Being awake and talking during brain surgery

The tumour was in the left side of the brain, in the part that controlled his speech. The surgeon told him that the tumour needed surgery and that it had to be removed. But the big question was : Could it be removed without the speech getting affected?

One of the major aims of brain surgery is to ensure that the patient does not suffer any new disabilities after the procedure. The most effective method of treatment of a brain tumour is to remove it completely. The surgeon therefore has to be aggressive and remove the tumour completely on the one hand, while at the same time avoid giving the patient a disability that will affect the quality of life.  Advances in technology and the availability of new anaesthetic drugs have made neurosurgical operations on the brain safe, with the complication rate down to less than three per cent in most cases. However when the tumour or pathology lies in a part of the brain that is responsible for speech or for movement of either the hands or legs, it is a challenge. To help overcome this challenge, technological advances in radiology have come to our aid with special MRI techniques.

Functional MRI (or fMRI) shows the exact relationship between the tumour and important ‘functional’ areas of the brain like the speech area and motor areas. Diffusion Tensor Imaging (DTI), also called tractography, helps the surgeon visualise the nerve fibres and connections between different parts of the brain and their displacement by the tumour.

‘Awake craniotomy’ is a technique when the patient is kept awake, is able to obey simple commands and talk during the brain surgery. Critical to this technique is the fact that the brain itself does not feel any pain sensation. It is the scalp, the bone and the coverings of the brain that receive pain sensation. In order to perform “awake craniotomy”, it is essential to have a cooperative and well-informed patient, as well as synchronised team work between the anesthesiologists and the surgeons.

Patients need to be counselled before surgery, as they would need to lie still and not move their head for the duration of the procedure. They also have to understand that they would be woken up and kept awake during their surgery. It is essential that the doctor explains to the patient that they would hear a lot of different sounds from the various equipment in the operation theatre, which ordinarily can severely raise anxiety levels. The patient would also need to understand what the anesthesiologist and the surgeon would be asking of them.