Throughout the history of neurosurgery, awake craniotomies have been used for different indications with the overarching goal of enhancing safety. Meta-analyses based on cohorts of patients with low-grade glioma suggest that awake craniotomy could be valuable for increasing the extent of resection while preventing postoperative neurological deficits.
Evidence from small retrospective studies has supported the hypothesis that this approach could also be beneficial for patients with glioblastoma. However, discussion continues about the indication setting of awake surgery in these patients because its impact in clinically important subgroups is still unknown.
The international, multicentre GLIOMAP study assessed the association between awake mapping and survival, functional, neurological, and radiological outcomes in 1047 patients with eloquent, primary glioblastoma. This is the first study to assess the effect of this approach in clinically relevant patient subgroups.
In the overall matched cohort, awake craniotomy versus asleep resection resulted in fewer neurological deficits at 3 months (p = 0.019) and 6 months (p = 0.0048) postoperatively, longer overall survival (p = 0.00054) and progression-free survival (p = 0.0060). In subgroup analyses, awake craniotomy was especially useful to improve postoperative outcomes in patients younger than 70 years, with a NIHSS score of 0–1, or a preoperative KPS of 90–100. For patients aged 70 years and older, with a preoperative NIHSS scores of 2 or higher, or a preoperative KPS of 80 or lower, it should be considered with the goal of preventing late neurological morbidity.
These findings, therefore, provide neurosurgeons with the evidence to assess the optimal surgical strategy and to improve the decision-making process in individual patients with glioblastoma.
Author: Cleiton Formentin is a Neurological Surgeon from University of Campinas (UNICAMP) and a former Neurosurgical Oncology fellow.
Article link:https://doi.org/10.1016/S1470-2045(22)00213-3