Dr. Amitabha Chanda – Senior Consultant, Neurosurgery (Brain & Spine), Narayana Hospital RN Tagore Hospital, Mukundapur
Awake brain surgery, also known as awake craniotomy, represents a significant advancement in neurosurgical techniques, offering a beacon of hope for patients with specific neurological conditions such as brain tumors and epileptic seizures. It is well known that conventional brain surgeries are conducted under general anesthesia. Awake brain surgery is a revolutionary procedure as it avoids general anesthesia and performed while the patient is awake and alert.
Iatrogenic injury, or injury caused by treatment, has long been a challenge for both patients and doctors, particularly in the delicate realm of brain surgery. Operating on brain tumors poses considerable risks, primarily due to the potential damage to surrounding intact tissues. Conducted under local anesthesia, this procedure intentionally keeps the patient conscious during some or all of the surgical process, a critical measure to preserve the eloquent functions of the cerebral hemispheres.
The presence and active participation of the patient during the surgery allow the surgeon to receive real-time feedback. This guidance ensures that the surgeon can precisely target the area of the brain requiring treatment while minimizing the risk of damaging functional areas crucial for vision, movement, or speech. By lowering the risk of postoperative deficits, awake brain surgery not only enhances the safety and efficacy of the procedure but also significantly improves the patient’s quality of life post-surgery.
The patient’s responses during awake brain surgery guide the surgeon to ensure precise treatment of the targeted brain area. This approach significantly reduces the risk of damaging functional regions responsible for vision, movement, or speech. When removing a tumor or a brain section causing seizures, it is crucial for the surgeon to avoid impairing areas that control language, speech, and motor skills. Pre-surgical pinpointing of these areas can be challenging, but awake brain surgery allows the surgeon to identify and preserve them accurately.
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The neurosurgeon will first determine if awake brain surgery is suitable for the patient. Thorough counseling is essential, as doctors will explain what to expect during the procedure, along with its benefits and risks.
Awake brain surgery offers numerous advantages. Patients with brain tumors or seizure centers (epileptic foci) near critical brain tissue, previously deemed inoperable, may now consider this procedure to minimize complications and the risk of damaging functional brain regions. By safely reducing the size of growing brain tumors, awake brain surgery can prolong life and enhance quality of life.
Nevertheless, awake brain surgeries are not completely risk free. Some of the risks include bleeding, brain swelling, infection, brain damage, or even death. Other possible surgical complications include seizures, muscle weakness, and issues with memory and cognitive functions.
An anesthesia specialist (anesthesiologist) will give the patient some medication to make the patient sleepy for parts of awake brain surgery. The neurosurgeon will apply numbing medications to scalp to ensure comfort. During the procedure, doctors place the head in a fixed position to keep the head still and ensure surgical accuracy. The surgeon then removes part of the skull to reach the brain. The patient may be sedated and sleepy while part of the skull is removed in the beginning of the surgery, and when doctors reattach the skull at the end of the surgery. During the surgery, the anesthesiologist will stop administering the sedative medications and allow the patient to wake up.
If the brain tumor or epileptic focus is near regions that control vision, speech, or movement, the neurosurgeon will perform brain mapping. This technique creates a detailed map of the brain centers responsible for these functions. Additionally, the neurosurgeon can conduct deeper brain mapping during the surgery to ensure precise targeting and avoid damaging critical areas.
The neurosurgeon uses this map to avoid damaging critical areas and preserve essential functions. Combined with 3D computer imaging, brain mapping enables the neurosurgeon to safely remove as much of the brain tumor or epileptic focus as possible while minimizing the risk of impairing vital body functions
During surgery, the neurosurgeon may ask the patient questions or ask to identify pictures and words on cards or computer. Based on the responses, the neurosurgeon will identify and avoid the functional areas in the brain. The surgical team also uses detailed 3-D computer images of the patient’s brain taken before the surgery, including computer-assisted brain surgery, to guide removal of as much of the brain tumor or epilepsy focus as possible. The anesthesiologist and surgical team carefully monitor and assess the body and brain functions.
After the surgery, ppatients usually stay in the intensive care unit for a period before spending three to four days in the hospital. Recovery time varies, but many can return to work and normal activities within six weeks to three months, with ongoing follow-up care based on their specific condition. In cases where awake brain surgery is performed for epilepsy, many patients see significant improvements, with some becoming seizure-free and others experiencing fewer seizures. Regular monitoring and potential radiation treatment, depending on biopsy results, ensure comprehensive post-operative care.
Awake brain surgery represents a significant advancement in neurosurgical techniques, offering hope to patients with brain tumors or epileptic foci near critical brain areas. By reducing complications and enhancing the quality of life, awake brain surgery has become a viable option for conditions once deemed inoperable.
