Eligibility criteria and psychological profiles in patient candidates for awake craniotomy: a pilot study

Although generally well tolerated, awake craniotomy is burdened by non-negligible failure rates. The aim of this pilot study was to verify the feasibility of a wider research scope to define objective criteria for patient exclusion and the risk of intraoperative mapping failures. Twenty-one patients with brain tumors were subjected to a procedure in 3 steps: neuropsychological criteria for both cognition and language; psychological questionnaires for anxiety, attitude to pain and depression, and psychophysiological monitoring for the candidate's capacity for self-control; and an intraoperative interview for the patient's perception during awake procedure. Outcome measures were as follows: (1) patient compliance, defined as patient response to the intraoperative procedure and measured by psychological scale scores for fear and pain, and (2) failure, defined as the impossibility to complete brain mapping (minor) or conversion to general anesthesia (major). Data analysis included the description of preoperative and intraoperative assessments and their evaluation (Spearman ρ test), and the prognostic factors for intraoperative compliance and procedure failure (Mann-Whitney test). Three patients were considered ineligible after the first step. In the remaining 18, the responses of 10 patients fell within the normal range and 8 showed some degree of impairment on at least 1 preoperative evaluation, but not enough to be excluded from awake surgery. The data analysis also showed that fear of pain correlated with pain felt during the operation and preoperatively with depression and psychophysiological changes, the latter of which was associated with fear felt during craniotomy. Minor failures occurred in 2 patients. From these preliminary results, we observed that warning signs for minor failure were fear of pain and anxiety, as revealed by psychological questionnaire responses, and the incapability of self-control at psychophysiological monitoring. This assessment may serve to fit mapping modality to the single patient and to avoid complications.