Abstract
Background: Low- (LIC) and Lower-Middle Income Countries (LMIC) are presented with unique challenges and opportunities when performing awake craniotomy (AC) for brain tumors. These circumstances arise from factors that are financial, infrastructural, educational, personnel, and socio-cultural in nature.Methods: We performed a systematic narrative review of series on AC for intra-axial brain tumors in LIC/LMIC using PRISMA guidelines, focusing on the challenges and opportunities in these settings. The PubMed, Scopus, and Web of Science databases were searched.Results: After initially identifying 74 studies, inclusion-exclusion criteria were applied, leaving a total of 14 studies included in the review. These involved 409 patients who underwent AC in LIC/LMIC. These series were from India, Ghana, Nigeria, Iran, Pakistan, Morocco, the Philippines, and Egypt. The most common pathology encountered were gliomas (10-70%). Most studies (11/14, 78.5%) reported on their technique of cortical-subcortical mapping. All reported on motor mapping and 8 of these performed language mapping. The most common outcomes reported were seizure and neurologic deficits, and longest follow-up was at 1 year. Challenges noted were lack of equipment and trained personnel, need for validated tests for the local setting, and sociocultural factors. Opportunities identified were volume for training, technique innovation, and international collaboration.Conclusion: There are numerous challenges and opportunities that arise when performing AC in LIC/LMIC. A collaborative approach towards harnessing the opportunities, and seeking creative solutions to address the challenges, would provide an ideal mechanism towards advancing neurosurgical care and specialty worldwide.