Abstract Body (Do not enter title and authors here): Background: Awake craniotomy for ruptured and unruptured intracranial aneurysms poses distinct neurovascular challenges. Identifying key barriers and strategies is essential to improve outcomes, yet current evidence is limited, underscoring the need for systematic evaluation.
Research Questions: What are the main barriers and strategies in the neurovascular care of ruptured and unruptured intracranial aneurysms during awake craniotomy?
Methods: A systematic search was conducted on May 5, 2025, in PubMed, Scopus, Embase, and Web of Science, without language restrictions. This was supplemented by gray literature identified from reference lists and the first 10 pages of Google Scholar. The review followed PRISMA 2020 guidelines, and study quality was assessed using the Newcastle-Ottawa Scale (NOS). Two trained reviewers independently screened studies after pilot training. Data synthesis was descriptive.
Results: The final analysis included 12 observational studies with 119 patients (58.4% unruptured, 25% ruptured, 8.3% mixed, and 8.3% unreported status), primarily in adults(91.7%) at university hospitals (75%). All cases reported "good" surgical outcomes, though 33.3% had transient or permanent sequelae. The most prevalent barriers were intraoperative patient discomfort (50%), anesthetic management challenges (41.7%), and lack of specialized training or advanced equipment (25%). Successful strategies included multidisciplinary team collaboration (58.3%), real-time functional monitoring via awake testing (100%), and intraoperative ultrasound (33.3%). Studies originated from the USA (41.7%), Europe (25%), and Asia (16.7%), revealing geographic disparities in resource availability. These findings demonstrate the procedure's feasibility while highlighting the need for standardized protocols to address technical and logistical challenges. Study quality assessed by tool NOS revealed: High quality (33.3%), Moderate quality (50%), and Low quality (16.7%).
Conclusions: Awake craniotomy is a feasible and promising approach for managing intracranial aneurysms. However, its widespread adoption is hindered by significant implementation barriers. Further high-quality studies are needed to validate current strategies, evaluate outcomes, and ensure their safe integration into neurovascular care.