Intraoperative Hemodynamic Management and Cerebral Protection During Awake Craniotomy: Evidence-Based Approaches

Awake craniotomy is a standard neurosurgical technique that enables real-time assessment of brain functions during tumor resection, with high success rates. Although highly effective, the procedure is associated with hemodynamic disturbances, including blood pressure variability and impaired cerebral perfusion, compromising intraoperative safety. A focused literature search of PubMed, Embase, and Google Scholar was performed to identify relevant studies on intraoperative hemodynamic management during awake craniotomy. Findings were synthesized narratively to summarize current evidence, highlight emerging strategies, and identify knowledge gaps. Hypertension (8%-34%) was the most common disturbance, often triggered by painful surgical stimuli or emergence from sedation, with repeat craniotomy, impaired autoregulation, and glioma pathology as additional risk factors. Hypotension (10%-11%) was linked to perioperative stroke and mortality. Cerebral hypoperfusion contributed to poor outcomes, with stroke up to 23% and neurological morbidity in 68% of patients. Preventive strategies, such as scalp blocks, individualized blood pressure targets, and the use of dexmedetomidine and midazolam, improved intraoperative stability, while short-acting agents, including esmolol and labetalol, were preferred for rapid control. Advanced monitoring modalities, including arterial lines, near-infrared spectroscopy, and cerebral autoregulation indices, enhance safety and support accurate functional mapping. Hemodynamic instability during awake craniotomy influences outcomes. Current evidence supports multimodal prevention, tailored blood pressure control, and short-acting pharmacological agents; practice variation and the lack of randomized trials limit standardization. Looking ahead, advanced monitoring and emerging AI systems may provide new opportunities to enhance cerebral protection and optimize patient safety. This review summarizes evidence on intraoperative hemodynamic control in awake craniotomy, emphasizing strategies that enable maximal safe resection while preserving neurological function.