Preliminary study of awake craniotomy in the treatment of recurrent gliomas in eloquent areas

Objective To investigate the feasibility, efficacy and safety of awake craniotomy with brain functional mapping for the interoperative resection of recurrent gliomas in eloquent areas. Methods A total of 36 patients who underwent awake craniotomy for recurrent gliomas at General Hospital of Southern Theatre Command from January 2020 to December 2023 were enrolled, with 38 newly diagnosed glioma patients treated via awake craniotomy as control. Cortical and/or subcortical functional areas were mapped using direct electrical stimulation (DES) during the awake phase, and maximal tumor resection was achieved while preserving neurological function. Results Among 36 recurrent glioma patients, 27 cases (75%) exhibited positive responses to intraoperative cortical or subcortical DES. Postoperative MRI within 48 h revealed the lesion total resection in 26 cases (72.22%), subtotal resection in 6 cases (16.67%), and partial resection in 4 cases (11.11%). Early postoperative (7-10 d) neurological dysfunction (new or worsened) occurred in 25 cases (69.44%), including mild 14 cases (38.89%), moderate 2 cases (5.56%), and severe 9 cases (25%). Late postoperative (3 months) neurological dysfunction was observed in 6 cases (16.67%), with mild, moderate and severe each accounting for 2 cases (5.56%). Compared to newly diagnosed gliomas, recurrent gliomas treated with awake craniotomy had a lower rate of achieving functional boundary⁃based maximal resection (χ2 = 9.187, P = 0.002). However, no significant differences were found in intraoperative cortical or subcortical DES rates (χ2 = 1.690, P = 0.194), total/subtotal tumor resection rates (Fisher's exact probability: P = 1.000), early postoperative neurological dysfunction (χ2 = 0.009，P = 0.924), late postoperative neurological dysfunction (χ2 = 0.599, P = 0.439), or postoperative seizure control (Fisher's exact probability: P = 1.000). Conclusions Awake craniotomy for recurrent gliomas in eloquent brain areas is feasible, effective and safe. It enhances the tumor resection extent and prolongs survival, serving as a critical approach for managing recurrent gliomas in eloquent areas.