Feasibility and safety of awake craniotomy in adult patients with drug‐resistant focal epilepsy

Objective Although awake craniotomy can guide functional brain mapping and resection, its feasibility and safety have been poorly studied in large series of patients with drug‐resistant focal epilepsy surgery. Methods We conducted an observational, retrospective, single‐center cohort study of 588 consecutive awake craniotomies (2010–2024). Patients with drug‐resistant focal epilepsy were compared to controls, with a focus on subgroup analysis of patients with low‐grade, developmental, epilepsy‐associated brain tumor and an associated nontumoral epileptogenic brain lesion group (46/558 patients, 8.2%), patients with ≥2 years of uncontrolled epileptic seizures (32/558 patients, 5.6%), and patients on ≥2 antiseizure medications (77/588 patients, 13.1%). Feasibility outcomes included time to awakening, intraoperative cooperation, and procedure abortion. Safety outcomes included surgery‐related risks and intraoperative and early postoperative epileptic seizures. Results Compared to controls, patients with medically drug‐resistant focal epilepsy (1) did not present higher rates of late awakening (6.5%–14.3% vs. 8.7%–9.8%, p = .450, p = .972, p = .143) or of insufficient intraoperative cooperation (0%–9.1% vs. 5.0%–6.1%, p = .019, p = .345, p = .173), (2) did not require abortion of the awake procedure because of epilepsy (0% vs. 0%, p = 1.0), (3) did not present a higher rate of intraoperative epileptic seizures (4.3%–9.1% vs. 2.7%–5.0%, p = .226, p = .529), (4) presented a higher rate of intraoperative epileptic seizures when presenting a ≥2‐year history of uncontrolled epileptic seizures (12.9% vs. 2.3%, p < .001), and (5) did not exhibit a higher rate of early postoperative epileptic seizures (13.0%–19.3% vs. 9.8%–10.6%, p = .613, p = .143, p = .078). In multivariable analysis, drug‐resistant focal epilepsy was not independently associated with time to awakening, intraoperative cooperation, procedure abortion, or occurrence of intraoperative or early postoperative epileptic seizures. Significance Awake craniotomy appears feasible and safe in patients with medically drug‐resistant focal epilepsy, with similar and low rates of adverse events, including intraoperative epileptic seizures.