Awake craniotomy for drug-resistant non-oncological epilepsy: a systematic review of feasibility, reported safety, and seizure outcomes
9 affiliations
- 1School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
- 2Department of Neurosurgery, Neuro International Collaboration (NIC), London, UK
- 3Faculty of Medicine, Division of Neurosurgery, University of Ottawa, Ottawa, ON Canada
- 4Department of Neurosurgery, Neuro International Collaboration (NIC), Vancouver, Ottawa, ON Canada
- 5Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
- 6Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
- 7National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- 8Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- 9ATLAS Institute of Brain and Spine and Neurosurgical Atlas, Los Angeles, CA USA
Abstract
Introduction: Complete resection of the epileptogenic zone offers the best chance of seizure control in patients with drug-resistant epilepsy. However, surgical management remains challenging when the epileptogenic zone is located within or adjacent to eloquent brain regions. Awake craniotomy (AC), combined with intraoperative functional mapping, has the potential to maximize resection while preserving neurological function. Despite its increasing use, evidence regarding its safety and efficacy in epilepsy surgery remains limited. This study aimed to systematically evaluate the feasibility, reported safety, and reported seizure outcomes of awake craniotomy in patients undergoing surgery for drug-resistant non-oncological epilepsy.
Methods: A systematic literature search was conducted in PubMed, Scopus, and Web of Science databases in accordance with PRISMA guidelines.
Results: Seven retrospective studies comprising 231 patients from six countries were included; 120 patients underwent AC. Four studies (57.1%) included mixed adult and pediatric populations and three (42.9%) included adults only; however, none provided age-stratified seizure or complication outcomes, precluding separate pediatric analysis. Reported seizure duration ranged from 2 to 39 years. The frontal lobe was the most frequently involved region (n = 52; 43.3%), followed by the temporal lobe (n = 27; 22.5%), and cortical dysplasia was the most common underlying pathology (n = 30; 25.0%). Language and sensorimotor functions were the most commonly mapped eloquent areas, each reported in five studies (71.4%). Seizure outcomes were predominantly assessed using the Engel classification. Complete seizure freedom (Engel class I) was reported in 69 of 120 AC patients (57.5%); a random-effects single-arm synthesis estimated an Engel I proportion of 59.3% (95% CI: 46.3–71.2%; I2 = 31.9%). Comparisons with surgery under general anesthesia (GA) were available in only two non-randomized studies and should be interpreted cautiously. No study reported conversion from AC to GA. Postoperative neurological deficits were largely transient, with a low reported incidence of permanent morbidity. Owing to substantial differences in patient selection, surgical indications, and study design, these findings should be considered exploratory and should not be interpreted as demonstrating comparable seizure outcomes or treatment effectiveness.
Conclusions: In carefully selected patients with drug-resistant non-tumor epilepsy involving or adjacent to eloquent cortex, AC with intraoperative functional mapping appears feasible and may help preserve neurological function while enabling tailored resection. The current evidence base remains limited by retrospective designs, heterogeneous populations and techniques, inconsistent outcome reporting, and sparse comparative data; therefore, efficacy and equivalence with surgery under general anesthesia should not be inferred.
Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s12893-026-04115-4.
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BibTeX
@article{mofatteh2026awake,
title = {{Awake craniotomy for drug-resistant non-oncological epilepsy: a systematic review of feasibility, reported safety, and seizure outcomes}},
author = {Mohammad Mofatteh and Mohammad Sadegh Mashayekhi and Sho Giersztein and Arad Iranmehr and Maysam Alimohamadi and Davide Giampiccolo and Hugues Duffau and Aaron A. Cohen-Gadol},
journal = {BMC Surgery},
year = {2026},
month = aug,
doi = {10.1186/s12893-026-04115-4},
url = {https://doi.org/10.1186/s12893-026-04115-4},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Awake craniotomy for drug-resistant non-oncological epilepsy: a systematic review of feasibility, reported safety, and seizure outcomes
AU - Mohammad Mofatteh
AU - Mohammad Sadegh Mashayekhi
AU - Sho Giersztein
AU - Arad Iranmehr
AU - Maysam Alimohamadi
AU - Davide Giampiccolo
AU - Hugues Duffau
AU - Aaron A. Cohen-Gadol
PY - 2026
DA - 2026/08/10
JO - BMC Surgery
DO - 10.1186/s12893-026-04115-4
UR - https://doi.org/10.1186/s12893-026-04115-4
AB - Introduction: Complete resection of the epileptogenic zone offers the best chance of seizure control in patients with drug-resistant epilepsy. However, surgical management remains challenging when the epileptogenic zone is located within or adjacent to eloquent brain regions. Awake craniotomy (AC), combined with intraoperative functional mapping, has the potential to maximize resection while preserving neurological function. Despite its increasing use, evidence regarding its safety and efficacy in epilepsy surgery remains limited. This study aimed to systematically evaluate the feasibility, reported safety, and reported seizure outcomes of awake craniotomy in patients undergoing surgery for drug-resistant non-oncological epilepsy. Methods: A systematic literature search was conducted in PubMed, Scopus, and Web of Science databases in accordance with PRISMA guidelines. Results: Seven retrospective studies comprising 231 patients from six countries were included; 120 patients underwent AC. Four studies (57.1%) included mixed adult and pediatric populations and three (42.9%) included adults only; however, none provided age-stratified seizure or complication outcomes, precluding separate pediatric analysis. Reported seizure duration ranged from 2 to 39 years. The frontal lobe was the most frequently involved region (n = 52; 43.3%), followed by the temporal lobe (n = 27; 22.5%), and cortical dysplasia was the most common underlying pathology (n = 30; 25.0%). Language and sensorimotor functions were the most commonly mapped eloquent areas, each reported in five studies (71.4%). Seizure outcomes were predominantly assessed using the Engel classification. Complete seizure freedom (Engel class I) was reported in 69 of 120 AC patients (57.5%); a random-effects single-arm synthesis estimated an Engel I proportion of 59.3% (95% CI: 46.3–71.2%; I2 = 31.9%). Comparisons with surgery under general anesthesia (GA) were available in only two non-randomized studies and should be interpreted cautiously. No study reported conversion from AC to GA. Postoperative neurological deficits were largely transient, with a low reported incidence of permanent morbidity. Owing to substantial differences in patient selection, surgical indications, and study design, these findings should be considered exploratory and should not be interpreted as demonstrating comparable seizure outcomes or treatment effectiveness. Conclusions: In carefully selected patients with drug-resistant non-tumor epilepsy involving or adjacent to eloquent cortex, AC with intraoperative functional mapping appears feasible and may help preserve neurological function while enabling tailored resection. The current evidence base remains limited by retrospective designs, heterogeneous populations and techniques, inconsistent outcome reporting, and sparse comparative data; therefore, efficacy and equivalence with surgery under general anesthesia should not be inferred. Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s12893-026-04115-4.
SN - 1471-2482
ER -