The Remarkable Reality of Awake Brain Surgery
Imagine answering questions in one of the five languages you are fluent in or playing your guitar while undergoing brain surgery. As you provide the Armenian word for “puppy” or strum out the tune to a well known pop song, a team of surgeons is meticulously mapping out your brain functions. No, this isn’t science fiction or your worst nightmare. It’s the remarkable reality of awake brain surgery or awake craniotomy, a procedure that offers incredible insights and improved outcomes for patients with brain tumors and other neurological conditions. And it is exactly what patients Ani and Robert did while doctors operated on their brains.
An awake craniotomy involves removing a piece of the skull to access the brain. But what sets this procedure apart is that the patient is woken up during the surgery, allowing the surgical team to communicate with the patient and map out critical brain functions in real-time. This approach is particularly beneficial when tumors are near areas of the brain that control essential functions like speech, language, and movement as surgeons are able to ask the patient questions and monitor the brain’s activity as they respond.
In this article, we’ll explore the history of brain surgery, explain what awake craniotomies are and why they are performed, and share some fascinating examples of these groundbreaking procedures.
The Evolution of Brain Surgery
The history of brain surgery dates back thousands of years. Evidence has shown that ancient civilizations from around the globe from Peru to France to China, as well as various parts of Africa and the Middle East, practiced trepanation, where holes were cut, scraped, sawed or drilled into the skull to treat head injuries and neurological conditions. Most trephined skulls that have been discovered by archeologists come from long vanished non-literate cultures, making it difficult to know the exact motivation for the procedure. However, information has been uncovered about trephining in Western medicine beginning in the fifth century BCE.
While rudimentary and often dangerous, some argue that this early form of brain surgery laid the groundwork for modern neurosurgical techniques. Over centuries, advancements in medical knowledge and technology have transformed brain surgery into a precise and life-saving field.
Awake craniotomies have been performed on epilepsy patients for decades. Surgeons kept patients alert to ensure they were targeting the correct brain tissue to alleviate seizures. With the advent of advanced brain-mapping technology and sophisticated anesthetics, in addition to epilepsy, this procedure has become more widely used for various types of brain tumors and spinal cord injuries. The ability to interact with patients during surgery helps surgeons perform more precise, less damaging procedures.
The Procedure and Preparation for Awake Craniotomy
Preparation for an awake craniotomy involves thorough consultations with the neurosurgeon and neuroanesthesiologist. Patients are briefed on what to expect and are encouraged to ask questions and express any concerns. Building a rapport is essential for a smooth surgery.
Doctors get to know their patients well before surgery which helps them to tailor the neurological exams and ensures that patients feel safe, supported, and fully engaged during the procedure.
During the surgery, patients wake up and perform tasks that help map their brain’s functions. They might be asked to name objects, count, or describe images. The surgical team monitors their responses to ensure they avoid damaging critical areas.
With today’s techniques, Dr. Harbaugh, director Penn State’s neuroscience institute president of the American Association of Neurological Surgeons, noted that waking a patient and putting them back to sleep is almost like flipping a light switch, giving surgeons the flexibility to gather critical information without causing undue stress to the patient.
In their interview from 2018, Dr. Jeffrey Weinberg, a neurosurgeon, and Dr. Shreyas Bhavsar, a neuroanesthesiologist from MD Anderson Cancer Center, explained that the primary benefit of an awake craniotomy is the ability to remove as much of a brain tumor as possible while preserving essential functions. While doctor’s are aware of the general location of certain brain functions on the brain’s surface it becomes more complicated below the surface where there are bundles of nerves that pass through the spinal cord and the rest of the body. As a result, these nerve bundles must be mapped during surgery to understand which ones are connected to key functions so as to avoid them as damaging them could cause permanent disabilities. By awakening the patients during surgery, doctors receive immediate feedback as they are operating, providing invaluable data in addition to that obtained using other mapping techniques.
You might be wondering whether this causes the patient any pain but you can rest assured that it does not. Brain tissue itself doesn’t have pain fibers, so patients feel no pain when their brain is stimulated. They might feel pressure or vibrations, but a local anesthetic numbs the muscles, skin, and bone.
Awake surgery makes it possible to identify exactly where critical functions such as speech are located, ensuring that these areas are not damaged as the tumor is removed. This level of precision is crucial for maintaining the patient’s quality of life post-surgery.
Case Studies: Real-Life Experiences with Awake Craniotomy
Ani, a multilingual woman, had a cavernoma—a cluster of malformed blood vessels—in a critical area of her brain, right next to the areas that control movement and language. Her neurosurgeon, Dr. Gloria Villalba, a renowned doctor from Barcelona who has performed more than 5,000 brain surgeries over the course of her career, needed to remove it while ensuring Ani’s ability to speak five languages remained intact.
During the surgery, Dr. Villalba and her team used miniature flags to mark where each language—Armenian, Russian, Spanish, English, and French—was processed in Ani’s brain. This meticulous mapping was crucial because even a slight error could impair her linguistic abilities permanently which were essential to her career. During the procedure, Ani participated in various tasks, like counting and naming objects in all five languages. These tests ensured the surgeons avoided critical language areas while removing the cavernoma. How, you might wonder? Well, whenever she was asked a question and her response was delayed or she couldn’t respond at all, the surgical team knew they were close to a risk area and placed a tiny flag there to indicate that it was an area to be avoided. She also helped researchers by analyzing pictures of facial expressions to study how the brain processes emotions.
Ani’s case was exceptionally complex for the surgical team due to the involvement of five languages. Larger areas of her brain were dedicated to linguistic tasks, giving the team a tighter margin to remove the lesion safely. However, after completing various exercises over the course of two hours, the doctors were able to map an extremely narrow but viable route through which to extract the cavernoma.
After six hours of intricate work, Dr. Villalba successfully removed the cavernoma. The procedure was a success, but the journey for Ani was far from over. Recovery would be a long and challenging process.
Post-surgery, Ani faced both physical and linguistic challenges. She maintained her five languages, but speaking them didn’t come as easily as before. However, she remained optimistic about her full recovery.
Brittany is another example. At 24 years old, she underwent an awake craniotomy to remove a tumor near her brain’s speech center. Her surgeon Dr. Philip Gutin needed her awake to ensure he could remove the tumor without affecting her ability to talk. As you can imagine, she was worried that she might feel something but, later when asked about her experience, she noted that it was more intriguing than scary and that she hadn’t felt a thing.
The Future and Expanding Applications of Awake Craniotomy
The principles of awake craniotomy are expanding beyond brain surgery. Surgeons performing head, neck, and spinal surgeries also use these techniques to ensure precise, less invasive operations.
Awake craniotomies represent the cutting edge of neurosurgery, offering patients the best chance to maintain their quality of life while addressing serious medical conditions. As we’ve seen in the cases of Robert, Brittany and Ani, for instance, patients might be asked to speak, move or play the guitar during surgery precisely to ensure that their critical functions remain intact.
In particular, for multilingual individuals, such as Ani, awake craniotomies allow for real-time mapping and differentiation of the distinct neural regions involved in each language.
This is crucial because different languages can be processed in slightly different areas of the brain, even if they are close together. By being awake and responsive, patients can help surgeons identify and preserve these areas, reducing the risk of postoperative language deficits. This results in better surgical outcomes, reduced risk of language impairments, and improved overall quality of life for the patient.
By directly involving the patient in tasks related to each of their languages, the surgical team can avoid inadvertent damage to language pathways, which can result in aphasia or other language impairments, which can significantly impact quality of life.
Awake craniotomy is at the forefront of modern neurosurgery, blending advanced technology with patient interaction to achieve remarkable precision. The expanding applications of awake craniotomy promise a future where even more patients can benefit from these groundbreaking techniques, ensuring safer, more effective treatments for a variety of neurological conditions.
