TABLE 3.
Main Outcomes and Conclusions from Each Study Reviewed
| References | Main outcomes | Comment | AC caused an increase in stress/anxiety/depression |
|---|---|---|---|
| Whittle et al48 | A small group of patients reported more than minor anxiety (29%), discomfort (20%), or fear (15%). Most patients can tolerate AC well if they are well informed about the procedure and some simple precautions are taken. Three patients (20%) had little or no memory of the operation. None of the patients was unhappy with the theatre staff numbers. | Single-center study with a small sample size. | No |
| Hol et al49 | AC is physically and emotionally less stressful for patients compared with GA. Both preoperative and postoperative anxiety was lower for AC compared with GA (P < .05). Hospitalization time was 4.53 ± 2.12 for AC and increased significantly for GA to 6.17 ± 1.62 (P = .012). | Patients with surgeries after 11:00 am were excluded because of the effect of the circadian rhythm. Patients with endocrine problems were excluded. | No |
| Klimek et al50 | Postoperative anxiety and stress declined similarly in both the AC and GA groups. AC does not cause a greater emotional challenge compared with GA. Postoperative anxiety (P = .013) and stress (P < .001) decreased in both the AC and GA groups. A significant reduction in mean hospitalization time was seen in AC patients leaving after 4.53 ± 2.12 d and GA patients after 6.17 ± 1.62 d (P = .012). | Patients with surgeries after 11:00 am were excluded because of the effect of the circadian rhythm. Patients with endocrine problems were excluded too. Allocating patients to AC or GA groups cannot be randomised because of ethical reasons. | No |
| Goebel et al51 | Preoperative and postoperative anxiety (P = .17) and depression (P = .35) do not differ in AC. Combining AC and intraoperative MRI is tolerable and reasonable for the patients. | Single-center study with a small sample size. | No |
| Santini et al52 | Warning signs for the minor failure of AC are fear of pain and anxiety. PASS CA (cognitive anxiety) correlated with BDI (P < .05). There was no statistical significance in the psychological questionnaire response of patients who had compliance in AC vs those who did not (P > .05). Minor compliance was defined as the inability to repeat the mapping tasks during AC because of the patient's emotional distress. | Small sample size. Patients were included if they did not have pre-existing psychiatric disorders and had Karnofsky Performance Scale score <70. | No |
| Santini et al53 | Cognitive assessment of patients undergoing AC in addition to language testing before and after the surgery is essential for evaluation. AC resulted in a significant reduction in anxiety. Patients awaiting AC did not have a higher anxiety level compared with those awaiting general anesthesia. Nine (41%) of 22 patients had depressive moods in the preoperative phase. Two patients (9%) improved, and 7 (32%) did not postoperatively. Five patients (24%) had preoperative anxiety, and 2 patients (14%) with postoperative anxiety (P < .05). | Other factors such as personality traits and coping mechanisms were not assessed. | No |
| Patients with long-lasting epilepsy and/or antiepileptic therapy were excluded. | |||
| Milian et al54 | AC is a safe method and does not cause PTSD in patients. Two (12%) of 16 patients reported postoperative PTSD symptoms. One patient had chronic PTSD and the other had resolved symptoms after 3 mo. | The time between surgery and survey varied widely between 1 wk and 284 wks. Self-developed PTSD questionnaire which is not validated. | No |
| Beez et al55 | AC is well-tolerated among low-grade glioma patients. Intraoperative anxiety levels did not change during different phases of the procedure. Female patients had a higher anxiety level compared with male patients (P = .0103). Patients younger than 60 y had higher anxiety (P = .0145). | Different AC protocols were used in each center. | No |
| Zemmoura et al32 | Hypnosis was not superior compared with asleep-awake-asleep craniotomy for resection of low-grade gliomas. Hypnosis can be suggested as an alternative for older patients because of shorter waking periods and no management of airway contradictions. Eight patients (22%) had a pathological score of stress on PSS. | Hypnosis is limited by access to an anesthetic team experienced in both hypnotherapy and neuro-anesthesiology. No control group existed for psychological assessments. | No |
| Joswig et al56 | 29% of patients had transient neurological deficits. AC was not successful in 2 patients (9.1%), which switched to GA. | Single-center study with a small sample size. Retrospective study subject to bias. Patients with good physical, cognitive, and affective states and without language barriers were included. | No |
| Goettel et al57 | The quality of intraoperative brain mapping during AC for supratentorial tumor resection and efficacy of sedation was similar in dexmedetomidine and propofol—remifentanil. VAS for anxiety was not different between different anesthetic groups (P < .05). | The anesthetist was not blind to the medications. The brain mapping duration was short, and results could not be generalized to longer and more complex procedures. Patients with severe cardiovascular or respiratory disease were excluded. | No |
| Riquin et al58 | Two patients had a higher level of preoperative anxiety. Patients experienced little preoperative anxiety. No patient had symptoms of post-traumatic stress disorder or acute stress. | Single-center study with a small sample size. | No |
| Wu et al59 | Listening to music was associated with a decreased level of anxiety and distress among patients after AC. Not listening to music did not increase the anxiety level. Preoperative anxiety in the music vs nonmusic group was not different (P = .311). Postoperative anxiety was higher in the nonmusic group compared with the music group (P < .01). Preoperative and postoperative anxiety was not different in the nonmusic group (P = .097). Preoperative and postoperative anxiety was different in the music group (P < .001). | Single-center study with a small sample size. | No |
| Ruis et al5 | Anxiety of patients awaiting to undergo AC was not increased and was comparable with other surgical procedures. Only 25% of AC patients showed significantly increased anxiety (HADS >7) in the preoperative phase. A significant regression equation (F = 12.3, P < .001) and R2 = 0.153 predicts anxiety based on sex. | Other factors such as personality traits, coping mechanisms, and cognitive functions were not assessed. | No |
| van Ark et al60 | A significant correlation existed between anxiety after the operation and the quantity of memories. Patients undergoing AC experienced less anxiety compared with general anesthesia (P = .02). There was no significant correlation between age and anxiety in preoperative and postoperative phases (P = .417 vs P = .725). Preoperative anxiety was not different between AC and GA groups (P = .096). Preoperative anxiety was lower in AC compared with GA (P = .020). Postoperative anxiety was not different in AC and GA groups (0.564). | Retrospective study; therefore, recall bias is possible. The self-developed questionnaire was not validated. Patients requiring other types of surgeries during the study period were excluded. | No |
| Hejrati et al61 | Mental health was not negatively affected in AC. Preoperative and postoperative anxiety was related to pain intensity. Preoperative and postoperative stress and depression were not related to pain intensity (P < .05). | Treatment effect could not be calculated and selection bias was possible. Heterogeneity of diagnosis was present. Age heterogeneity was present in the sample. The effect of adjuvant therapies, such as chemotherapy and radiotherapy, was not investigated. | No |
| Patients with developmental delays, significant communication barriers, and obesity were excluded. | |||
| Cathey et al62 | Patients were willing to complete lavender aromatherapy, and this can be integrated into the operating room. Intraoperative lavender aromatherapy did not reduce anxiety levels significantly. After lavender aromatherapy, the trend toward reduced anxiety did not reach statistical significance. | A large placebo effect exists in conditions such as anxiety. Potential benefits can be due to a raised sense of control because of lavender self-administration. Patients with a history of asthma, chronic obstructive pulmonary disease, and pregnant patients were excluded. | No |
| Huguet et al63 | Professional psychological preparation and support from families were the key elements for the successful completion of AC in children. Only 1 patient showed persistent depressive thoughts postoperatively in long-term follow-up. | Single-center study with a small sample size. | No |
| Colgan et al64 | General anxiety was reduced after AC. In the preoperative phase, 75% of patients had high anxiety, 33% had moderate to high generalized anxiety, and 33% had moderate to severe depression. In the postoperative phase, 20% reported moderate to high general anxiety and 20% had moderate to severe depression. | Single-center study with a small sample size. High-grade tumors are associated with specific clinical features. The questionnaire was not specific to AC. The interviewer for some was the same as the person who interacted during the AC, so answers might be influenced. Pregnant patients were excluded. | No |
| Staub-Bartelt et al65 | The prevalence of distress, anxiety, or depression was not significantly different in awake vs nonawake surgery. AC did not affect anxiety and depression scores. Six patients (17%) in AC reported increased anxiety compared with 6 patients in the GA group (32%). Five patients in the AC group reported depression (14%) compared with 3 patients (16%) in the GA group. The prevalence of anxiety (P = .223) and depression (P = .882) did not differ in AC and GA groups. | A small sample size because of strict inclusion criteria. Only patients with full data set of psycho-oncological testing were included. The size of the 2 groups differed, which may cause analysis bias. 74.65% of patients were excluded because of missing data due to the retrospective design of the study. | No |
| Kamata et al66 | Sixteen of 405 patients had a panic attack during AC. Intraoperative anxiety (P = .0002) and age younger than 39 y (P = .0328) are associated with a panic attack during AC. | This study was conducted single-center and retrospectively. | No |
| Bakhshi et al67 | Resection of tumors under AC did not increase postoperative depression compared with GA. Twelve patients (12%) in AC and 29 patients (30%) in GA groups had postoperative depression. The median depression scale between AC and GA groups was not different (P = .06). | The sample size in the AC group was smaller. Some patients underwent other postoperative treatments such as chemotherapy and radiotherapy, which could affect stress, anxiety, and depression. Patients with a confirmed diagnosis of depression 1 y before the brain diagnosis were excluded. | No |
| Stalnacke et al68 | Preoperative and postoperative anxiety and depression did not change significantly. However, the postoperative anxiety trend increased to above threshold level for 4 patients, although this was not significant. Surgeries in eloquent areas are safe and can be tolerated by patients. | Women were over-represented in the sample. The sample was underpowered for identifying minor or medium changes. | No |
| Rahmani et al43 | There were no statistically significant changes in preoperative and postoperative stress and anxiety. Patients with speech disturbances, female patients, and those suspected of glioblastoma had higher preoperative anxiety. Female patients had significantly higher postoperative anxiety than male patients (P = .001). | No control group of patients with similar lesions operated under GA. Postoperative pharmacological and psychological treatments could bias the findings during the follow-up. Patients with previous craniotomy and/or cranioplasty were excluded. | No |
AC, awake craniotomy; BDI, Beck depression inventory; GA, general anesthesia; HADS, hospital anxiety and depression scale; PASS, pain anxiety symptoms scale; PSS, perceived stress scale; PTSD, post-traumatic stress disorder; VAS, visual analog scale.