Awake craniotomies: Burden or benefit for the patient?

An awake craniotomy with intraoperative neuropsychological monitoring and brain mapping is still the gold standard for resections of tumors in or near eloquent areas of the brain. Since it has been shown by several authors that an awake craniotomy is the only way to reliably preserve speech function during tumor resections, the benefits for patients undergoing such a procedure are obvious. However, an awake craniotomy represents an exceptionally stressful situation for a patient, which could possibly lead, similar to an awareness experience during surgery, to long-term psychological sequelae. Therefore the question has to be raised if it is justified and ethical to submit patients already under a high amount of stress due to the uncertain future and with existential fears to even more strain by operating them awake. However, when balancing the burdens of an awake craniotomy for a patient with the benefits of such a procedure, it becomes obvious that an awake craniotomy and here especially the awake–awake (¼ continuous awake craniotomy - CAC) method offer the best thinkable balance between an optimal tumor resection and the best possible preservation of cognitive functions. Considering that persistent deficits of essential language and motor function have amuchworse effect on a patient’s quality of life than rare but treatable posttraumatic stress disorder symptoms, it seems unethical not to offer an awake craniotomy to patients when the location of the tumor justifies such an operation.