Awake Craniotomy in Pediatric Patients: A Meta-analysis of Operative Outcomes

Awake craniotomy allows neurosurgeons to make critical decisions when operating in eloquent regions of the brain. The phenomenon of “waking up” during surgery is underexplored in pediatric patients, and the operative outcomes following awake craniotomy are not well understood. Correspondingly, the aim of this study was to quantitatively aggregate the contemporary metadata regarding the operative outcomes of awake craniotomy when used in the pediatric setting. Multiple electronic databases from inception to June 2023 were searched following PRISMA guidelines. Respective cohort-level outcomes were then abstracted and pooled by means of meta-analysis utilizing random-effects modeling, and trends evaluated by meta-regression analysis. There were 4 observational studies that satisfied all selection criteria, describing a total cohort of 57 pediatric patients undergoing awake craniotomy. There were 34 (60%) male patients with a median age of 14 years old, with lesions on the left side in 80% of cases when reported. Meta-analysis demonstrated pooled incidences of intraoperative complication to be 17% (95% CI 4%–37%), the need to convert cases to general anesthesia to be 2% (95% CI 0%–9%), immediate postoperative complication to be 18% (95% CI 6%–33%), and long-term complications to be 6% (95% CI 0%–15%). The most common intraoperative complication reported was seizure. Certainty of these estimates were very low due to limited metadata. Meta-regression did not indicate any trend bias due to study and cohort parameters. Multiple studies have demonstrated the feasibility of the awake craniotomy approach in pediatric patients. The risks for intraoperative and postoperative complications are non-zero, with their incidences trending towards incidences seen in the adult demographic. It is likely formal neuropsychologic preparation and follow-up will increase the candidacy and success of this approach in the future.