Acta Neurochirurgica (2025) 167:239
Awake surgery with direct electrical stimulation and real-time cognitive monitoring enables maximal safe brain tumor resection by mapping individual functional networks, preserving quality of life and cognitive abilities. This multidisciplinary, patient-centered approach is gold standard for low-grade gliomas and is increasingly applied to other brain tumors.
• Awake surgery with direct electrical stimulation (DES) mapping is the gold standard for low-grade glioma resection and can also be applied to other brain tumors.
• This approach uses real-time cognitive monitoring to guide tumor removal based on the patient’s individual brain connectome, preserving neurocognitive functions and quality of life.
• A multidisciplinary team—including neurosurgeons, anesthesiologists, and neuropsychologists or speech therapists—is essential for patient selection, preparation, and intraoperative mapping.
• The asleep–awake–asleep protocol with continuous cognitive testing and tailored tasks optimizes functional mapping and minimizes permanent deficits.
• Subpial dissection and limited coagulation reduce vascular injury and promote better cognitive outcomes.
• Early postoperative rehabilitation is crucial for neuroplasticity and functional recovery.
• Careful patient selection and preparation are vital; conditions impairing intraoperative testing are relative contraindications.
• This personalized surgical philosophy has led to high cognitive preservation, low permanent deficit rates, and high return-to-work rates.
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