Operative Neurosurgery 30:653–667, 2026
Awake versus asleep (general anesthesia) craniotomy are two approaches for glioma resection, and this work compares their intraoperative costs and survival outcomes.
Key Insights and Themes
Clinical question centers on whether awake craniotomy (AC) differs from asleep craniotomy under general anesthesia (GA) in intraoperative cost and in survival for glioma patients.
Cohort identification included all glioma resections at one institution from 2017–2022: 298 GA cases and 67 AC cases.
Awake-craniotomy indication primarily involved tumors in eloquent brain regions to allow intraoperative monitoring of neural function, while noneloquent tumors typically started under GA.
Costing method (TDABC) used process maps plus automated time-stamped extraction from the electronic medical record to capture intraoperative resources and time.
Cost components were dominated by supplies and personnel, with other elements (turnover and overhead) described as relatively minor contributors.
Baseline overall intraoperative cost had a median total of $6600 (IQR $2875), largely driven by supply cost (median $3178) and personnel cost (median $3141).
Operating-room time was longer for AC (median 5.2 hours) than GA (median 4.5 hours), and AC had about 30 additional minutes of incision-to-closure time.
Patient/tumor comparability showed GA patients were older, but there were no differences in WHO grade distribution or extent of resection between groups.
Unadjusted total cost difference showed higher median intraoperative cost for AC ($8506) versus GA ($6033).
Unadjusted subcomponent differences showed AC had higher median supply cost ($4238 vs $2928) and higher median personnel cost ($4111 vs $2962) than GA.
Adjusted total cost effect found AC associated with $2175 additional intraoperative cost versus GA after accounting for confounders.
Adjusted cost drivers attributed the added AC cost to higher supply cost (+$1272) and higher personnel cost (+$970).
Supply subcomponents were higher for AC than GA across consumables, implants, sterilization, and medications in unadjusted comparisons.
Personnel mix differed in that neurology attendings/fellows were included in AC but not GA at this institution, contributing to personnel-cost differences.
Unadjusted survival showed higher overall survival for AC on Kaplan–Meier analysis (log-rank P = .011), while progression-free survival did not significantly differ (log-rank P = .106).
Adjusted survival showed no significant differences between AC and GA in overall survival (HR 0.84, P = .48) or progression-free survival (HR 0.9, P = .66) after multivariable adjustment.
Key limitation (missing GA neuromonitoring costs) is that electrophysiological neuromonitoring personnel costs for GA were not captured due to EMR documentation limits.
Scope limitation (episode-of-care costs) is that the analysis focuses on intraoperative costs, and commenters note postoperative/inpatient costs could change conclusions about overall expense.
Conclusion
Awake craniotomy for glioma resection had higher intraoperative costs than asleep craniotomy, but after adjustment it showed no significant survival advantage in overall or progression-free survival.
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