Implications of cranial pinning during awake craniotomy on anesthetic requirements: A retrospective cohort study

Awake craniotomy (AC) is the gold standard for tumor resections in eloquent brain regions requiring surgical precision. Traditional AC uses pins to immobilize the head, which may contribute to scalp injury, discomfort, and hemodynamic fluctuations. We evaluated perioperative outcomes of AC performed with and without pin fixation at a single tertiary center.

We conducted a retrospective cohort study of adults undergoing AC between October 2018 and June 2023. Outcomes included head movement and movement-related workflow disruptions, anesthetic dosing, hemodynamics, operative duration, and postoperative recovery.

Head movement was greater in unpinned cases (p < 0.001), although disruptive movements were uncommon (Grade 4: 6 %; no Grade 5 events). Propofol dosing was higher in pinned patients (3.2 ± 1.9 vs 2.4 ± 2.2 mg/kg/hr; p = 0.029), while dexmedetomidine dosing was similar between groups. RASS scores were comparable overall, with sex-based differences observed. Unpinned AC was associated with smaller increases in systolic blood pressure (17.5 ± 24.1 vs 25.4 ± 24.7 mmHg; p = 0.021), shorter operative duration (151.7 ± 56.3 vs 184.2 ± 74.7 min; p = 0.001), and similar ICU length of stay (p = 0.649).

Unpinned AC was associated with greater head movement but rare clinically disruptive events, alongside modest differences in anesthetic requirements, hemodynamics, and operative duration. These findings suggest potential workflow and comfort benefits in carefully selected patients rather than major safety differences. Prospective multicenter studies with standardized protocols are warranted to better define patient selection and validate these observations.