Who Needs Sleep? An Analysis of Patient Tolerance in Awake Craniotomy

Background: Awake craniotomy (AC) is generally a safe and effective procedure; however, a small but not insignificant portion of cases are aborted due to patient intolerance of the awake portion of surgery. There is not yet a firm understanding of what characteristics indicate patient tolerance or failure of AC. Methods: We retrospectively reviewed a single-surgeon database of patients treated by AC over a 5-year period. Charts were reviewed for demographic, clinical, and operative characteristics, including anesthetic administration during the awake portion of surgery. Statistical analysis was performed to determine which factors predicted patient tolerance or failure. Results: Our study cohort comprised 120 patients with an average age of 56.0 ± 15.2 years. A majority of patients were male (55.8%). The most common surgical indication was tumor (95.8%), with gliobastoma as the most common diagnosis (43.3%). Male sex predicted surgical tolerance on univariate analysis (P = 0.015). Remifentanil administration was associated with surgical failure on univariate analysis (P = 0.068), and also predicted failure on multivariate analysis (P = 0.030). Preoperative seizure, ketamine administration, and right-sided surgery each predicted patient tolerance, but did not achieve statistical significance. Similarly, respiratory comorbidity was associated with surgical failure, but did not achieve significance. Conclusions: AC remains an effective treatment option; the majority of patients tolerate the procedure without issue. Male patients have lower rates of surgical failure, whereas remifentanil administration may increase failure rate.