Anesthesia Management of Awake Craniotomy for Excision of a Supratentorial Hemorrhagic Brain Tumor Affecting Speech and Memory

BACKGROUND Awake craniotomy is a neurosurgical approach used for resecting brain tumors in eloquent areas, where real-time neurological monitoring is critical to preserving function. Selecting the appropriate anesthesia approach is essential when preoperative language deficits or patient anxiety may limit intraoperative participation. While motor mapping is an established component of awake craniotomy, the use of a speech-language pathologist for real-time intraoperative monitoring remains underutilized. CASE REPORT A 31-year-old woman presented with a 1-year history of seizures, headaches, and progressive speech disturbances. Imaging revealed a left-sided supratentorial hemorrhagic brain tumor measuring 4.1×3.8×3.6 cm located near language centers. Given the proximity to the eloquent cortex and the patient's significant preoperative speech and memory deficits, a sleep-awake-sleep (SAS) anesthesia technique was chosen for awake craniotomy with intraoperative speech mapping. Uniquely, a speech-language pathologist (SLP) was integrated into the surgical team to conduct real-time assessments of language function. After induction with propofol and remifentanil, the patient was awakened during resection for real-time speech testing, allowing maximal tumor removal without compromising language function. She was then re-sedated for surgical closure. Postoperatively, there were no new deficits, speech remained at baseline, and magnetic resonance imaging (MRI) confirmed gross total resection. CONCLUSIONS This case report highlights the importance of individualized anesthesia planning and the under-recognized role of intraoperative SLP integration in awake craniotomy, which offers a more responsive approach to functional preservation than standard practice alone. For select patients, the SAS method provides a balance between patient comfort, surgical access, and preservation of neurological function.