Ten Questions Asked About Awake Craniotomy

  1. What is awake craniotomy ?
    Brain operations are generally done under general anesthesia. But in awake craniotomy it is done without putting the patient under general anesthesia. Patient is fully awake during the entire operation. He or she can speak, move limbs and see during the brain operation.
  2. Why do you need this ?
    Patients with brain tumors especially those located in the eloquent (important) areas like those that controls the speech, the movements of the limbs, vision can have major problems after surgery if these areas are damaged during surgery. These important areas are vulnerable for damage and eventually can result in loss of speech, functions of limbs or vision despite the complete removal of the tumor. Awake craniotomy plays a very important role in these situations. This is because while doing the operation it is possible to identify the exact location of the areas controlling these main functions. Hence patients with lesions in eloquent area are benefitted from awake craniotomy.
  3. Will there be pain ?
    Since no general anesthesia is administered the next question is how to get rid of pain during the procedure. There wont be any significant pain during the procedure. At the start of the operation the scalp is numbed by using medication (local anesthetic) as injection to specified areas over the scalp (scalp block) i.e local anesthesia is given in order to make the scalp area numb and patient will have mild pricking type of pain during this time. Once the bone flap is removed and the covering of the brain (dura) is opened the remaining part of the procedure is pain less. Brian parenchyma cannot perceive pain. It carries pain information form all parts of the body but as such it will not perceive pain. Hence patient will not feel any pain during the entire procedure. This important feature that brain is insensitive to pain is made use of during awake craniotomy.
  4. Can all the patients with brain tumor undergo this procedure ?
    No. The potential patient should co operate fully with the entire operating team. These patients should also be fully conscious. Patients who not fully conscious and uncooperative are not candidates for this kind of procedure. The operating surgeon and his entire team should be well trained to handle the situation. They should educate the patient well in advance about the entire procedure The Centers with good infrastructure and team of neurosurgeons with good experience and anesthetists who are experts in this procedure are a must for this operation.
  5. What are the advantages of this operation ?
    As general anesthesia is not employed during this procedure patients recovery time is shorter and with less incidence of chest infection and prolonged stay in the hospital. From surgerys point of view the functions can be preserved carefully and objectively. The morbidity of a neurological deficit can be avoided with awake craniotomy.
  6. What are the risks of the operation ?
    The major concern would be the airway protection and anesthetists should be equipped to convert it to general anesthesia if needed. Patients should be made of aware of the dos and donts of the procedure. The concept of fear should be removed from the patient and every effort should be made to calm down the patient. During the operation patient can throw fits which will be yet another concern and suitable precautions like anticonvulsant medication and other supportive measures are necessary.
  7. How safe is this operation ?
    In centers with good facilities and team of expert neurosurgeons and anesthetists, the operation is considered safe in select patients. With rapidly expanding technology newer medications for anesthesia have come which are very short acting and patients recovery form anesthesia is very fast. The only limitation at this point of time is infra structure.
  8. In which all conditions is this technique indicated ?
    This technique of awake craniotomy is used during surgeries for low grade and high grade cancers in the eloquent areas of the brain. The motor strip which controls the movements of the opposite side of the body is a very crucial area in the brain. Surgery for lesions in and around the area is very difficulty because the margin of error is very narrow. Awake craniotomy in such a situation is very helpful. Similarly awake craniotomy is useful in operations in or near speech areas and visual areas. It is also useful in epilepsy surgery.
  9. Has technology played any role in awake craniotomy ?
    Yes. Newer trends and developments in anesthetic medication has played a major role in this technique becoming more and more popular. These days we have anesthetic drugs which are very short acting and have very few or no side effects. We have situations where patients become fully awake as soon as the medication is stopped with no change in blood pressure and heart rate. We have very good medications to prevent seizures with out affecting the sensorium of the individual.
  10. Do you need any costly equipment for awake craniotomy ?
    No. Awake craniotomy can be done with usual equipment for routine neurosurgery. All one needs is a dedicated team and newer anesthetic medications and a very cooperative patient. With the advent of awake craniotomy the neurological morbidity during operations in and around eloquent areas has come down.