Awake craniotomy vs general anesthesia for brain metastases in eloquent areas: neurological and survival outcomes

Brain metastases (BMs) occur in 10–20 % of cancer patients and significantly impact mortality in adults. While awake craniotomy (AC) is established as safe for primary brain tumors in eloquent areas, evidence for its use in BMs remains limited. This study evaluates AC versus general anesthesia (GA) for surgical resection of BMs in eloquent brain regions. This retrospective cohort study analyzed 77 patients who underwent surgical resection of BMs at Soroka University Medical Center between 2015–2022. Patients were divided into AC (n = 16) and GA (n = 61) groups. A secondary analysis examined outcomes across three groups: AC, GA with neuromonitoring (n = 21), and GA without neuromonitoring (n = 40). Primary outcomes included postoperative neurological status, overall survival, and hospital length of stay (LOS). The AC group demonstrated significantly better neurological improvement rates at 14 days (93.8 % vs 21.3 %, p < 0.001) and six weeks post-surgery (56.3 % vs 1.6 %, p < 0.001) compared to the GA group. Mean LOS was shorter in the AC group (4.25 vs 7.18 days, p = 0.072), with lower mortality rates (62.5 % vs 83.6 %, p = 0.085). In the three-group analysis, AC showed superior neurological outcomes, with improvement rates at six weeks being 56.3 % for AC, 4.8 % for GA with neuromonitoring, and 0 % for GA without neuromonitoring (p < 0.001). Awake craniotomy demonstrates superior outcomes for resecting BMs in eloquent areas, with significantly better neurological recovery and trends toward shorter LOS and lower mortality. Neuromonitoring improves surgical outcomes, particularly in GA cases. These findings support AC as a preferred approach for appropriately selected patients with BMs in eloquent regions.