Anatomical Considerations in Dominant Temporal Lobe Gliomas: A Propensity-matched Comparative Analysis of Awake and Asleep Craniotomies

Introduction: No clinical trials have directly compared outcomes following awake (AWA) versus asleep (ASL) resection for dominant temporal lobe (DTL) gliomas. Given the DTL’s critical contribution to language, an understanding of the tumor depth and location within the DTL should be considered when comparing these procedures.

Methods: A total of 152 newly diagnosed gliomas receiving surgery from January 1, 2005, to June 6, 2021, were retrospectively analyzed. The AWA and ASL cohorts were propensity score matched on age and pre-operative language deficits. Craniotomy type, distance from the temporal tip to posterior tumor margin (TTP), and tumor depth (TD), were evaluated for their effects on post-operative outcomes.

Results: In the 142 matched cases contrast-enhancing volume and EOR in the AWA and ASL groups were 18.4 (9.7, 38.5) and 18.7 (9.6, 31.8) and 98% (IQR, 80-100) and 98% (IQR, 92,100), respectively (P>.5). Median OS in the AWA and ASL groups were 21.4 and 13.1, respectively (P=.04). In the AWA group, length of stay (4 [IQR, 3-6] vs. 6 [3-8]; P<.001), discharges home (66 [93%] vs 52 [73%]; P=.002), and discharges to an acute care facility (4 [5.6%] vs 18[25%]; P=.001) were more favorable. In those with a TTP > 3cm, persistent and new post-operative LD were more likely in the ASL group (11 (16%) vs. 3 (4.5%); P=.03 and 25 (36%) vs. 14 (21%); P=.048, respectively).

Conclusion : These results suggest that TD and TTP are important parameters for neurosurgeons to consider prior to DTL glioma resection. Gliomas with an increased TD and TTP may benefit from an awake resection with language mapping to optimize post-operative outcomes. Additional prospective studies (NCT04708171) are underway to further investigate the benefit of awake craniotomy.