Efficacy and safety of anesthetic agents in awake craniotomy using monitored anesthesia care protocol: a systematic review and meta-analysis.

Awake craniotomy (AC) facilitates real-time brain mapping, maximizing tumor resection while preserving critical neurological functions. This study systematically reviews the efficacy of several anesthetic protocols under Monitored Anesthesia Care (MAC) during AC, focusing on clinical outcomes. A systematic review and meta-analysis were conducted using data from observational studies and randomized trials involving AC under MAC. Databases searched included PubMed, Embase, and Web of Science. The analysis employed mixed-effects models to assess both the overall rate of the outcomes and the impact of anesthetic agents on clinical outcomes. The primary outcome was the rate of postoperative neurological deficits. Of 468 studies initially identified, 26 met the inclusion criteria. The overall adverse event rate was 23.7%. The pooled proportion of patients with postoperative neurological deficits and intraoperative seizures was 10.45% and 8.8%, respectively. Remifentanil use was associated with a lower risk of neurological deficits in mixed effects meta-analysis (6.9% vs 16.5%), while intraoperative seizure rate was slightly lower with propofol use (7.1% vs. 11.8%). Midazolam use was also associated with lower agitation (5.5% vs. 10.9%). The rate of secondary adverse outcomes other than hypertension (10.2%) and tense brain (10%) were below 10% and comparable to the previous literature. The findings highlight the variability in anesthetic protocols used in MAC for AC. Despite limited evidence regarding safety concerns and potential confounders, Remifentanil, Propofol, and Midazolam appear to be superior to other agents evaluated in these procedures. However, further research is required to draw definitive conclusions.