Awake Craniotomy in Eloquent-Area Brain Tumors: Indications, Surgical Techniques, and Functional Outcomes

Abstract

Awake craniotomy has become an important surgical strategy for the management of brain tumors located within or adjacent to eloquent cortical and subcortical regions. The principal objective of the procedure is to achieve maximal safe resection while preserving neurological functions, particularly language and motor abilities. Unlike surgery performed under general anesthesia, awake surgery permits direct assessment of neurological function during tumor resection through real-time cortical and subcortical stimulation mapping. Preoperative functional imaging, neuronavigation, tractography, and careful patient selection complement intraoperative mapping and assist in defining individualized surgical boundaries. Language mapping may incorporate object naming, counting, repetition, reading, writing, and other language tasks, whereas motor mapping can be performed through direct cortical and subcortical stimulation with complementary motor-evoked potential monitoring. Evidence from the selected literature indicates that awake craniotomy can facilitate extensive tumor resection while maintaining acceptable neurological outcomes. Subcortical mapping is particularly important because functional language and motor pathways may extend beyond anatomically recognizable cortical regions. In glioblastoma, available evidence suggests that awake craniotomy can achieve substantial tumor-volume reduction and acceptable gross total resection rates, although the available evidence remains predominantly retrospective. This review discusses the indications, patient selection, preoperative assessment, anesthetic considerations, cortical and subcortical mapping techniques, and functional outcomes associated with awake craniotomy for tumors involving eloquent brain regions.