Why are some people required to be awake during brain surgery? By Maria Munden

You might have seen patients playing the violin/piano during awake brain surgery on TV shows such as Grey’s Anatomy or Holby City, but is it necessary in the real world and why is it needed?


The answer is yes. The early principles of awake craniotomy were established more than 50 years ago. It may seem strange, but some patients are required to stay awake during brain surgeries such as the removal of brain tumours or Deep Brain Stimulation. This helps to ease symptoms of conditions such as essential tremors and Tourette’s Syndrome - through the use of electrodes to regulate abnormal brain impulses and normalise involuntary movement.


The main reason for doing this is to allow surgeons to map and preserve areas of the brain that are vital to a patient’s functioning such as speech, movement, and control centres (– the eloquent cortex). Whether awake craniotomy is an option or not depends on the location of the damage/tumour. The closer this is to an important function, e.g. speech, the more crucial it is to be awake. Surgeons can map the safest route to the tumour or seizure area when it is located in these areas as they are in similar parts of the brain. This differs from patient to patient as the pathways in the brain would vary in a violinist compared to a pianist, for example.


During the surgery, patients are asked to perform a series of speaking, reading and movement tests. This takes place whilst stimulating the exposed brain with a mild current probe. If the stimulation impairs the performance of said task, the surgeon must find an alternative pathway to the tumour/lesion/seizure area. This is aided by the use of a functional MRI (fMRI), which measures brain activity by detecting changes associated with blood flow.


These tasks can vary greatly and are tailored to the individual patient. For example, 27-year-old Jazz musician, Carlos Aguilera, played the alto saxophone during surgery to remove a brain tumour. Also, in June 2014; Slovenian opera singer, Ambraz Bajec-Lapajne sang excerpts from Schubert’s ‘Gute Nacht’ during life-saving surgery to remove a Glioblastoma, which is a type of brain tumour.


If you thought that was peculiar, a 60-year-old- Italian woman prepared stuffed olives during a procedure to remove a left temporal lobe tumour at Ancona’s Riuniti Hospital. She managed to prepare a grand total of 90 stuffed olives during the surgery! Another patient was even asked to watch cartoons!


How is this possible without causing an immense amount of pain? Well first, the patient is given a local anaesthetic to numb the scalp. Then, they are given a sedative/general anaesthetic before surgery and are woken up when the brain is exposed. The brain itself has no pain receptors, so this part is not painful. However, there have been exceptions when the patient is awake throughout the whole surgery. Dr Ilyess Zemmoura of Centre Hospitalier Universitaire de Tours, France, uses hypnosedation which is when the patient is hypnotised by a medical professional and stays awake throughout the whole procedure. However, the results of this method have been mixed and there has been no significant difference in the surgical outcome.


Does being awake come with added risks? Patient, Lisa Upton, underwent an awake craniotomy and suffered a seizure mid-surgery. Strangely, the solution was to pour freezing-cold water on the brain, which Upton reported she could feel, even though the brain has no nerve endings. Also, brain damage is an obvious risk in all brain surgeries. In the case of Lisa Upton, her speech started to slur as she was performing various mental tasks on an iPAD. However, a speech therapist was on hand and gave signals to the surgeon that brain damage was being inflicted, forcing the surgeon to find an alternative route. Lisa’s surgery was successful, and she recovered in a record-breaking time.


The patient is also encouraged to stay calm during the surgery, as stress and anxiety could overstimulate the brain and could possibly cause damage.


Awake craniotomy is for certain the method for the future, as it allows precise removal of tumours whilst preserving functions important to each patient, as well as speech and motor skills. It really is revolutionary in the field of neurosurgery.


By Maria Munden


References

- https://www.healthline.com/health-news/awake-during-brain-surgery#5

- https://www.pacificneuroscienceinstitute.org/blog/brain-tumor/the-evolution-of-awakebrain-surgery/

- https://www.bbc.co.uk/news/world-europe-52990921

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