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Purpose: To inquire into clinical practices perceived to mitigate patients' intraoperative distress during awake craniotomies., Methods: This mixed-methods study involved administration of Amsterdam Preoperative Anxiety and Information Scale and PTSD Checklist prior to the awake craniotomy to evaluate anxiety and information-seeking related to the procedure and symptoms of PTSD. Generalized Anxiety Disorder Scale and Depression Module of the Patient Health Questionnaire were administered before and after the procedure to evaluate generalized anxiety and depression. Patient interviews were conducted 2-weeks postprocedure and included a novel set of patient experience scales to assess patients' recollection of intraoperative pain, overall distress, anxiety, distress due to noise, perception of empowerment, perception of being well-prepared, overall satisfaction with anaesthesia management, and overall satisfaction with the procedure. Qualitative data were analysed using conventional content analysis., Results: Participants ( n  = 14) had undergone an awake craniotomy for tissue resection due to primary brain tumours or medically-refractory focal epilepsy. Validated self-report questionnaires demonstrated reduced levels of generalized anxiety (pre mean = 8.66; SD  = 6.41; post mean= 4.36; SD  = 4.24) following the awake craniotomy. Postprocedure interviews revealed very high satisfaction with the awake craniotomy and anaesthesia management and minimal levels of intraoperative pain, anxiety, and distress. The most stressful aspects of the procedure included global recognition of medical diagnosis, anxiety provoked by unfamiliar sights, sounds, and sensations, a perception of a lack of information or misinformation, and long periods of immobility. Important factors in alleviating intraoperative distress included the medical team's ability to promote patient perceptions of control, establish compassionate relationships, address unfamiliar intraoperative sensations, and deliver effective anaesthesia management., Conclusion: Compassion, communication, and patient perception of control were critical in mitigating intraoperative distress. Clinical practice recommendations with implications for all clinicians involved in patient care during awake craniotomies are provided. Use of these interventions and strategies to reduce distress are important to holistic patient care and patient experiences of care and may improve the likelihood of optimal brain mapping procedures to improve clinical outcomes during awake craniotomies.

Importance: Several studies have reported a higher incidence of neurodevelopmental delays and cognitive deficits in patients with single-suture craniosynostosis; however, there are few studies examining the associations of repair type with cognitive outcomes., Objective: To measure differences in neuropsychological outcomes between school-age children who were treated for sagittal craniosynostosis and unaffected controls and explore differences in cognitive function among children with sagittal craniosynostosis who were previously treated with either endoscopic strip craniectomy or open calvarial vault surgery., Design, Setting, and Participants: This cohort study was performed between 2018 and 2022. Eligible participants included patients aged 5 to 17 years who had previously been seen as infants or toddlers (<3 years) at 1 of 3 surgical centers for craniosynostosis repair with either endoscopic surgery or open calvarial vault surgery. A separate cohort of unaffected controls were included for comparison. Data analysis was conducted from November 2023 to February 2024., Exposures: Open calvarial vault surgery or endoscopic repair for single-suture craniosynostosis., Main Outcomes and Measures: The primary outcome was the Differential Ability Scales-II (DAS-II) General Conceptual Ability (GCA) score, an index for overall intellectual ability. Secondary outcomes included DAS-II subscale scores (Verbal Ability, Nonverbal Reasoning, Spatial Ability, Working Memory, and Processing Speed), and Patient-Reported Outcomes Measurement Information System (PROMIS) cognitive function scores., Results: A total of 81 patients with sagittal craniosynostosis (59 male [73%]; 22 female [27%]) and 141 controls (81 male [57%]; 60 female [43%]) were included. Of the 81 participants with sagittal craniosynostosis, 46 underwent endoscopic repair and 35 underwent open repair. Median (range) age at time of follow-up assessment was 7.7 (5.0-14.8) years for children with sagittal craniosynostosis and median age at assessment was 8.5 (7.7-10.5) years for controls. After controlling for age at assessment, sex, and socioeconomic status, there was no statistically significant or clinically meaningful difference in GCA scores between children who underwent endoscopic repair (adjusted mean score, 100; 95% CI, 96-104) and open repair (adjusted mean score, 103; 95% CI, 98-108) (P > .99). We found no significant difference in PROMIS scores between repair types (median [range] for endoscopic repair 54 [31-68] vs median [range] for open repair 50 [32-63]; P = .14). When comparing the treatment groups with the unaffected controls, differences in subscale scores for GCA and working memory were observed but were within normal range., Conclusions and Relevance: In this cohort study, there were no statistically or clinically significant differences in cognitive outcomes among school-age children by and type of surgical procedure used to repair nonsyndromic sagittal craniosynostosis. These findings suggest primary care clinicians should be educated about different options for craniosynostosis surgery to ensure early referral of these patients so that all treatment options remain viable.

Introduction: This cohort study aimed to elucidate the caregiver burden of helmet therapy (HT), following endoscopic strip craniectomy (ESC) to treat craniosynostosis, in an effort to inform clinicians and future caregivers navigating this therapeutic option., Methods: Fourteen caregivers of children with positional plagiocephaly (6) and craniosynostosis treated by ESC (8) undergoing HT at a single center were recruited via convenience sampling. Using a phenomenological qualitative approach, semi-structured interviews were conducted to understand the experience of HT for caregivers. Data collection and analysis were iterative and conducted until thematic saturation was reached., Results: Emerging themes revealed five domains of caregiver burden: emotional, cognitive, physical, psychosocial, and financial. No caregiver felt the therapy was too burdensome to complete. Caregivers of both groups also expressed positive aspects of HT related to support from the team, the noninvasive nature of treatment, and the outcomes of therapy. Furthermore, caregivers report overall satisfaction with the process, stating willingness to repeat the treatment with subsequent children if required., Conclusion: HT is associated with five major domains of caregiver burden; however, none of the caregivers regret choosing this treatment option, nor was the burden high enough to encourage treatment cessation. This study will inform future prospective analyses that will quantify real-time caregiver burden throughout HT., (© 2024 S. Karger AG, Basel.)

Backup and Objective: Awake craniotomy (AC) for brain tumors, when the patient is conscious during the operation, allows to reduce the risk of motor disability and aphasia, however, it may be a source of extreme stress. The aim of our study was to examine the patients' subjective experience of the surgery including the level of psychological trauma and cognitive functioning., Method: Eighteen patients operated due to brain tumor were enrolled in this study. The Essener Trauma-Inventory Questionnaire and the Addenbrooke's Cognitive Examination (ACE III) were administrated. The patients' experience with awake craniotomy was evaluated with a qualitative descriptive survey., Results: All patients remembered the intraoperative neuropsychological examination and several sensations like: drilling, cold, head clamp fixation or having eyes covered. In most of the patients the postoperative psychological trauma experience did not reach the clinical level. The ACE III postoperative scores revealed partial cognitive deficits with the lowest scores in memory and word fluency domains. Slight amnestic aphasia was observed postoperatively only in two patients., Conclusions: Awake craniotomy for resection of brain tumors is well-tolerated by patients and does not cause significant psychological trauma. Nonetheless, anxiety about the procedure warrants further study and individualized neuropsychological care is needed for the emotional preparation of the patient.

Background: Brain tumors account for the majority of central nervous system tumors, and most are removed by craniotomies. Many postcraniotomy patients experience moderate or severe pain after surgery, but patient perspectives on their experiences with pain management in the hospital have not been well described., Objective: The aim of this study was to describe how patients who have undergone a craniotomy for brain tumor removal experience pain management while hospitalized., Methods: Qualitative descriptive methods using semistructured interviews were conducted with patients on a neurological step-down unit in an urban teaching hospital in the Midwest United States. Interviews focused on how patients experienced postcraniotomy pain and how it was managed. Narratives were analyzed with standard content analytic procedures., Results: Twenty-seven participants (median age, 58.5 years; interquartile range, 26-41 years; range, 21-83 years) were interviewed. The majority were white (n = 25) and female (n = 15) and had an anterior craniotomy (n = 25) with sedation (n = 17). Their pain experiences varied on 2 dimensions: salience of pain during recovery and complexity of pain management. Based on these dimensions, 3 distinct types of pain management experiences were identified: (1) pain-as-nonsalient, routine pain management experience; (2) pain-as-salient, routine pain management experience; and (3) pain-as-salient, complex pain management experience., Conclusions: Many postcraniotomy patients experience their pain as tolerable and/or pain management as satisfying and effective; others experience pain and pain management as challenging., Implications for Practice: Clinicians should be attuned to needs of patients with complex pain management experiences and should incorporate good patient/clinician communication., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Decline in neurocognitive functioning (NCF) often occurs following brain tumor resection. Functional connectomics have shown how neurologic insults disrupt cerebral networks underlying NCF, though studies involving patients with brain tumors are lacking., Objective: To investigate the impact of brain tumor resection upon the connectome and relationships with NCF outcome in the early postoperative period., Methods: A total of 15 right-handed adults with left perisylvian glioma underwent resting-state functional magnetic resonance imaging (rs-fMRI) and neuropsychological assessment before and after awake tumor resection. Graph theoretical analysis was applied to rs-fMRI connectivity matrices to calculate network properties. Network properties and NCF measures were compared across the pre- to postoperative periods with matched pairs Wilcoxon signed-rank tests. Associations between pre- to postoperative change in network and NCF measures were determined with Spearman rank-order correlations (ρ)., Results: A majority of the sample showed postoperative decline on 1 or more NCF measures. Significant postoperative NCF decline was found across measures of verbal memory, processing speed, executive functioning, receptive language, and a composite index. Regarding connectomic properties, betweenness centrality and assortativity were significantly smaller postoperatively, and reductions in these measures were associated with better NCF outcomes. Significant inverse associations (ρ = -.51 to -.78, all P < .05) were observed between change in language, executive functioning, and learning and memory, and alterations in segregation, centrality, and resilience network properties., Conclusion: Decline in NCF was common shortly following resection of glioma involving eloquent brain regions, most frequently in verbal learning/memory and executive functioning. Better postoperative outcomes accompanied reductions in centrality and resilience connectomic measures., (Copyright © 2020 by the Congress of Neurological Surgeons.)

Background: The informed consent is a defining moment that should allow patients to understand their condition, what procedure they are undergoing, and what consequences may follow. This process should foster trust and promote confidence, without increasing patients' anxiety. New immersive 3D imaging technologies may serve as a tool to facilitate this endeavor., Methods: In a prospective, single-center, randomized controlled clinical trial (SPLICE Study: Surgical Planning and Informed Consent Study; ClinicalTrials.gov NCT03503487), 40 patients undergoing surgery for intracranial tumors were enrolled. After undergoing a traditional surgical informed consent acquisition, 33 patients were randomized 1:1:1 to 3 groups: in 2 experimental groups, patients underwent a 3D, immersive informed consent with two different surgical planners (group 1 and group 2); in the control group, patients underwent an informed consent supported by traditional 2D radiological images., Results: Patients in the experimental groups appreciated this communication experience, while their objective comprehension was higher ((score mean (SD)): group 1 82.65 (6.83); group 2 77.76 (10.19)), as compared with the control group (57.70 (12.49); P < 0.001). Subjective comprehension and anxiety levels did not differ between experimental groups and control group., Conclusions: 3D virtual reality can help surgeons and patients in building a better relationship before surgery; immersive 3D-supported informed consent improves patients' comprehension of their condition without increasing anxiety. This new paradigm may foster trust between surgeons and patients, possibly restraining medical-legal acts., Trail Registration: ClinicalTrials.gov NCT03503487.

Background: Postcraniotomy individuals should be monitored because of the direct influence on brain function as well as constraints caused by underlying illness. The relationship between demographic and clinical characteristics of postcraniotomy individuals and their readiness for discharge was examined., Methods: A descriptive correlational study included 150 individuals. The Readiness for Hospital Discharge Scale and demographic variables were examined using descriptive statistics, correlation, and stepwise multiple linear regression., Results: The mean postcraniotomy score for the subdimension of knowledge related to readiness for discharge was 5.13 ± 3.04, and mean score for the whole scale was 7.76 ± 1.48. The individuals' age, employment status, presence of a person to provide care at home, poor financial status, and first hospitalization during the lifetime of the patient were statistically significant predictors of their readiness for discharge. This model was statistically significant (F = 25.572, P < .001) and accounted for 57% of the variance in discharge readiness., Conclusion: Patients had moderate levels of readiness for discharge and low levels of discharge-related knowledge. The findings point to the importance of individual approach to the discharge planning.

A 32-year-old man undergoing awake craniotomy for tumor resection was previously diagnosed with post-traumatic stress disorder (PTSD)-typically a relative contraindication for awake craniotomy. Preoperative neurocognitive assessment and counseling by a neuroanesthesiologist and neuropsychologist were undertaken to characterize his PTSD, identify triggers, and prepare him for the intraoperative events. Dexmedetomidine and remifentanil were used as intraoperative anxiolytics and analgesics. With an emphasis on open communication, the patient tolerated the awake craniotomy without complications. This case highlights the importance of multidisciplinary approach and meticulous perioperative preparation in successfully managing a patient who might otherwise be contraindicated for awake craniotomy.

Awake craniotomies are a crucial tool for identifying eloquent cortex, but significant limitations frequently related to patient tolerance have limited their applicability in pediatric cases. The authors describe a comprehensive, longitudinal protocol developed in collaboration with a certified child life specialist (CCLS) in order to enhance patient experiences and develop resiliency related to the intraoperative portion of cases. This protocol includes preoperative conditioning, intraoperative support, and postoperative positive reinforcement and debriefing. A unique coping plan is developed for each prospective patient. With appropriate support, awake craniotomy may be applicable in a wider array of preadolescent and adolescent patients than has previously been possible. Future prospective studies are needed to validate this approach.

Background: Experiencing cranial surgery under awake conditions may expose patients to considerable psychological strain., Methods: This study aimed to investigate the occurrence and course of psychological sequelae following awake craniotomy (AC) for brain tumors in a series of 20 patients using a broad, validated psychological assessment preoperatively, intraoperatively, postoperatively and a standardized follow-up of 3 months. In addition, the association of the preoperative psychological condition (including, but not limited to, anxiety and fear) with perioperative pain perception and interference was assessed., Results: AC did not induce any shift in the median levels of anxiety, depression, and stress symptoms already present prior to the procedure. Furthermore, anxiety and depression were all moderately to strongly associated over time (all P < 0.05). Stress symptoms also correlated positively over all times of measurement. Stress 3 days after surgery was strongly associated with stress 3 months after surgery (P < 0.001), whereas the correlation between preoperative and immediate postoperative stress showed a statistical trend (P = 0.07). Preoperative fear was not related to intraoperative pain, but to pain and its interference with daily activity on the third postoperative day (P < 0.001 and P < 0.01, respectively)., Conclusions: Postoperative psychological symptoms clearly correlated with their corresponding preoperative symptoms. Thus, mental health was not negatively affected by the AC experience in our series. Intraoperative fear and pain were not related to the preoperative psychological condition. However, preoperative fear and anxiety were positively related with pain and its interference with daily activity in the immediate postoperative period., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: The diagnosis and the surgical removal of a brain tumor can have serious impact on the quality of life of a patient. The question rises, whether having more or just less memories of the procedure is better for coping with such an event. Furthermore, for preoperative information of future patients it is important to know how patients process their emotions and memories. The primary objective of this study was to investigate the link between preoperative anxiety, the perioperative experience and the quantity and quality of postoperative memories in patients who underwent intracranial tumor surgery., Patients and Methods: This study was a retrospective observational study; all patients who underwent intracranial tumor surgery at the Erasmus Medical Centre Rotterdam between January 1st 2014 and December 31st 2015 were identified. In May 2016, all patients who were not registered as deceased were sent a questionnaire about their anxieties, perceptions and memories of the perioperative period., Results: In total 476 patients were included. 272 patients responded, which resulted in a response rate of 57.14%. In the general anesthesia (GA) group there was a significant negative correlation between anxiety in the perioperative period and the quantity and quality of memories. In the awake craniotomy group, there was a significant negative correlation between anxiety after the operation and the quantity of memories., Conclusion: Patients in the GA group who experienced anxiety in the perioperative period had less quantity and quality of memories and less patient satisfaction. Patients in the AC group who experienced anxiety after the operation had only a lower quantity of the memory; there was no correlation with patient satisfaction., (Copyright © 2018 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: To explore the perspective on Decompressive craniectomy (DH) of each of these specialties to establish common grounds for improved clinical practice., Methods: An electronic survey was distributed via email and social media groups to members of these specialties in Kingdom of Saudi Arabia and the Gulf countries. Local practices, common triggers for referral for DH, perceived outcomes of these procedures, individual impression of what constitutes good clinical outcomes were explored., Results: There are 89 physicians participated: 41 (46.1%) neurologists, 34 (38.2%) neurosurgeons, and 14 (15.7%) intensivests. Participants are mostly practicing in intermediate volume centers or high volume centers. Half of the neurosurgeons preferred to be consulted immediately on candidates with large middle cerebral artery (MCA) strokes. The most important referral trigger for DH was clinical changes. The modified Rankin Scale (mRS) cutoff for good clinical outcome was 3 for 73.6% of respondents. There was agreement that DH only improves survival (64.4%). A third of the neurologists considered it to improve functional outcome compared to 15.4% of intensivests and 14.8% of neurosurgeons. There was agreement (66.7%) that patients older than 60 years with involvement of more than one territory should be excluded from DH. Only 7.7% of neurosurgeons excluded patients with dominant hemispheric strokes., Conclusion: Our physicians` views are variable in what`s called acceptable outcome, and further studies are needed to to test the characteristics that helps in decision making such as hemisphere dominancy, time onset of stroke and vital radiological signs. This is seen despite the literature being full of data that supports the DC over medical management in malignant MCA infarction. Better multidisciplinary education initiatives are needed to unify the understanding and help improve the practices in this challenging subset of patients.

Background: Awake craniotomy is performed with increasing frequency for brain tumor surgery in eloquent areas; however, little is known about patients' memories of this procedure. Here we retrospectively analyzed the quality and quantity of memories in a series of patients treated following a standardized protocol., Methods: We treated 61 consecutive patients within 3 years, 48 of whom were alive when the study was performed. Each of these patients received a questionnaire eliciting information about their perioperative memories and perceptions. The perioperative process was broken down into steps, and for each step the patient was to judge the quantity (nothing-everything) and quality (very negative-very positive) of his or her memories., Results: Thirty-six of the 48 patients completed the questionnaire (75%). The quantity of memories was quite incomplete, even for intraoperative moments when patients were awake and cooperative. On average, the quality of memories was neutral or positive. A higher quantity of memories was associated with a higher quality of memories. The most commonly reported sources of discomfort were placement of the Mayfield clamp, followed by laying on the operating room table with movement restriction, and irritation by the urinary catheter in situ., Conclusions: Awake craniotomy can be performed following our protocol in such a way that it is experienced as (very) comfortable. However, there are moments of discomfort, which can be managed by the team. Extensive preoperative preparation may be considered a crucial part of the procedure. Less amnesia seems to improve patient satisfaction. The results of this study can help guide protocol optimization, expectation management, and information for future patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Awake craniotomy for tumor resection and epilepsy surgery is a well-tolerated procedure. Qualitative data on patients' experience of awake deep-brain stimulation (DBS) are, however, lacking. We collected qualitative data on patients' experience of awake DBS with a view to identifying areas for improvement., Methods: Forty-one patients undergoing DBS for Parkinson disease between 2009 and 2015 were surveyed with a structured questionnaire designed to receive patient feedback regarding perioperative management of the awake stage of the procedure., Results: More than 90% of patients felt well-informed. Most remembered the procedure, and almost all were happy that they did. One half of the patients experienced pain, often significant, during the procedure. This mainly occurred during burr-hole drilling and stereotactic frame placement., Conclusions: Although awake DBS is well-tolerated, pain and off-period symptoms are an issue for a significant number of patients. Efforts should be made to minimize these unpleasant aspects of awake DBS., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Awake craniotomy with brain mapping is the gold standard for eloquent tissue localization. Patients' tolerability and satisfaction have been shown to be high; however, it is a matter of debate whether these findings could be generalized, since patients across the globe have their own cultural backgrounds and may perceive and accept this procedure differently., Methods: We conducted a prospective qualitative study about the perception and tolerability of awake craniotomy in a population of consecutive brain tumor patients in Brazil between January 2013 and April 2015. Seventeen patients were interviewed using a semi-structured model with open-ended questions., Results: Patients' thoughts were grouped into five categories: (1) overall perception: no patient considered awake craniotomy a bad experience, and most understood the rationale behind it. They were positively surprised with the surgery; (2) memory: varied from nothing to the entire surgery; (3) negative sensations: in general, it was painless and comfortable. Remarks concerning discomfort on the operating table were made; (4) postoperative recovery: perception of the postoperative period was positive; (5) previous surgical experiences versus awake craniotomy: patients often preferred awake surgery over other surgery under general anesthesia, including craniotomies., Conclusions: Awake craniotomy for brain tumors was well tolerated and yielded high levels of satisfaction in a population of patients in Brazil. This technique should not be avoided under the pretext of compromising patients' well-being.

Aims and Objectives: To investigate the effects of different types of shaving on body image and surgical site infection in elective cranial surgery., Background: Hair shaving before cranial surgery is commonly performed in many countries. However, the impact of shaving on the patients' body image and surgical site infection is not, as yet, well investigated., Design: A randomised-controlled design was used in this study., Methods: The sample comprised 200 patients who underwent elective cranial surgery between March 2013-August 2014. The Center for Disease Control and Prevention criteria were applied for the preoperative preparation of patients and for the follow-up of surgical site infection. Wound swab cultures were obtained four times from all patients. The Social Appearance Anxiety Scale was used to assess changes in the body image of patients., Findings: The rate of surgical site infection was 1% for each group and for all patients. There was no difference between the groups of surgical site infection. Coagulase-negative staphylococci and Staphylococcus epidermidis were mostly isolated in the swab cultures. The Social Appearance Anxiety Scale score decreased in patients who underwent strip shaving and increased in patients with regional shaving., Conclusion: There is no difference between strip shaving and regional shaving in the development of surgical site infection after cranial surgery. In addition, regional hair shaving negatively affects the patients' body image., Relevance to Clinical Practice: Findings of this study provide useful evidence-based information for healthcare professionals. The development and implementation of effective interventions result in the prevention of surgical site infection and improvement of the patients' body image in elective cranial surgery., (© 2016 John Wiley & Sons Ltd.)

Background: Awake craniotomy for brain lesions in or near eloquent brain regions enables neurosurgeons to assess neurologic functions of patients intraoperatively, reducing the risk of permanent neurologic deficits and increasing the extent of resection., Methods: A retrospective review was performed of a consecutive series of patients with awake craniotomies in the first year of their introduction to our tertiary non-university-affiliated neurosurgery department. Operation time, complications, and neurologic outcome were assessed, and patient perception of awake craniotomy was surveyed using a mailed questionnaire., Results: There were 24 awake craniotomies performed in 22 patients for low-grade/high-grade gliomas, cavernomas, and metastases (average 2 cases per month). Mean operation time was 205 minutes. Failure of awake craniotomy because of intraoperative seizures with subsequent postictal impaired testing or limited cooperation occurred in 2 patients. Transient neurologic deficits occurred in 29% of patients; 1 patient sustained a permanent neurologic deficit. Of the 18 patients (82%) who returned the questionnaire, only 2 patients recalled significant fear during surgery., Conclusions: Introducing awake craniotomy to a tertiary non-university-affiliated neurosurgery department is feasible and resulted in reasonable operation times and complication rates and high patient satisfaction., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: In the pediatric population, awake craniotomy began to be used for the resection of brain tumor located close to eloquent areas. Some specificities must be taken into account to adapt this method to children., Objective: The aim of this clinical study is to not only confirm the feasibility of awake craniotomy and language brain mapping in the pediatric population but also identify the specificities and necessary adaptations of the procedure., Methods: Six children aged 11 to 16 were operated on while awake under local anesthesia with language brain mapping for supratentorial brain lesions (tumor and cavernoma). The preoperative planning comprised functional magnetic resonance imaging (MRI) and neuropsychologic and psychologic assessment. The specific preoperative preparation is clearly explained including hypnosis conditioning and psychiatric evaluation. The success of the procedure was based on the ability to perform the language brain mapping and the tumor removal without putting the patient to sleep. We investigated the pediatric specificities, psychological experience, and neuropsychologic follow-up., Results: The children experienced little anxiety, probably in large part due to the use of hypnosis. We succeeded in doing the cortical-subcortical mapping and removing the tumor without putting the patient to sleep in all cases. The psychological experience was good, and the neuropsychologic follow-up showed a favorable evolution., Conclusions: Preoperative preparation and hypnosis in children seemed important for performing awake craniotomy and contributing language brain mapping with the best possible psychological experience. The pediatrics specificities are discussed., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Patient-reported experience is often used as a measure for quality of care, but no reports on patient satisfaction after cranial neurosurgery exist., Objective: To study the association of overall patient satisfaction and surgical outcome and to evaluate the applicability of overall patient satisfaction as a proxy for quality of care in elective cranial neurosurgery., Methods: We conducted an observational study on the relationship of overall patient satisfaction at 30 postoperative days with surgical and functional outcome (modified Rankin Scale [mRS] score) in a prospective, consecutive, and unselected cohort of 418 adult elective craniotomy patients enrolled between December 2011 and December 2012 at Helsinki University Hospital, Helsinki, Finland., Results: Postoperative overall (subjective and objective) morbidity was present in 194 (46.4%) patients; yet almost 94% of all study patients reported high overall satisfaction. Low overall patient satisfaction at 30 days was not associated with postoperative major morbidity in elective cranial neurosurgery. Dependent functional status (mRS score ≥3) at 30 days, minor infections, poor postoperative subjective overall health status, and patient-reported severe symptoms (double vision, poor balance) may contribute to unsatisfactory patient experience., Conclusion: Overall patient satisfaction with elective cranial neurosurgery is high. Even 9 of 10 patients with postoperative major morbidity rated high overall patient satisfaction at 30 days. Overall patient satisfaction may merely reflect patient experience and subjective postoperative health status, and therefore it is a poor proxy for quality of care in elective cranial neurosurgery.

Objective: To report the personal experiences of patients undergoing awake craniotomy for brain tumor resection., Methods: We carried out a qualitative descriptive survey of patients` experiences with awake craniotomies for brain tumor resection. The survey was conducted through a standard questionnaire form after the patient was discharged from the hospital., Results: Of the 9 patients who met the inclusion criteria and underwent awake craniotomy, 3 of those patients reported no recollection of the operation. Five patients had auditory recollections from the operation. Two-thirds (6/9) reported that they did not perceive pain. Five patients remembered the head clamp fixation, and 2 of those patients classified the pain from the clamp as moderate. None of the patients reported that the surgery was more difficult than anticipated., Conclusion: Awake craniotomy for surgical resection of brain tumors was well tolerated by patients. Most patients reported that they do not recall feeling pain during the operation. However, we feel that further work and exploration are needed in order to achieve better control of pain and discomfort during these types of operations.

Objectives: Patients undergoing awake craniotomy may experience high levels of stress. Minimizing anxiety benefits patients and surgeons. Music has many therapeutic effects in altering human mood and emotion. Tonality of music as conveyed by composition in major or minor keys can have an impact on patients' emotions and thoughts. Assessing the effects of listening to major and minor key musical pieces on patients undergoing awake craniotiomy could help in the design of interventions to alleviate anxiety, stress and tension., Methods: Twenty-nine patients who were undergoing awake craniotomy were recruited and randomly assigned into two groups: Group 1 subjects listened to major key music and Group 2 listened to minor key compositions. Subjects completed a demographics questionnaire, a pre- and post-operative Beck Anxiety Inventory (BAI) and a semi-structured open-ended interview. RESULTS were analyzed using modified thematic analysis through open and axial coding., Results: Overall, patients enjoyed the music regardless of the key distinctions and stated they benefitted from listening to the music. No adverse reactions to the music were found. Subjects remarked that the music made them feel more at ease and less anxious before, during and after their procedure. Patients preferred either major key or minor key music but not a combination of both. Those who preferred major key pieces said it was on the basis of tonality while the individuals who selected minor key pieces stated that tempo of the music was the primary factor., Conclusion: Overall, listening to music selections was beneficial for the patients. Future work should further investigate the effects of audio interventions in awake surgery through narrative means.

Cranioplasty is performed, using autograft materials, to treat the "trephined syndrome" in patients previously submitted to craniectomy. Indeed, considerable improvements in neuropsychological deficits, control of convulsions and partial prevention of cerebral atrophy are achieved after this surgical procedure. We describe the pre- and post-operative neuropsychological and functional evaluation of a 30-year-old male patient who underwent cranioplasty following previous craniectomy for a subarachnoid hemorrhage due to a spontaneously ruptured aneurysm of the right middle cerebral artery.

Background: The optimal type of surgical management for isolated sagittal synostosis remains a source of significant debate. There is a paucity of data regarding possible differences in long-term neuropsychological outcomes following treatment with whole-vault cranioplasty or endoscopic strip craniectomy. This study provides the first comparative analysis examining the effects of the two techniques related to long-term intellectual functioning., Methods: A total of 70 patients were enrolled in this multicenter study, 29 of whom had previously undergone endoscopic strip craniectomy and 41 of whom had previously undergone whole-vault cranioplasty. All patients completed a battery of neurodevelopmental tests (Beery-Buktenica Developmental Test of Visual-Motor Integration, Wechsler Abbreviated Scale of Intelligence, and Wechsler Fundamentals) to evaluate various domains of neuropsychological function., Results: In a group comparison of those treated before 6 months of age, whole-vault patients obtained higher scores relative to endoscopic strip craniectomy patients on visuomotor integration, full-scale intelligence quotient, verbal intelligence quotient, word reading, and reading comprehension (p < 0.05 for all). When compared against strip craniectomy performed before 3 months of age, the whole-vault group still showed significantly higher scores in verbal intelligence quotient, reading comprehension, and word reading (p < 0.05 for all)., Conclusions: The type of surgical intervention for isolated sagittal synostosis impacts long-term neuropsychological outcomes. Patients undergoing early whole-vault cranioplasty attained higher intelligence quotient and achievement scores relative to those undergoing strip craniectomy. Surgical management with whole-vault cranioplasty performed before 6 months of age provides the most favorable long-term intellectual outcomes in patients with isolated sagittal synostosis., Clinical Question/level of Evidence: Therapeutic, II.

Awake craniotomy is the technique of choice in patients with brain tumours adjacent to primary and accessory language areas (Broca's and Wernicke's areas). Language testing should be aimed to detect preoperative deficits, to promptly identify the occurrence of new intraoperative impairments and to establish the course of postoperative language status. Aim of this case series is to describe our experience with a dedicated language testing work up to evaluate patients with or at risk for language disturbances undergoing awake craniotomy for brain tumour resection. Pre- and intra operative testing was accomplished with 8 tests. Intraoperative evaluation was accomplished when patients were fully cooperative (Ramsey < 3). Postoperative evaluation was scheduled at early (within 21 days) and long-term follow-up (3-6 months). Twenty consecutive patients were prospectively recruited. Preoperative language testings were normal in 9 patients (45%), showed mild to moderate language deficit in 8 (40%) and severe language deficit or aphasic disorders in 3 (15%). Broca's area was identified in 15 patients, in all cases by counting arrest during stimulation and in 12 cases by naming arrest. In this article we describe our experience using a language testing work up to evaluate - pre, intra and postoperatively - patients undergoing awake craniotomy for brain tumour resection with preoperative language disturbances or at risk for postoperative language deficits. This approach allows a systematic evaluation and recording of language function status and can be accomplished even when a neuropsychologist or speech therapist are not involved in the operation crew.

Background: Awake craniotomy is a valuable procedure since it allows brain mapping and live monitoring of eloquent brain functions. The advantage of minimizing resource utilization is also emphasized by some physicians in North America. Data on how well an awake craniotomy is tolerated by patients and how much stress it creates is available from different studies, but this topic has not consequently been summarized in a review of the available literature. Therefore, it is the purpose of this review to shed more light on the still controversially discussed aspect of an awake craniotomy., Methods: We reviewed the available English literature published until December 2013 searching for studies that investigated patients' responses to awake craniotomies., Results: Twelve studies, published between 1998 and 2013, including 396 patients with awake surgery were identified. Eleven of these 12 studies set the focus on the perioperative time, one study focused on the later postoperative time. The vast majority of patients felt well prepared and overall satisfaction with the procedure was high. In the majority of studies up to 30 % of the patients recalled considerable pain and 10-14 % experienced strong anxiety during the procedure. The majority of patients reported that they would undergo an awake craniotomy again. A post traumatic stress disorder was present neither shortly nor years after surgery. However, a normal human response to such an exceptional situation can for instance be the delayed appearance of unintentional distressing recollections of the event despite the patients' satisfaction concerning the procedure., Conclusions: For selected patients, an awake craniotomy presents the best possible way to reduce the risk of surgery related neurological deficits. However, benefits and burdens of this type of procedure should be carefully considered when planning an awake craniotomy and the decision should serve the interests of the patient.

Reduction cranioplasty for macrocephaly improves patients' quality of life both functionally and aesthetically. However, it is indicated for only a small number of patients because of the risks of complications. Thus, it is rarely performed, and not many reports have been published. In Dandy-Walker syndrome, there is often a posterior fossa cyst continuous with the fourth ventricle. We report here a case of scaphocephalic macrocephaly because of such a cystic lesion. The patient underwent a single-stage surgery with plication of the cyst wall and posterior reduction cranioplasty. This procedure achieved good results.

Patient anxiety and fear about an awake craniotomy can affect the patient's choice about having an operation despite comprehensive pre-operative counselling. We report three cases in which a family member came into theatre during the procedure to support the patient during surgery. All three cases, which involved intra-operative cortical and subcortical stimulations and intra-operative patient testing, were successfully completed with major tumour resections and no post-operative complications. We suggest that family support should be considered in patients who have extreme fear and anxiety about awake surgery.

Objectives: Previous research exploring the patient experience of awake craniotomy (AC) has yielded contrasting accounts. The current study aimed to explore the lived experience of having undergone an AC in the United Kingdom., Design: This was a qualitative, semi-structured interview study. Interviews were audio-recorded and transcribed verbatim. Data were analysed using interpretative phenomenological analysis (IPA)., Methods: Seven participants (three males, four females) who had undergone an AC in the United Kingdom took part in the study. Ages ranged between 26 and 41 years old at the time of interview. Time since AC ranged from 5 months to 4 years., Results: Participants appeared to be satisfied with, and tolerant of, the AC experience. Three superordinate themes: use of self-preservation strategies prior to and during AC, a bizarre yet pleasant operation experience, and the need for more concrete information prior to surgery were identified. These themes appeared to be embedded in a core theme: relationship with the neurosurgeon., Conclusions: The relationship with the neurosurgeon appears crucial to the patient experience of AC. This knowledge underscores the need for effective doctor-patient communication skills which could lead to improved delivery of care and more positive outcomes., (©2012 The British Psychological Society.)

Awake craniotomy has become an increasingly utilized procedure in the treatment of supratentorial intra-axial tumors. The popularity of this procedure is partially attributable to improvements in intraoperative technology and anesthetic techniques. The application of awake craniotomy to the field of neuro-oncology has decreased iatrogenic postoperative neurological deficits, allowed for safe maximal tumor resection and improved healthcare resource stewardship by permitting early patient discharge. In this article, we review recent evidence for the utility of awake craniotomy in the resection of gliomas and describe the senior author's experience in performing this procedure. Furthermore, we explore innovative applications of awake craniotomy to outpatient tumor resections and the conduct of neurosurgery in resource-poor settings. We conclude that awake craniotomy is an effective and versatile neurosurgical procedure with expanding applications in neuro-oncology.

Objectives: The aim of this study was to objectively assess the patients' acceptance for awake craniotomy in a group of neurosurgical patients, who underwent this procedure for removal of lesions in or close to eloquent brain areas., Patients and Methods: Patients acceptance for awake craniotomy under local anesthesia and conscious sedation was assessed by a formal questionnaire (PPP33), initially developed for general surgery patients. The results are compared to a group of patients who had brain surgery under general anesthesia and to previously published data., Results: The awake craniotomy (AC) group consisted of 37 male and 9 female patients (48 craniotomies) with age ranging from 18 to 71 years. The general anesthesia (GA) group consisted of 26 male and 15 female patients (43 craniotomies) with age ranging from 26 to 83 years. All patients in the study were included in the questionnaire analysis. In comparison to GA the overall PPP33 score for AC was higher (p=0.07), suggesting better overall acceptance for AC. The subscale scores for AC were also significantly better compared to GA for the two subscales "postoperative pain" (p=0.02) and "physical disorders" (p=0.01) and equal for the other 6 subscales. The results of the overall mean score and the scores for the subscales of the PPP33 questionnaire verify good patients' acceptance for AC., Conclusion: Previous studies have shown good patients' acceptance for awake craniotomy, but only a few times using formal approaches. By utilizing a formal questionnaire we could verify good patient acceptance for awake craniotomy for the treatment of brain tumors in or close to eloquent areas. This is a novel approach that substantiates previously published experiences., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Objective: Patients with intracranial tumours often suffer from clinically relevant psychological distress. However, levels of distress and contributing factors have not been systematically evaluated for the early course of the disease. Using the National Comprehensive Cancer Network's Distress Thermometer (DT), we evaluated the extent and sources of distress within a population of patients with intracranial neoplasms., Methods: One hundred and fifty-nine patients were included who underwent craniotomy for newly diagnosed intracranial tumours at our department. All patients completed the DT questionnaire, a single-item 11-point visual analogue scale measuring psychological distress. The appendant problem list (PL) consists of 40 items representing problems commonly experienced by cancer patients. Patients were asked to mark any experienced sources of distress., Results: Percentage of patients suffering from relevant distress was 48.4% (cut-off ≥6). DT-scores were significantly associated with depression and anxiety as well as reported number of concerns. On average, patients reported 6.9 sources of cancer-related distress. Objective medical data (e.g. tumour stage) as well as sociodemographic data (e.g. gender, IQ) were not associated with psychological distress at this early phase., Conclusions: Prevalence of elevated distress is high shortly after primary neurosurgical treatment in patients with intracranial tumours and cannot be predicted by objective data. As a consequence, sources of distress can and should be routinely assessed and targeted in these individuals in this particular period. Further studies are needed to help to identify patients who are at risk of suffering from long-term emotional distress in order to enable targeted psychosocial intervention., (Copyright © 2011 John Wiley & Sons, Ltd.)

Background: Craniotomy is considered less painful than other surgical procedures and supratentorial surgeries are thought to be the least painful among them. We studied the intensity of pain in the postoperative period following a supratentorial craniotomy while using oral paracetamol as the sole analgesic. The effect of temporalis muscle incision on the intensity of pain was also studied., Methods: In a prospective study over 6 months, 43 patients with a pre-operative Glasgow coma scale (GCS) score 15/15, aged  >16 years who underwent a supratentorial craniotomy and were admitted to neurosurgical ICU were included in the study. Patients with a postoperative GCS score of  <15 on admission to the ICU were excluded from the study. All patients received oral paracetamol for pain relief. Postoperative pain scale was used in the first hour to assess pain objectively. Visual analogue scale was used thereafter to record pain at 8, 12, 24 and 48 h post-craniotomy. Patients were familiarised with these scales preoperatively. Postoperative pain scores were compared with preoperative scores using paired T test, whereas significance of temporalis muscle involvement in incision for increased post-craniotomy pain was evaluated using Fischer's exact test., Results: Inadequate analgesia was complained of by 63% (n = 27) patients in the first 12 h postoperatively. However, severe pain was present only in 12% (n = 5) of patients. Incidence of pain decreased thereafter at 24 and 48 h. Twenty-seven percent (n = 12) patients were free of pain at all study periods. Fifty percent (n = 3) of patients who complained of significant pain beyond 12 h developed postoperative complications. Incision of temporalis muscle was not associated with a significant increase in severity of postoperative pain., Conclusion: Pain following craniotomy is adequately addressed in only about 27% of patients with oral paracetamol. However, the long-term analgesic effect is satisfactory. Persistence of pain of moderate or severe intensity 24 h after a craniotomy could suggest an impending postoperative complication.

The author, a practicing psychiatrist, describes his own experience in becoming a neurosurgical patient, three times in quick succession, for a recurring subdural hematoma. In addition to a brief review of the literature, he observes his own experience, including reaction to the diagnosis and to the surgical, postsurgical, and intensive-care experience. Suggestions are made to neurosurgeons and their staff to help patients during this experience and in recovery, from the vantage point of a psychiatrist who specializes in dealing with psychological issues arising from illness.

Malignant middle cerebral artery (MMCA) infarction is associated with a mortality rate of 80% under conservative treatment. Decompressive hemicraniectomy (DH) reduces mortality and improves the functional outcome of surviving patients. The purpose of this study was to examine quality of life (QoL) and neurobehavioral deficits in patients with space-occupying infarctions of the right- or left-sided hemisphere at 6 months after stroke. The Sickness Impact Profile (SIP) was used to assess QoL in 19 out of 29 consecutive patients that underwent DH after a malignant MCA infarction (14 on the right and 5 on the left hemisphere). Behavioral changes were evaluated with the Frontal Behavioral Inventory and the Beck Depression Inventory. Patients and relatives were also asked if, knowing the present outcome, they would agree again, in retrospect, to a DH. Barthel Index >60 was seen in 37% of our patients. Functional outcome was related to age. We found a higher reduction in the SIP's physical domain than in the psychosocial domain. Depressive symptoms were present in 50% of the patients. We didn't find significant differences in QoL or functional outcome between patients with right or left-sided infarctions. The most frequent neurobehavioral symptoms were decreased speech output, apathy, reduced spontaneity and irritability. Most patients and their relatives would again give consent to hemicraniectomy. The results show that younger patients had a significantly better outcome. QoL seems to be acceptable in both left- and right-sided infarctions, and retrospective agreement to hemicraniectomy is high in both patients and their relatives.

Overweight and obese patients are at especially high risk for delayed awakening after general surgery. Whether this risk also applies to cerebral neurosurgical procedures remains unclear. This study evaluated early postoperative cognitive recovery and gas exchange patterns, after balanced anesthesia with sevoflurane or desflurane, in overweight and obese patients undergoing craniotomy for supratentorial expanding lesions. Fifty-six patients were consecutively enrolled, and randomly assigned to 1 of 2 study groups to receive balanced anesthesia with sevoflurane or desflurane. Cognitive function was evaluated with the Short Orientation Memory Concentration Test and the Rancho Los Amigos Scale and gas exchange patterns (pH, PaO2, and PaCO2) were recorded in all patients at 5 time-points: preoperatively and postoperatively, after patients reached an Aldrete score >or=9, at 15, 30, 45, and 60 minutes. Preoperative cognitive status was similar in the 2 treatment groups. Early postoperative cognitive recovery was more delayed and Short Orientation Memory Concentration Test scores at 15 and 30 minutes postanesthesia were lower in patients receiving sevoflurane-based anesthesia than in those receiving desflurane-based anesthesia (21.5+/-3.5 vs. 14.9+/-3.5) (P<0.005) and (26.9+/-0.7 vs. 21.5+/-1.4) (P<0.005), and the postoperative Rancho Los Amigos Scalegrade 8 showed a similar trend (25/28 patients 89% vs. 8/28 patients 28% (P<0.005) and 28/28 patients (100% vs. 13/28 patients 46%) (P<0.005). Similarly, gas-exchange analysis showed higher PaCO2 at 15 and 30 minutes and lower pH up to 45 minutes postextubation in patients receiving sevoflurane-based anesthesia. In overweight and obese patients undergoing craniotomy desflurane-based anesthesia allows earlier postoperative cognitive recovery and reversal to normocapnia and normal pH.

Intraoperative mapping is a well-established and safe technique to maximize the excision of tumors involving the eloquent cortex while minimizing neurological damage. Although different techniques are used, very little has been documented about how the patients feel, what they think about, or how they approach this type of surgery without an anesthetic. Considering the inconsistency of literature, a phenomenology study was conducted with the purpose to describe the human experience of patients before, during, and immediately after awake craniotomy. Twenty-one patients were interviewed at length, both the evening before and the evening after surgery. Awake craniotomy is a complex and subjective experience, the behavioral patterns of the subjects interviewed can be attributed to the instinct of self-preservation, the ability to participate during the procedure helping the surgeon in avoiding brain damage; to be in control of the situation; and to reassure themselves and others. It is most important for a healthcare team to understand the patients' experiences. Immediately before and after surgery, the patients seem to concentrate more on keeping their emotions in check and focus on the risk of subsequent defect or disability, rather than on the brain cancer and what it may imply on life. During the surgery, they become particularly involved in the task: they feel directly responsible for the results of surgery relating this to the effectiveness of collaboration with the neurosurgeons.

Object: The role of residents in surgery is not clearly explained to patients. The authors undertook a study to explore the level of knowledge and anxiety in patients regarding residents' involvement in their surgery., Methods: Qualitative case study methodology was used. Thirty face-to-face interviews of patients were conducted prior to elective neurosurgery. Interviews were transcribed and subjected to modified thematic analysis by 4 reviewers. The majority of patients had a postsecondary education, and there was substantial religious and ethnic diversity among them. Most underwent craniotomy for brain tumor., Results: Six prominent themes arose from the analysis: 1) the level of knowledge about residents is low; 2) the level of anxiety about residents is low; 3) it is desirable for patients to meet the residents before surgery; 4) residents' educational needs are understood and supported; 5) anxiety was not increased by the interview; and 6) patients trust in the medical system., Conclusions: Patients appear to be unaware of the role of residents in their surgical care but do not seem anxious about it. Trust in the medical system helps patients proceed with risky operations. Surgeons could be more forthcoming with patients about the role of residents.

We prospectively studied headache characteristics during 6 months after craniotomy performed for treatment of cerebral aneurysms in 79 patients. Semistructured interviews, headache diaries, the Hospital Anxiety and Depression Scale and the Epworth Sleepiness Scales, the Short Form-36 Health Survey (SF-36) and McGill Pain Questionnaire were used. Seventy-two patients had headaches, half before the fifth day after surgery. Changes were observed in headache diagnosis, side and site in the postoperative period. Headache frequency increased immediately after surgery and then decreased over time. Headache frequency was associated with depressive and anxiety symptoms. Pain intensity was higher in women and in patients with more anxiety symptoms. An incidence of post-craniotomy headache of 40% was observed according to International Headache Society classification criteria, 10.7% of the acute and 29.3% of the chronic type. The bodily pain domain of the SF-36 was worse in patients with more anxiety symptoms. Greater frequencies of headache were associated with lower scores on bodily pain and social functioning.

Objective: To present our method for excision of complex anterior skull base tumors via combinations of the subcranial approach., Patients: Of 120 anterior skull base tumor resections, 41 that included 27 (66%) malignant and 14 (34%) benign lesions were performed via combinations of the subcranial approach. Unilateral or bilateral medial maxillectomy was performed using the subcranial approach alone for 13 tumors infiltrating the anterior skull base, ethmoid bones, and medial maxillary wall. A combined subcranial-transfacial approach in 2 lesions or a combined subcranial-midfacial degloving approach in 14 lesions was performed for tumors involving the skull base and the lower or lateral segments of the maxilla. A combined subcranial-transorbital or transfacial-transorbital approach was used for 5 tumors invading the orbit. An extended subcranial-orbitozygomatic approach was used for 6 tumors invading the middle cranial fossa or involving the cavernous sinus. A combined subcranial-Le Fort I down-fracture approach was used for 1 dedifferentiated chordoma invading the anterior skull base and lower clivus. The surgical results, patient quality of life, survival, and complications were measured., Results: Thirty-seven of 41 tumors (90%) were completely resected. Fifteen patients (35.5%) had perioperative complications. There were no postoperative deaths. Two-year overall and disease-free survival in patients with malignant tumors who underwent combined approaches was 66% and 60%, respectively. There was no significant difference in the quality of life between patients operated on via combined or classic subcranial approaches., Conclusion: Combinations and modifications of the subcranial approach for excision of complex anterior skull base tumors yield surgical results, survival, quality of life, and complications similar to those found with the classic subcranial technique.

This is a descriptive study that evaluates the quality of live (QOL) of road accident head-injured patients after craniotomy. It investigates the relationship between the independent variables of demographic data, health, and social and economics and four aspects of participants' QOL, satisfaction, perception, health, and social and economics. The ninety participants in the study were patients with head injuries resulting from involvement in road accidents who were attending a neurological clinic at Sapasithiprasong Hospital, Ubon Ratchathani, Thailand. Data was collected by participants completing a questionnaire. Results showed most participants had high QOL after craniotomy in satisfaction, life perception, health, and social and economics. There were negative relationships between QOL and duration of hospital stay, medical complications, and levels of disability. The study indicates the need for efficient postoperative care of head-injured patients to return them quickly to their daily lives.

Background: Awake brain tumour surgery allows intraoperative patient assessment and is done to optimise safe tumour removal. It is an established technique but little is known about patient perceptions of the procedure., Method: Fifteen adult patients filled out a dedicated questionnaire to assess 10 aspects of patient perceptions of the procedure., Findings: All patients, who were awake for a median of 45 minutes (range 10-105), stated they were adequately prepared for the operation. Most recollected various aspects of the procedure, although 3 patients (20%) had little memory of actually being awake during the surgery despite being cooperative. A minority reported more than minor discomfort (20%), fear (15%) or anxiety (29%), and most felt they coped with the cortical stimulations and functional testing well. Sources of discomfort and pain were the cranial pin holding device, operative position, inadequate infiltration of the cranial wound with local anesthetic, a full bladder causing a desire to micturate and a hard and uncomfortable operating table., Conclusions: These results, are very similar to a previous American report using a different anesthetic technique, in that most patients tolerate awake craniotomy remarkably well if the procedure is explained to them and some simple precautions are taken. Additionally between 8%-37% of patients (95% Confidence Interval, summing data from the two studies, n = 35) will have no recollection of being awake. Ways of minimising discomfort and problems of anxiety in this patient cohort are discussed.