Awake craniotomy for brain tumors

Imagine being able to talk to your doctors during brain tumor surgery without pain and give them immediate feedback while they operate.  That’s exactly what happens during an awake craniotomy.

A craniotomy is a type of Micro surgery where a small piece of the skull is temporarily removed to access the brain. In an awake craniotomy, the patient is gently woken up during surgery.

This highly specialized surgical procedure requires a team approach led by an experienced neurosurgeon and a neuroanesthesiologist. To learn more, we spoke to neurosurgeon Dr Prem Pillay from the Singapore  Brain Spine Nerves Center.


Awake craniotomy for brain tumors

What’s the benefit of being awake during brain tumor surgery?

Our goal is to remove as much of the tumor as possible, as safely as possible. When a tumor is near an area of the brain that controls critical functions — such as speech, language or movement — an awake craniotomy is the best way to identify and safely preserve those abilities.

We know where certain functions are generally located on the brain’s surface. But below the surface, bundles of nerves pass through the brain to the spinal cord and throughout the body. We have to map these nerves to understand which ones are connected to key functions, so that we can avoid them as we remove the tumor. Damaging critical nerves could cause permanent disability.

We also use other tools to map the brain including Computer aided Neuro Navigation of the Brain, but mapping nerves during an awake craniotomy is the only way to obtain immediate feedback during surgery.

Which patients are candidates for awake craniotomies?

Awake craniotomies are frequently — but not always — used for gliomas (including glioblastoma, astrocytomas and oligodendrogliomas),
ependymomas ,Neurocytomas and some Brain metastases. These brain tumors especially the Gliomas occur at the frontal and temporal
lobes, which control speech and motor function. The patient also has to feel comfortable with the idea of waking up during surgery. A
patient with severe symptoms may not be able to effectively contribute to the neurological exams during surgery. A neuropsychological
evaluation can help determine if the patient has deficits or would be a good candidate for this procedure.

How is it possible to wake up during brain surgery without feeling pain?

Brain tissue doesn’t have any pain fibers, so while you may feel pressure or vibrations from the surgery, you shouldn’t feel pain. We use a local anesthetic (similar to those used at a dentist’s office) to numb the muscles, skin and bone that the surgeon has to cut through to get to the brain.

What should I expect when I wake up during surgery?

When you wake up, you’ll hear the neuroanesthesiologist reassuring  you. You won’t be able to move your head, but the neuroanesthesiology team will make you as comfortable as possible and stay with you the entire time.

How long will I be awake?

You could be awake for 45 minutes to several hours, depending on how big your tumor is, where it’s located and the type of symptoms you had
before surgery.

What happens while I’m awake?

While you’re awake, you’ll be an essential participant in the most critical part of the surgery. You’ll help map your own brain function through a series of simple neurological exams. The neurosurgeon will stimulate part of your brain near the tumor by sending a light electrical current down the central nervous system. At the same time, the Neuro Psychologist /neuroanesthesiologist will give you some simple verbal tasks to see if the stimulation affected your
neurological function.

For example, you may be shown flashcards with common objects. If you suddenly can’t name an object or can’t get any words out at all, the neurosurgeon will know the area they’ve stimulated is connected to a critical speech area.

Even when you’re not actively mapping, you’ll talk to the neuroanesthesiologist and neurosurgeon, who are in constant communication throughout the surgery. This is important for ensuring a safer surgery, with the best possible outcomes.

When will you put me back to sleep?

We’ll put you back to sleep after we’ve collected as much helpful  information as possible from the neurological exam. You’ll be asleep as the incision is closed, and you’ll wake up again when the Brain Micro surgery is completely over.

How can I prepare for an awake craniotomy?

Before surgery, you’ll meet with the neurosurgeon, neuro psychologist and neuroanesthesiologist. We’ll explain what to expect and answer your questions. We’ll take time to get to know you and learn what’s important to you. This will help us personalize your neurological exam and talk about things you care about during surgery, which will help you stay awake and actively participating in the mapping process longer. It’ll also help us build trust, which is important for a
surgical procedure like this. We’re most likely to get the best possible outcome when you feel safe, supported and fully engaged. So don’t be afraid to ask questions and share your concerns at your initial appointment and while you’re awake during your craniotomy.

MD Anderson Cancer Center : Awake Craniotomy information
Cleveland Clinic Brain Tumor Center : Awake Craniotomy information/Protocols
Singapore Brain Spine Nerves Center : Awake Craniotomy Protocol