Awake craniotomy for brain tumors during pregnancy: An updated scoping review

The management of brain tumors during pregnancy presents a complex clinical challenge, balancing maternal neurological needs with fetal safety. Awake craniotomy (AC) is a potential strategy to maximize tumor resection in eloquent areas while minimizing fetal anesthetic exposure, but the literature remains sparse. The objective of this review is to summarize the current evidence regarding the use of AC for brain tumors during pregnancy. Following PRISMA guidelines, a systematic search was conducted in PubMed, Scopus, Cochrane Library, and ScienceDirect databases for studies reporting on AC in pregnant patients. Data on clinical characteristics, anesthetic techniques, and maternal/fetal outcomes were extracted. Methodological quality was assessed using the Joanna Briggs Institute checklist for case reports. Eleven studies, comprising 11 patients, met the inclusion criteria. All were case reports or a small case series. AC was performed across all trimesters for various tumors, predominantly gliomas. Anesthetic techniques included both "awake throughout" and "asleep-awake-asleep" approaches, with dexmedetomidine and propofol being common agents. All cases reported successful surgical resections with positive fetal outcomes, resulting in the delivery of healthy infants. Short-term maternal neurological outcomes were generally favorable; however, long-term maternal prognosis was variable and dependent on the underlying tumor pathology. A multidisciplinary approach was highlighted as crucial for success. The available evidence, though limited to case reports, suggests that AC is a viable, effective option for carefully selected pregnant patients with brain tumors. However, the high potential for publication bias warrants caution, and larger, prospective studies are needed to establish definitive guidelines.