AC has become routine in the armamentarium of modern neurosurgical clinics. Also, the combination of AC and ioMRI scanning has become routine in specialized centers. Long-term follow-up of patients will show whether this additional burden on the patients and the surgeon and their team, as well as the increased surgical time (also related to increased cost), is warranted by longer survival and higher quality of life, as would be expected, a question that can only be solved by careful data pooling and multicenter studies. It has been suggested by some surgeons to perform awake surgery for nearly all brain tumor patients in order to save money on anesthesia costs, and then discharge the patient the day after surgery.

The high number of patients in our series who agreed to undergo repeat AC for recurrent glioma shows the “comfort” that they had experienced during the first operation and that they were able to balance the benefit of surgery in the awake state against the psychological discomfort, despite the psychological burden [10]. It needs to be stressed that discomfort during a second AC is worse than that during the first AC, since, in most instances, the dura is firmly attached to the bone flap, which causes pain at operation even if one adds what would be considered a sufficient amount of local anesthetic around the scar. Also, the patient is usually more attentive, since they are more experienced with what could happen and they try to compare the first and second surgeries. Another possibility of reducing the discomfort during a second surgery would certainly be to use more propofol during the initial steps of the surgery. This, however, would prevent the patient from being completely awake when they need to be tested. Furthermore, it has been our experience that surgery, even if smoothly performed, needs to be finished rapidly, because the patient’s cooperative capacity is not endless [9].