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 (e.g., not awake for the scalp incision or bony opening). A sophisticated operating microscope is used during an awake craniotomy, as are specialised equipment and surgical techniques for, say, brain tumour removal or aneurysm clipping or AVM disconnection [these features distinguish "awake craniotomy" from other important but "NON-microsurgical" or "functional" procedures such as brain electrode or brain stimulator placement (e.g., for Parkinson's disease) where the patient is also awake].

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, aneurysm, 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-Anaesthesia Care Unit. For the above reasons, the procedure is also referred to as "awake brain surgery".

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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 brain blood vessel disorders 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 brain vascular abnormalities may not need awake surgery because their tumours or vascular conditions 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. In our team's hands, the surgery aims to prolong both the quantity and quality of the patient's life compared to standard "non-awake" neurosurgery by allowing the surgeon to push the frontier of surgical resection in the "patient comfortably awake and testable" mode.

Is "awake craniotomy"/"awake brain surgery" right for me? Awake craniotomy/awake brain surgery may be very appropriate for you if:

1. You can tolerate the concept of undergoing some part of the neurosurgical procedure in a fully awake state; and
2. You have a condition such as a brain tumour or blood vessel disorder that is located in or very close to a highly functionally important part of your brain; and
3. Your neurosurgical team is experienced and comfortable with such an approach, and the neurosurgeon and anaesthetist explain the expected procedure to you in appropriate detail prior to the day of the operation.

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 striven to make this a comfortable and safe experience for those patients who are advised and choose to undergo this kind of surgery. In our Program, written feedback from awake craniotomy patients operated on by Dr Khurana has been overwhelmingly positive. Only during "awake" portions of the surgery will you see the anaesthetist 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 anaesthetist 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 should 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.

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Will I be in any pain during "awake craniotomy"/"awake brain surgery"? In the hands of experienced neurosurgical and anaesthetic teams, 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 4-6 hours, while Dr Khurana carries out his awake craniotomies on average in less than 4 hours from skin incision to closure. Further, the anaesthetist 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). Our patients undergoing awake craniotomy have confirmed their experience of high comfort levels during the procedure.

Does Dr Khurana offer an Awake Craniotomy Service/Awake Brain Surgery Program? Yes. Our awake craniotomy Program involves:

• Thorough pre-operative consultation with Dr Khurana and team regarding the technique, the technologies used, the alternatives, benefits, risks, team approach and expected hospital course
• Where appropriate, the use of state-of-the-art MRI scanning technologies using functional MRI (fMRI) and MR diffusion tractography (DTI) to accurately map critical brain anatomy prior to the awake surgery
• Educational material (including multimedia; see below) posted on this Website as a reference for patients and their carers and physicians
• A series of post-operative clinical and radiological followup visits with Dr Khurana and team
• Hospital Ethics Committee-approved confidential patient "experience and satisfaction" surveys. These were completed by the first 26 consecutive awake craniotomy patients at this hospital to assist in understanding the "awake craniotomy experience" from patients' perspectives. Their feedback was overwhelmingly positive.

The medical conditions for which Dr Khurana has carried out awake brain surgery: brain aneurysm and arteriovenous fistula; brain tumours near or in language, vision and/or limb movement areas; cavernous malformations (cavernoma) in language, vision and/or limb movement centres. Dr Khurana and team have a high success rate for awake brain surgeries based on a comprehensive study of the clinical and personal experiences of the first 26 consecutive awake craniotomy patients operated on at this hospital. That study has recently been submitted for peer-review journal publication.

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Where can I view multimedia related to "awake craniotomy"/"awake brain surgery"?

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