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Awake Craniotomy

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An awake craniotomy is exactly what it sounds like: open brain surgery, with a part of the skull removed and a neurosurgeon operating on the brain, while a patient is awake. It’s performed when the surgical team will be operating on an area of the brain that is “eloquent,” meaning a section that controls critical functions such as language and cognition. Before cutting into eloquent cortex (to remove a tumor or make a vascular repair, for example) the neurosurgeon needs to find a safe path from the surface of the brain to the target area. Keeping the patient awake and responsive is the way to ensure the patient doesn’t suffer neurological deficits as a result of the surgery.

The patient is under light anesthesia for the scalp incision and the bone removal, then awakened for the next stage. With the skull section removed and the brain exposed, the surgical team passes an electrical current through different areas to find a suitable point of entry. The electrical current stuns and temporarily disables a specific area of the brain, mimicking what would happen if the surgeon were to cut in that area. That allows the surgical team to test a path first before cutting, to make sure that disabling that specific part of the brain doesn’t affect critical functions.

A video message from a patient who underwent an awake craniotomy with Dr. Stieg:

“Many people are surprised to learn that there are areas of the brain that can be removed or cut with no noticeable effects,” says Dr. Philip Stieg, chair of the neurosurgery department and an expert in awake craniotomies. “The human brain is remarkable in that it has many more nerve cells than needed. In many sections you can safely make the kinds of tiny cuts required for surgical access and the brain compensates for those cuts with no perceptible damage. Other areas are what we call ‘eloquent’ – they affect speech and language, sensory function, and motor skills– and we don’t want to cut there.”

It’s up to the neuropsychologists in the surgical suite to assess the patient’s cognitive, motor, and language abilities. “There’s a very specific paradigm of tests that we administer because different language abilities live in different areas of the brain,” says Dr. Heidi Bender, director of neuropsychology services. “We always ask the patient to talk, to say the days of the week, months of the year. Or we have them count. We also make sure they can name things.”

The neuropsychologists spend time with the patient during prep before surgery, so they become familiar with the patient’s normal speech before it is affected by anesthesia or the surgery itself. By establishing the patient’s baseline, the neuropsychologists can better evaluate any changes that occur during the testing with electrical currents.

If the patient shows deficits when a particular area of the brain is tested, the neuropsychologist tells the neurosurgeon that path is not safe. The neurosurgeon then tests the next area, and the language tests are repeated. When the patient is able to speak normally with a section of the brain undergoing current, the path is deemed safe and the surgeon begins. The patient remains awake for the duration of the surgery while the neuropsych team keeps them talking for continuous monitoring during the procedure.

After the surgery is completed, the patient is put back under light anesthesia for the skull replacement and closure.  

Two patients who had awake craniotomies tell their stories:

“Listen to Someone Who’s Been Through It” – A Cav-Mal Story

"I Was Awake During My Brain Surgery"

Dr. Stieg and Dr. Rohan Ramakrishna talk about awake craniotomies during this episode of This Is Your Brain, the podcast:

Listen to Dr. Stieg with host Kate Delaney on America Tonight as he talks about awake craniotomies.

More about Dr. Stieg
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