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Frequently asked questions (FAQs) regarding awake Brain Surgery / Awake Craniotomy:
Answers to those FAQs: What is an "awake craniotomy"/"awake brain surgery"? An "awake craniotomy" is a neurosurgical procedure that involves the use of specialised equipment to make a bony opening (craniotomy) in a part of the skull of a patient who is awake during some part of the operation. HOWEVER, the patient is NOT AWAKE for any potentially uncomfortable parts of the operation. Our anaesthesia team will wake the patient early on for a few minutes to check that the patient is comfortable, and then have the patient asleep with rapid-onset and rapid-reversal intravenous sedation till AFTER the scalp and bone work have been completed. There is typically no need for endotracheal intubation or urinary catheterisation during this surgery. The anaesthetist and surgeon will be closely in touch with the patient during any "awake" periods. Remember, the brain itself doesn't physically sense the surgeon's presence. The part of the operation for which patients are awake is usually the "critical part" involving removal of the brain tumour itself, or during the surgical obliteration or disconnection of a brain vascular malformation (e.g., AV malformation, AV fistula, or cavernous malformation). During these critical parts, the patient undergoes some form of neurological testing by the team members (e.g., speech and movement testing). After the critical portion is done, the patient is put back to sleep till they are finally awakened completely in the Post-Operative Care Unit. For the above reasons, the procedure is also referred to as "awake brain surgery". Currently, it is a procedure carried out comfortably by only some neurosurgeons worldwide.
Why is an "awake craniotomy"/"awake brain surgery" carried out? Awake craniotomy is carried out or recommended to be carried out only in SOME neurosurgical patients. Its purpose (i.e., the purpose of the patient being awake during the critical part of the operation) is to make the operation safer (i.e., reduce the likelihood of a neurological impairment or "deficit" in that particular patient). CERTAIN or "SELECT" PATIENTS with brain tumours or vascular malformations involving highly eloquent (i.e., highly functionally important) parts of the brain may benefit from an awake craniotomy because the neurosurgeon can be assured of the neurological progress of the patient in real-time. Of course, the majority of patients with brain tumours or vascular malformations may not need awake surgery because their tumours or vascular malformations may not involve any highly eloquent parts of their brains. It's in the select few that being awake during the critical part of the operation can make a very positive difference to the outcome, as the neurosurgeon can be more aggressive with the condition (such as a brain cancer) knowing that the patient is awake and responsive and neurologically intact as the tumour removal or resection proceeds while the patient is being functionally tested by other members of the team. This is the key advantange of awake brain surgery. Is "awake craniotomy"/"awake brain surgery" right for me? Awake craniotomy/awake brain surgery may be very appropriate for you if:
Are there any disadvantages of "awake craniotomy"/"awake brain surgery"? There are no significant downsides to this approach if all of the three criteria mentioned above are met. What will I see, hear, smell and feel during "awake craniotomy"/"awake brain surgery"? Remember, we have perfected making this a comfortable and safe experience for those patients who are advised and choose to undergo this kind of surgery. Only during "awake" portions of the surgery will you see the anaesthesiologist as he or she talks and interacts with you. You will NOT see the surgeon or the surgery itself and you will NOT feel claustrophobic as there are translucent drapes placed widely and appropriately around you. Only during "awake" portions of the surgery will you hear the anaesthesiologist and surgeon as they talk and interact with you to check to see if you are comfortable and to test your neurological function whenever feasible. You will be breathing through a comfortable, wide oxygen mask, so you will smell and breathe nothing but fresh oxygen. You will FEEL no pain during this procedure (see below). You will neither hear nor feel any bone-drilling as those portions of the surgery are done while you are asleep. You WILL be able to move your arms and legs during the procedure. There is no urinary or "bladder" catheter used for patients undergoing awake surgery, as our patients are requested to pass urine immediately before the surgery and typically do not require to do so again before the surgery is over (generally within 4 hours of the commencement of the anaesthetic). Our patients confirm intraoperatively and postoperatively that they are comfortable throughout, and this is a priority for our team.
Neurosurgery operating room at The Canberra Hospital during awake brain surgery. Above left photo: Dr Khurana removing a brain tumour from a young patient whose tumour was infiltrating into movement and language areas. Multiple monitor screens are also seen here (left screen: operating microscope view; middle screen: neuronavigation view; right screen: preoperative imaging). Above right photo: At the same time, our anaesthetist, Dr James French, interacts with the patient. Note the clear plastic drape to optimise lighting for the patient, and the wide oxygen mask. The special draping we use contains an antibiotic solution within it (orange-yellow regions immediately surrounding patient's head in the above right photograph). Photo credit: Jaime Valenzuela, Medtronic. Will I be in any pain during "awake craniotomy"/"awake brain surgery"? In the hands of an experienced neurosurgical team, you will not be in any pain during awake brain surgery. Why? Because appropriate local anaesthetic nerve blocks are administered around the scalp while you are asleep prior to the commencement of surgery, to allow those tissues to go numb for the duration of the procedure and from the time before any incision is made. Such nerve blocks can last up to 8 or so hours, while Dr Khurana carries out his awake craniotomies on average in less than 4 hours from incision to closure. Further, the anaesthesiologist adminsters certain medications in precise amounts to allow the patient to be asleep during some of the noncritical parts of the procedure, and awake for the critical parts, or as desired. Finally, the brain itself feels no pain (the brain's leathery covering known as the "dura" does sense pain, and therefore this covering layer is numbed well by the neurosurgeon using directly applied local anaesthetic solution before it is incised/opened). Does The Canberra Hospital Offer an Awake Craniotomy Service/Awake Brain Surgery Program? Yes. Dr Khurana, a staff specialist neurosurgeon at The Canberra Hospital, is one of the few neurosurgeons in the Southern Hemisphere to comfortably offer awake neurosurgery as an option to some of his patients with "eloquent" brain tumours or vascular malformations. His experience was derived from training in this approach under the tutelage of Dr Fred Meyer, Chairman of the Dept. of Neurosurgery at the Mayo Clinic in Rochester, Minnesota USA, during the course of Dr Khurana's nine years at the Mayo. Awake neurosurgery has already been successfully carried out many times at The Canberra Hospital by Dr Khurana and the anaesthesiologists Dr David Duke and Dr James French and their dedicated team members. The medical conditions for which we carried out awake brain surgery at The Canberra Hospital: brain aneurysm and arteriovenous fistula; brain tumours near or in language and limb movement areas; cavernous malformation (cavernoma) in the speech centre. We have consistently had excellent results thus far.
The top left image shows an MRI scan of a cavernous malformation (cavernoma; in red dotted circle) that had ruptured several times in a young woman who had a previous arteriovenous malformation (AVM) treated with radiation. The radiation led to the growth of the cavernous malformation, which was now severely symptomatic. The cavernoma shown here was located at the junction of the sensory and movement areas for her left arm and leg. Surgery to remove this disorder would be risky owing to the the size, depth and functional location of this particular cavernoma. It was safely accessed and removed (top-centre and top-right images) by Dr Khurana and his team during awake surgery. During this surgery, the patient's movement and sensation were tested repeatedly. The lower image shows Dr Khurana removing a brain tumour from another young patient who is awake during this part of the surgery. One of our awake craniotomy anaesthetists (encircled in green on the other side of the translucent drape) tests the comfortably awake patient's neurological function while the tumour is being debulked. Where can I see other images and video footage of an "awake craniotomy"/"awake brain surgery"? Click on the In The Media tab at the top of this page to see news reports and a video of awake craniotomy carried out by Dr Khurana. To see still images of awake craniotomy...
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