Awake craniotomy for brain tumor resection in the elderly: an institutional experience

Awake craniotomy (AC) maximizes safe resection of tumors that encroach on functionally critical areas. However, AC presents additive challenges that are further compounded in the geriatric population. We aim to show that AC is safe and feasible in the elderly, and reveal which peri-operative metrics contribute towards post-operative outcomes, including length of stay, readmissions and discharge disposition.

We conducted a decade-long retrospective review of AC in patients older than 75 years old. Multivariate linear and logistic regressions were used to identify independent predictors of re-admission, length of stay in ICU and the hospital, and discharge disposition. Variables included Karnofsky Performance Status (KPS), American Society for Anesthesiologists score, frailty index (mFI-11), age in addition to other key metrics.

There were 70 patients with mean age 80 and KPS 75.2 included in our cohort. Glioblastoma was the most common pathology (61.4%) followed by metastasis (22.9%). Only one patient required conversion to general anesthesia, and there were three (4.3%) who had post-operative complications. Re-operation rates following neurosurgical re-admission were 11.4%. Patients with higher pre-operative KPS had shorter hospitalizations (ρ = -0.31, p = 0.011). Regarding readmission, mFI-11 was an independent predictor of all-cause 30-day readmission (OR 2.38, p = 0.007). In contrast, when restricting analysis to neurosurgery-specific readmissions, age emerged as the only inverse predictor (OR 0.59, p = 0.010).

AC is a feasible and necessary tool in the geriatric population. In appropriately organized centers, the surgical success of AC in the elderly can be high. Lower frailty (rather than younger age) predicted shorter stays and reduced all-cause re-admission rates.