Awake craniotomy as a routine pathway for supratentorial tumor surgery: A 500-case awake-craniotomy experience with institutional resource and charge benchmarking

Background: Integrated safety, tolerability, and resource data on awake craniotomy in resource-constrained settings are lacking. Improving accessibility has remained central to our program. We report an experience exceeding 500 awake craniotomies with structured comparator synthesis. Methods: Three nested cohorts from one Central American institution were analyzed: 218 awake craniotomies (2007–2018, audited safety), 500 procedures spanning neoplastic and non-neoplastic lesions (2007–2026, program tolerability), and 30 awake versus 30 contemporaneous general-anesthesia craniotomies (2024–2026, descriptive benchmarking). The two contemporary groups were restricted to elective supratentorial intraparenchymal tumor resections. The contemporary cohort was derived from billing and administrative records; baseline clinical, radiological, and histopathological data were unavailable; groups were managed by different teams. Results: Across the 500-case program, completion without conversion was 99.0%; 30-day mortality, ascertainable only for the 282 registry-era procedures, was 3.2%. In the 218-case cohort, seizures occurred in 5.1%, perioperative mortality was 0.5%, and none required ventilation; extent of resection was 73%, 94%, and 100% in eloquent, adjacent to eloquence, and non-eloquent cortex. In the contemporaneous institutional benchmark, the awake pathway showed shorter stay (1.0 vs. 2.0 days), no intensive-care use (0/30 vs. 9/30), shorter incision-to-closure time, and $5,205 lower median billed charges than the general-anesthesia pathway. Outcomes were consistent with 14 comparator studies. Conclusion: In this high-volume, resource-constrained program, to the best of our knowledge, the only protocolized awake-craniotomy program in the region, awake craniotomy served as a routine pathway for eligible supratentorial intraparenchymal lesions, with high completion, favorable safety, short hospitalization, no intensive-care admission, and lower observed billed charges than conventional practice.