Awake craniotomy in a patient with ejection fraction of 10%: considerations of cerebrovascular and cardiovascular physiology

•An unique case: A 37-year-old man with nonischemic 4-chamber dilated cardiomyopathy and low-output cardiac failure (estimated ejection fraction of 10%), a candidate for cardiac transplantation, underwent awake craniotomy for a low-grade oligodendroglioma resection under monitored anesthesia care.•Educational: The unique challenges and key points of management pertinent to cerebrovascular and cardiovascular physiology are discussed.•The relationship between cardiac output and cerebral blood flow is discussed.•The management of systemic hemodynamics including arterial blood pressure and cardiac output is discussed.•The rationale behind the management of red blood cell transfusion is presented.•All clincial decision-making processes are presented.

A 37-year-old man with nonischemic 4-chamber dilated cardiomyopathy and low-output cardiac failure (estimated ejection fraction of 10%) underwent awake craniotomy for a low-grade oligodendroglioma resection under monitored anesthesia care. The cerebrovascular and cardiovascular physiologic challenges and our management of this patient are discussed.