Most studies focused on low grade tumours and there remains limited evidence assessing utility of AC for glioblastoma (GB). This systematic review evaluates current evidence for safety and efficacy of GB resection under AC versus general anaesthetic (GA) conditions. We carried out a systematic review and meta-analysis of original studies assessing comparative outcomes of supratentorial GB resection via AC versus GA. Studies included patients > 18 years of age, with histopathological diagnosis of Grade 4 GB affecting an eloquent location. Medline, Embase and Pubmed were searched from inception to the 30th of June 2025. The outcomes assessed included: EOR, rates of temporary and permanent post-operative neurological deficits, survival, and functional outcomes. Eleven studies were included, with 1355 patients (402 AC and 953 GA resections). AC achieved greater percentage EOR (MD = 7.55 [CI 2.94-12.15], p = 0.001), and non-significant increase in rates of gross total resection (OR = 1.66 [CI 0.64-4.35], p = 0.30). The risk of developing a post-operative neurological deficit was significantly lower with AC (OR = 0.55 [CI:0.36-0.85], p = 0.008). Overall survival (HR = 7.99 [CI 2.29-13.69], p = 0.007) was significantly increased with AC but there was no significant difference in progression-free survival (HR = 2.03 [CI -1.32-5.37], p = 0.23). AC for eloquently located GB is associated with improved EOR, survival and lower risk of neurological complications. When feasible, AC should be considered for eloquent GB resection.