Researchers examine early neurological changes after awake brain surgery and highlight the need for long-term follow-up assessments

A retrospective study of 30 patients undergoing awake craniotomy found that 30% experienced new or worsened neurological dysfunction within 48–72 hours after surgery. Early functional and cognitive score reductions were common, while new-onset aphasia occurred in 10% of patients. No statistically significant predictors of acute deterioration were identified. The findings highlight the importance of interpreting early postoperative changes cautiously, as their long-term significance remains uncertain, and conducting larger, prospective, controlled studies with longer-term follow-up.

Awake craniotomy allows surgeons to operate on brain lesions near areas responsible for essential functions, such as movement and language, while patients are awake during critical stages of surgery. By using direct electrical stimulation to identify functional brain regions, surgeons can guide lesion removal while seeking to preserve these abilities. However, neurological changes in the first few days after surgery can be difficult to interpret. Temporary effects of surgery, including cerebral edema, fatigue, and residual sedation, may influence functional assessments, making it important to distinguish early postoperative changes from lasting neurological impairment.

Addressing this challenge, a research team led by Professor Fang Liu from Nanjing Medical University, China, examined short-term neurological outcomes and explored clinical factors associated with deterioration after awake craniotomy. The retrospective, single-center study included 30 patients who underwent surgery for intracranial lesions involving motor or language areas between January 2019 and November 2024. The team assessed neurological function 48–72 hours after surgery using the Karnofsky Performance Status (KPS), Glasgow Coma Scale (GCS), Mini-Mental State Examination (MMSE), and manual muscle strength testing. Survival outcomes were also examined in exploratory analyses that were not intended to establish definitive prognostic factors. This paper was made available online on September 1, 2026, and was published in Volume 12 of the Chinese Neurosurgical Journal.

The results showed that 9 of the 30 patients (30%) experienced new or worsened acute neurological dysfunction within 48–72 hours after surgery. A reduction of at least 10 points in KPS occurred in 30% of patients, while 26.7% experienced a decline of at least two points in MMSE. New or worsened motor weakness was observed in 16.7%, and new-onset aphasia occurred in 10%. Full intraoperative awake mapping was completed in 27 patients (90%); three required conversions to general anesthesia without completion of functional mapping.

The researchers emphasized that these early functional changes should not automatically be interpreted as permanent surgical injury. KPS and MMSE scores obtained soon after surgery can be affected by cerebral edema, postoperative fatigue, and recovery from sedation. Patients with successful mapping had a numerically lower rate of acute neurological decline than those with mapping failure (25.9% versus 66.7%), but the difference was not statistically significant. Univariate analyses also identified no statistically significant clinical predictors of acute neurological deterioration.

“Assessing neurological function in the first few days after awake craniotomy requires careful interpretation, as temporary postoperative effects may influence functional and cognitive scores,” Prof. Liu said. The findings underscore the importance of evaluating different types of postoperative changes separately, rather than treating every early decline as evidence of lasting neurological damage.

The study also examined survival, but these analyses were exploratory. During follow-up, 17 patients died, and median overall survival was 43 months. No statistically significant survival differences or independent prognostic factors were identified. The small sample, varied lesion types, missing information on extent of resection and molecular biomarkers, and absence of long-term functional assessments limit the conclusions that can be drawn. The study also lacked a comparison group undergoing craniotomy under general anesthesia.

“Our survival findings should be interpreted cautiously because of the small sample size, diverse intracranial pathologies, and lack of long-term neurological assessments,” Prof. Liu said.

Overall, the findings provide a preliminary description of neurological changes shortly after awake craniotomy and highlight the need for larger, prospective studies involving patients with more clearly defined pathological groups. Serial assessments over at least three months could help establish how often early deficits resolve and which patients experience persistent impairment. Such evidence could support more informative postoperative counselling, rehabilitation planning, and evaluation of surgical outcomes.