ST. LOUIS - Twelve to 15 times a year, Washington University neurosurgeons at Barnes-Jewish Hospital put a patient to sleep, remove part of their patient’s skull, exposing their brain and then wake the patient up. These surgeons are performing one of the most dramatic and difficult of surgical procedures – awake craniotomy.
Though it may seem shocking to wake a patient in the middle of surgery – especially a major surgery on a vital organ – awake craniotomy is a valuable treatment for brain tumors and epileptic seizures in carefully selected patients.
“With awake craniotomy, patients derive better outcomes,” says neurosurgeon Eric Leuthardt, MD, director of the Washington University Center for Innovation in Neurosciences and Technology. “We’re able to accomplish a more aggressive surgery in sensitive areas while preserving function.”
In a standard open craniotomy, part of the patient’s skull is removed so surgeons can have access to the brain. It’s a common procedure for removing many brain tumors, repairing bleeding in the brain or brain injury, and removing clots or tissue causing seizures. Patients remain fully anesthetized – asleep – during these procedures.
(To see an awake craniotomy procedure, watch this video.)
The difference with awake craniotomy is that after the patient’s skull is opened and before surgeons begin cutting or manipulating brain tissue, the patient is awakened in order to interact with the surgical team.
Awake craniotomies are usually performed on patients whose problems occur near the areas of the brain that control speech and motor function.
While removing or destroying troublesome tissue, surgeons need to insure that they’re not inadvertently damaging healthy tissue. The most reliable way to do this is to wake the patient up, ask him or her to answer questions and perform simple motor tasks, then monitor the responses.
“This procedure can give the surgeon the best balance between safely avoiding critical areas in the brain while at the same time being maximally aggressive towards the tumor.” Leuthardt says.
At Barnes-Jewish Hospital, several advanced technologies supplement this technique, making awake craniotomy even safer and more precise.
For instance, awake craniotomies are performed in the hospital’s intraoperative MRI suite. This suite is one of about 20 in the United States equipped with a high-field-strength MRI magnet, which allows surgeons to produce real-time MRI images during surgery. Surgeons can then consult the images during surgery to make sure they’ve removed as much tumor tissue as safely possible.
Washington University neurosurgeons also use stereotactic navigation, a system that works like GPS to guide them through the patient’s brain. The day before surgery, the patient has an MRI that helps doctors map certain points in the brain. The map is displayed on a screen during the operation and surgeons check their exact position within the brain by touching the area with a special probe.
Leuthardt also uses other sophisticated brain-mapping techniques, some of which he developed, to pinpoint areas of the brain that control very specific behaviors.
One technique involves laying a thin plastic sheet studded with a grid of sensors directly on the brain’s surface. The sensors detect minute electrical charges as they travel along pathways in the brain during a seizure or while the patient is speaking or moving. A computer program turns the data collected by the sensors into a map that can guide surgeons precisely to the area causing seizures or steer them away from healthy tissue surrounding a tumor.
But ultimately the skill and experience the surgical team is the key to a successful awake craniotomy procedure. The volume of awake craniotomies performed at a center translates into better outcomes, and the Washington University neurosurgeons are the most experienced in the region at surgery close to the motor and sensory cortexes.
Providing anesthesia for awake craniotomies also presents a special challenge, says Leuthardt. Typically, a patient who is asleep during surgery has a breathing tube inserted to keep the airway clear and open. A patient who is awake and talking can’t have a breathing tube so the anesthesia team monitor the patient very closely.
And although the brain itself has no pain receptors, the patient must be kept as calm and pain-free as possible during the surgery, especially as the scalp is cut and a portion of skull is removed. However, the patient can’t be so sedated that they can’t respond to the surgeon.
“Anesthesia for this procedures is certainly more difficult than a regular procedure,” Leuthardt says.
But awake craniotomy can pay off in both the short term and long-term benefits for the patient. In the long run, patients with difficult brain tumors can have extended quantity and improved quality of life when the maximum amount of tumor is removed.
In the short run, patients can often spend less time recovering in the hospital.
Patients typically spend a day or two in the neuro intensive care unit after surgery and are discharged from the hospital within about seven days.
For more information about awake craniotomy, click here.
Barnes-Jewish Hospital is 1,288 bed teaching hospital affiliated with Washington University School of Medicine in St. Louis, MO. The hospital has a 1,763 member medical staff with many recognized as "Best Doctors in America." Barnes-Jewish is a member of BJC HealthCare, which provides a full range of health care services through its 13 hospitals and more than 100 health care sites in Missouri and Illinois. Barnes-Jewish Hospital is also consistently ranked as one of America’s “Best Hospitals” by U.S.News & World Report.