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Journal Club

Tumor/Skull Base

Awake Craniotomy Versus General Anesthesia for Resection of High-Grade Gliomas: A Systematic Review and Meta-Analysis

Journal of Clinical Medicine | 2026

Rapid review note

Journal Club is a rapid, AI-assisted appraisal layer. It highlights study design, effect estimates, and practice relevance, but it is still a briefing, not a replacement for the paper.

For education only. Not medical advice.

Paper snapshot

Rapid study overview

Open paper

DOI

10.3390/jcm15041431

PMID

N/A

PICO

Population

Adults with WHO grade III-IV gliomas in comparative studies of awake craniotomy versus general anesthesia, including 2689 patients across 11 studies.

Intervention

Awake craniotomy with intraoperative brain mapping for high-grade glioma resection.

Comparator

Craniotomy under general anesthesia for high-grade glioma resection.

Outcomes

Overall survival, neurologic deficits, extent of resection, and hospital length of stay.

Design

Type

Systematic review and random-effects meta-analysis

Randomized

No

Multicenter

N/A

Blinded

N/A

Follow-up

Study-level follow-up varied; survival pooled from 4 studies

Primary endpoint

Overall survival and neurologic deficits after high-grade glioma resection.

Secondary endpoints

  • Extent of resection
  • Length of hospital stay
  • Subgroup effects for tumors in eloquent areas

Practice impact

What this means

This meta-analysis suggests that awake craniotomy may improve survival, extent of resection, and 3-month neurologic outcomes for selected patients with high-grade glioma, especially in eloquent areas. The catch is that most of the signal comes from observational studies, so read the paper as supportive rather than definitive proof.

Bottom line

Awake craniotomy is a reasonable default strategy for selected high-grade gliomas in eloquent areas, but the apparent survival and functional advantages still rest mainly on observational data.

Strength of evidence

low

Recommendation

consider change

Why it matters

  • The pooled data favored awake surgery for survival, extent of resection, and 3-month deficits.
  • Evidence certainty remains limited because most contributing studies were observational.
  • The best fit is selective adoption in appropriate patients rather than a blanket rule for all high-grade gliomas.

What would change my mind

  • A large randomized trial in molecularly characterized high-grade glioma showing no survival or functional advantage for awake mapping.
  • Prospective comparative data proving that case selection fully explains the observed pooled benefit.

Critical appraisal

How strong is the paper?

Methods critique

Risk of bias

Ten of 11 included studies were observational, so selection bias and confounding by tumor location, performance status, and surgeon choice remain major threats to causal inference.

Confounding

Awake cases may have been preferentially selected for patients expected to tolerate mapping or for tumors in eloquent cortex, while baseline molecular features and preoperative function were not harmonized across studies.

Missing data

The pooled analyses depended on study-level reporting, and not every outcome was available from every paper, which leaves the meta-analysis vulnerable to selective outcome reporting.

Multiplicity

The review pooled several outcomes and subgroup analyses, and the paper reports substantial heterogeneity for many endpoints, so secondary findings should be interpreted cautiously.

Notes

  • The review included 1 randomized trial and 10 observational studies.
  • GRADE certainty was downgraded for key outcomes because of observational evidence and heterogeneity.
  • The single randomized trial reportedly showed the opposite direction of effect from the pooled observational signal.

Stats check

NNT

Approximate NNT 13 for fewer 3-month deficits.

Effect sizes

  • Overall survival favored awake craniotomy: HR 0.70 (95% CI 0.60-0.82) across 4 studies and 1273 patients.
  • Neurologic deficits at 3 months favored awake craniotomy: RR 0.62 (95% CI 0.42-0.91) across 2 studies and 1111 patients.
  • Extent of resection was higher with awake craniotomy: mean difference 4.4% (95% CI 2.8-6.0) across 5 studies.

Absolute effects

  • Median overall survival was approximately 18.5 months with awake craniotomy versus 14.4 months with general anesthesia.
  • Three-month neurologic deficit rates were 13% with awake craniotomy versus 21% with general anesthesia.
  • Hospital stay was shorter by 2.85 days on average, roughly 4.1 versus 6.95 days.

Concerns

  • Most of the evidence base was observational rather than randomized.
  • Heterogeneity was substantial for most pooled outcomes.
  • A meta-analysis cannot fully remove confounding from case selection and center expertise.

External validity

Who it applies to

Adults with high-grade gliomas, especially tumors in or near eloquent cortex where awake mapping is technically feasible and supported by an experienced team.

Who it does not

Patients unable to tolerate awake mapping, deeply sedated workflows without mapping expertise, or settings where tumors are not near eloquent cortex.

Generalizability notes

  • Applicability is strongest in centers that routinely perform awake mapping.
  • The paper suggests larger benefits in eloquent-area tumors than in the overall mixed population.
  • Changing WHO glioma classifications and molecular stratification limit clean cross-study comparability.

Evidence trace

Source trace and metadata

Citations (5)

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Metadata

Generated at

2026-03-08T15:20:00-05:00

Version

manual-pdf-repair-v1