Awake craniotomy and language assessment in deaf patients: a systematic review of feasibility, communication strategies, and outcomes.

INTRODUCTION: Awake craniotomy (AC) relies on effective intraoperative communication for functional brain mapping and is often excluded in patients with hearing impairment. This exclusion is largely based on theoretical concerns rather than empirical evidence. This systematic review aimed to critically evaluate the feasibility, communication strategies, and reported neurological outcomes of AC in patients with hearing impairment. METHODS: A systematic search of PubMed, Scopus, and Web of Science was conducted from inception to December 2025 in accordance with PRISMA guidelines. Only English-language studies reporting AC in patients with hearing impairment were included. Data were extracted on patient characteristics, communication strategies, intraoperative mapping paradigms, and postoperative neurological outcomes. RESULTS: Eight single-center case reports published between 2017 and 2025 were included, comprising eight individual adult patients (5 males, 62.5%; mean age 55.57 ± 11.75 years, range 45–75). Seven patients (87.5%) used sign language-based intraoperative communication supported by professional interpreters, while one patient used a bone-conduction voice amplifier. Language mapping was reported in seven cases. No included report described intraoperative communication failure or conversion to general anesthesia; however, adverse event reporting was inconsistent across studies. Gross total or near-total resection was reported in three cases (37.5%). No permanent new postoperative neurological deficits were described, although follow-up duration and outcome reporting were heterogeneous. CONCLUSIONS: The available literature is limited to isolated case reports and provides very low-quality evidence. While these reports suggest that awake craniotomy can be technically feasible in highly selected hearing-impaired patients using individualized communication strategies, the findings are not generalizable and should be interpreted as hypothesis-generating. This review primarily highlights conceptual feasibility, identifies critical knowledge gaps, and proposes directions for future research rather than establishing safety or equivalence to standard AC populations. CLINICAL TRIAL NUMBER: Not applicable.