Authors: Cabral J et al.
Cureus, 18(1): e101278, January 2026 DOI: 10.7759/cureus.101278
Summary
This case report describes the anesthetic and multidisciplinary management of an awake craniotomy performed in a 12-year-old boy with recurrent left parietal ganglioglioma causing drug-resistant epilepsy. The lesion was located near eloquent language cortex, prompting selection of an awake approach to maximize tumor resection while preserving neurological function. Although awake craniotomy is well established in adults, its use in children remains uncommon because of concerns regarding cooperation, anxiety, and airway and anesthetic management.
Extensive preoperative preparation was central to success. The patient underwent detailed neuropsychological assessment confirming intact baseline cognitive and language function, and he was familiarized with the operating room environment and surgical process. A multidisciplinary team, including anesthesiologists, neurosurgeons, neuropsychologists, and neurophysiologists, was present throughout the procedure.
An asleep–awake–asleep anesthetic technique was used. Induction and initial surgical phases were managed with propofol and remifentanil using target-controlled infusions, with the airway secured via a supraglottic device. Analgesia at pin sites and incision was achieved with local anesthetic infiltration rather than a formal scalp block. During the awake phase, dexmedetomidine infusion provided anxiolysis and sedation without respiratory depression, allowing removal of the supraglottic device and maintenance of spontaneous ventilation.
Cortical language mapping was performed using direct cortical stimulation while the patient engaged in structured neurocognitive tasks. The child remained calm, cooperative, and interactive during an extended awake phase of nearly four hours, enabling reliable identification of language areas and guiding safe tumor resection. No seizures, airway complications, or hemodynamic instability occurred. Following resection, anesthesia was re-induced, and surgery was completed uneventfully.
Postoperatively, the patient demonstrated no neurological, cognitive, or psychological deficits. He was discharged home on postoperative day seven and remained seizure-free at one-year follow-up. The report demonstrates that with appropriate patient selection, meticulous preparation, and modern neuroanesthetic techniques, awake craniotomy is feasible and safe even in carefully selected pediatric patients.
Key Points
• Awake craniotomy can be successfully performed in selected pediatric patients
• Preoperative neuropsychological evaluation and psychological preparation are critical
• Asleep–awake–asleep technique with dexmedetomidine facilitated cooperation without respiratory compromise
• Reliable language mapping was achieved during a prolonged awake phase
• Excellent neurological and seizure outcomes were observed at one year
What You Should Know
For anesthesiologists, this case highlights that pediatric awake craniotomy is not limited by age alone but by preparation, communication, and multidisciplinary coordination. Dexmedetomidine-based sedation during the awake phase offers a favorable balance of anxiolysis, analgesia, and preserved ventilation, making it particularly valuable in children. In experienced centers, awake techniques may expand surgical options for pediatric patients with lesions near eloquent cortex while minimizing long-term neurological morbidity.
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