Pediatric Awake Craniotomy Within a Structured Perioperative Pathway: A Case Report of Anesthesiologic Management for...

Background: Awake craniotomy is well established in adult neurosurgery for lesions near eloquent cortical areas, but its use in children remains uncommon and presents substantial anesthetic, psychological, and organizational challenges. We report the anesthesiologic management of awake craniotomy in a child with constitutional mismatch repair deficiency (CMMRD). Case Presentation: A 10-year-old boy with CMMRD underwent resection of a recurrent left frontal IDH-mutant astrocytoma, WHO grade 3, located adjacent to eloquent language cortex. Because of the high risk of postoperative language impairment, a structured multidisciplinary pathway was implemented, including neurosurgical, neuropsychological, and anesthesiologic evaluation, preoperative familiarization, and intraoperative language testing. An asleep-awake-asleep strategy was used. After induction with propofol, fentanyl, and rocuronium, the airway was secured with a supraglottic airway device (air-Q) followed by fiberoptic-guided tracheal intubation. During the awake phase, propofol was discontinued, remifentanil reduced, and low-dose dexmedetomidine introduced to preserve cooperation. The patient completed intraoperative language mapping, enabling identification of functional language boundaries and safe resection. No major intraoperative adverse events, airway complications, or seizures occurred. Postoperative pain scores remained below 4 on an age-appropriate Numeric Rating Scale, and the patient showed no new neurological deficits. At 1-month follow-up he remained symptom-free. Conclusions: This case adds to the still limited pediatric experience with awake craniotomy and suggests that, in carefully selected children managed within a structured multidisciplinary perioperative pathway and with a tailored anesthetic strategy, the procedure can be performed safely; confirmation in larger series is nonetheless required.