Maximizing Tumor Resection and Managing Cognitive Attentional Outcomes: Measures of Impact of Awake Surgery in Glioma Treatment

Neurosurgery 98:365–375, 2026

This clinical research article compares awake surgery (AwS) and asleep surgery (AsS) in 64 glioma patients, focusing on attentional outcomes, extent of resection, and survival. Using neuropsychological testing at preoperative, 1-week, and 1-month intervals, combined with structural MRI, lesion-symptom mapping, and lesion network mapping, the study quantifies transient attentional decline and its anatomical correlates.

Results show AwS enables greater supramaximal resection of non–contrast-enhanced tumor tissue and improved overall survival for IDH wild-type glioblastoma, but is the sole predictor of transient postoperative attentional worsening at 1 week that recovers by 1 month. Analyses implicate left prefrontal/default mode network regions and large-scale attention networks in postoperative attentional changes, supporting tailored patient selection and development of intraoperative attention monitoring.

Awake Surgery (AwS) vs. Asleep Surgery (AsS): AwS enables a more extensive (supramaximal) resection of non–contrast-enhanced tumor areas in glioma patients compared to AsS, which correlates with improved oncological outcomes but higher transient attentional deficits postoperatively.

Transient Attentional Decline: Patients undergoing AwS experience a significant, temporary decline in attentional performance 1 week after surgery, with recovery to preoperative levels after 1 month; this effect is not observed with AsS.

Predictors of Attention Outcome: The only significant predictor of postoperative attentional deterioration is undergoing AwS; other factors such as age, sex, tumor location, grade, IDH mutation, and MGMT methylation do not significantly influence attentional decline.

Extent of Resection and Attention: Greater extent of resection (EOR) of non–contrast-enhanced tumor (especially >61%) is associated with immediate postoperative attentional worsening, but also with improved survival outcomes.

Oncological Benefit: In patients with IDH wild-type glioblastoma, AwS leads to significantly longer overall survival (mean 887.73 days) compared to AsS (mean 553.71 days), mainly due to lower non-contrast-enhanced residual tumor volume after AwS.

Functional Neuroanatomy: Postoperative attentional deficits are associated with lesions in the left prefrontal region of the default mode network (DMN); attention relies on distributed large-scale networks, including dorsal and ventral attention networks.

Patient Selection: Proper selection for AwS is crucial, especially for tumors involving anterior regions of the left DMN, and preoperative attentional abilities should be considered to balance oncological benefits and cognitive risks.

Monitoring Limitations: There are currently no established intraoperative tools for direct monitoring of attention during AwS; development of standardized, quantitative attention monitoring could further optimize outcomes.