From State to Trait: A Narrative Review Refining Our Understanding of Perioperative Anxiety in the Context of Awake...

Preoperative anxiety is common in patients undergoing neurosurgical procedures and is known to influence the perioperative experience, pharmacologic decisions, and postoperative outcomes. In awake neurosurgery procedures, anxiety is of particular relevance because the success of the procedure depends on sustained patient cooperation and intact cognitive performance under stress. Anxiety comprises transient situational responses to threat (state anxiety) as well as more stable individual predispositions (trait anxiety). In this narrative review, we first describe the concepts of state and trait anxiety in the preoperative context of awake brain surgery. We then review commonly used measurement instruments and discuss their respective strengths and limitations in capturing preoperative anxiety as a state versus a trait. Including descriptions of brief screening tools, state-trait inventories (e.g., State-Trait Anxiety Inventory STAI), and medical procedure-specific instruments such as the Amsterdam Preoperative Anxiety and Information Scale (APAIS). We further propose expert-based practical considerations for incorporating anxiety phenotyping into preoperative planning to support individualized anesthetic strategies and informed awake-versus-asleep decision-making in neurosurgery. Also, we integrate findings from perioperative neuroscience and neurocognitive research to explore potential mechanisms by which trait anxiety may impair cognitive flexibility and increase vulnerability of frontal executive networks under perioperative stress. These mechanisms have direct clinical relevance, as they may influence patient selection for awake techniques, anesthetic strategies, intraoperative task performance, and susceptibility to postoperative cognitive disturbances.