Introduction: Cost effectiveness has become an important factor in the healthcare system, requiring surgeons to improve efficacy of procedures, while reducing costs. An awake craniotomy (AC) with direct cortical stimulation (DCS) presents one method to resect eloquent region tumors, however, some authors assert that this procedure is an expensive alternative to surgery under general anesthesia with neuromonitoring (GA). Here we evaluate the cost effectiveness and clinical outcomes between the two groups.

Methods: Retrospective analysis of a cohort of 17 patients with perirolandic gliomas who underwent an awake craniotomy with DCS, by a single-surgeon at a single-institution, were case-control matched using SPSS with 23 patients with perirolandic gliomas who underwent surgery under general anesthesia with neuromonitoring (i.e. motor-evoked potentials,MEP; somatosensory-evoked potentials,SSEP; phase-reversal). Inpatient costs, quality adjusted life years (QALY), extent of resection (EOR), and neurological outcome were compared between the groups.

Results: Total inpatient expense per patient was $34,804 in the AC group and $46,798 in the GA group (p=0.046). QALY score for the AC group was 0.97 and 0.47 for the GA group (p=0.041). The incremental cost per QALY for the AC group was $82,720 less than the GA group. Postoperative karnofsky performance status (KPS) was 91.8 in the AC group and 81.3 in the GA group (p=0.047). Length of hospitalization was 4.12 days in the AC group and 7.61 days in the GA group (p=0.049).

Conclusions: The total inpatient costs for awake craniotomies were found to be lower than surgery under general anesthesia. Despite the trend of higher operating room costs for awake craniotomies, this expense was offset by the better postoperative status and shorter hospitalizations in AC patients. This study shows better cost effectiveness and neurological outcome with awake craniotomies for perirolandic gliomas.

Patient Care: This study provides a novel cost analysis for awake versus asleep craniotomies that will allow surgeons to choose the most safe and cost effective surgical strategies for their patients with eloquent gliomas.

Learning Objectives: 1)To determine the cost-effectiveness of awake craniotomies versus surgery under general anesthesia for eloquent region gliomas 2)To understand the impact of awake craniotomies and asleep craniotomies on quality of life in the patient population with an eloquent region tumor 3) To understand the postoperative clinical outcomes, regarding extent of resection and neurological outcomes, between an awake craniotomy and surgery under general anesthesia

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