Two-step awake craniotomy for diffuse supratentorial gliomas

Abstract Background Maximal safe awake resection is the standard for diffuse gliomas, as it optimizes extent of resection while preserving functional integrity. Progressive loss of accuracy during neurocognitive testing may preclude completion of a maximal function-based resection. We assessed the prevalence, feasibility, safety, and efficacy of a two-step awake craniotomy approach and identified predictors for requiring a second awake procedure to achieve maximal function-based resection. Methods We conducted a retrospective single-center cohort study of 449 consecutive supratentorial diffuse glioma awake craniotomies (2009–2024). Clinical, neurocognitive, imaging, oncological, and intraoperative data were collected. Results Among 449 awake craniotomies, 12 (2.8%) required a second awake procedure. The first surgeries were interrupted due to increasing spontaneous errors during intraoperative tests, fatigue, loss of participation, or pain-induced high blood pressure. The interval between procedures ranged from 1.0–7.5 months. Compared with all other awake surgeries, the second procedures showed no increase in intraoperative adverse events. Compared to the first awake procedure, the second awake procedure achieved a median additional resection rate of 32.3% (mean 38.6 ± 24.4%; range 8–83.2%) across all patients. The proportion of complete resections increased from 0/12 to 6/12. Independent predictors of a two-step awake craniotomy were preoperative attention impairment (p = 0.021), left-hemispheric location (p = 0.017), and insular involvement (p = 0.016). Conclusion Two-step awake craniotomy is a rare but effective and safe strategy when the initial awake procedure must be prematurely stopped. Patients with attention deficits, left-sided lesions, or insular tumor involvement are more likely to require a two-step awake craniotomy.