Maximizing Tumor Resection and Managing Cognitive Attentional Outcomes: Measures of Impact of Awake Surgery in Glioma Treatment

Background and objectives: Patients with gliomas often experience neuropsychological deficits affecting their quality of life. Awake surgery (AwS) can reduce permanent cognitive deficits compared with asleep surgery (AsS), but it does not allow intraoperative mapping of all cognitive functions, including attention. Understanding how AwS and AsS affect attention is crucial, given its pivotal role in supporting various cognitive functions. Methods: We conducted a retrospective analysis on 64 glioma patients treated with AwS or AsS. Attention was assessed with visual search tasks and Trail Making Test Part A before and 1 week and 1 month after surgery. Volumetric T1-weighted and T2/Fluid Attenuated Inversion Recovery MRI sequences before and after surgery were used to delineate the lesion and the surgical cavity. The extent of resection was calculated to determine supramaximal resection for both contrast-enhanced and non-contrast-enhanced tumor regions. Results: There was a significant decrease in attentional scores 1 week after surgery, followed by a complete recovery. AwS was the only significant predictor of postoperative attentional deterioration. Univariate lesion analysis revealed negative association between lesions in the default mode network and postoperative attentional scores, whereas a multivariate network approach highlighted the involvement of several large-scale functional systems in sustaining attentional processes. AwS patients exhibited more extensive supramaximal resections of non-contrast-enhanced areas, which correlated with immediate postoperative attentional deterioration. The Kaplan-Meier analysis showed significantly longer overall survival for AwS patients with isocitrate dehydrogenase wild-type glioblastomas (mean days = 887.73) compared with AsS patients (mean days = 553.71; P < .05). Conclusion: Although AwS enables a more extensive resection and thus an improved oncological outcome with longer overall survival rate, it also leads to higher transient postoperative decline in attentional performance. These results emphasize the need for careful patient selection, especially for lesions that involve anterior anatomical regions of the left default mode network. Future developments of standardized, reliable, and quantitative intraoperative monitoring of attention may further optimize surgical outcomes.