‘Awake’ Brain Surgery: It’s possible and effective!

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Surgery is the first line of treatment for the majority of brain tumor patients. The success rate for many benign tumors of the brain is quite high. Surgical treatment offers good results without sacrificing the unaffected tissues in the brain, especially those located close to the tumor. If a complete resection is not possible, you will still experience relief of most of the troublesome symptoms in addition to increasing the efficacy of other treatment options such as radiotherapy or chemotherapy.

The Role of Brain Surgery

Surgical intervention allows for: (I) The complete resection of many brain tumors, thereby preventing the extermination of healthy cells and tissue. (II) Improved diagnosis and allows the team of doctors to formulate the most appropriate treatment plan. (III) A longer and better quality of life. (IV) A reduction or elimination of symptoms, enhancing your ability to function normally (example- allows you to speak, see and think better).

Neurosurgeries are performed frequently in many hospitals each year. To further improve the outcome of any brain surgery, the latest techniques in imaging and surgery make precise surgical planning and execution a reality. The main focus nowadays is to opt for a minimally invasive approach. The type of intracerebral surgery performed varies with the size and exact location of the tumor in the brain.

Often, patients have to be kept conscious but sedated while the surgery is happening.

To preserve as much brain function as possible during such operations, state of the art intra-operative monitoring is used to record the neurophysiologic changes. This neuro physiological testing includes- (I) Intra-operative imaging (II) Brain mapping during surgery (also known as Awake brain surgery) (III) Image guided neurosurgery.

Intra-operative imaging: Skilled specialists known as neurosurgeons use either CT or MRI imaging equipment in the surgical room to effectively remove the tumor mass. This is called intra operative imagingm which empowers the doctor  to have a detailed view of the area of brain tissue being operated for either complete or maximum excision of the tumor. The vital structures close to the site of operation are protected.

This technique allows the specialists to accurately determine if thorough removal of the abnormal mass has been carried out successfully. The procedure is continued if any remaining tumor cells are detected. The recurrence rate is reduced as are post operative complications. Awake brain surgical operation is performed in order to treat certain serious neurological conditions such as tumors of the brain or epileptic seizures.

Considerations: General health status of the patient is always an important consideration. In case where the patient suffers from sleep apnoea or is obese, such a surgery is not suited for them. The ability of the patient to stay calm and give responses to the surgeon is highly essential.

Benefits: In certain cases, surgery is excluded due to the peculiar position of the epileptic foci or tumor. However, such patients now stand an equally good chance of fighting and surviving a brain tumor via awake craniotomy. Specialists now carry out tumor removal surgeries in cases in which the tumor has spread within the confines of the brain such that the borders are unclear (as may occur with gliomas). In such peculiar cases, instead of removal, shrinkage of the mass is done.

 The Procedure

                    

Brain surgeons, neurologists, anesthesiologists, speech specialists, computer engineers and sometimes language interpreters are required to work as a team during and after the surgery.

The awake craniotomy procedure commences as follows: The anaesthesiologist will sedate you using a local (Note: not general) anaesthetic along with specific strong numbing medications. This prevents you from feeling any pain. Only the type of anaesthesia that is most appropriate for the patient is administered. You will either-

(I)               Be kept conscious during the entire surgery. In this category, you’ll be injected with a scalp or nerve block to block out the sensation of pain.

(II)             In this category, you’ll be kept awake only during a certain part of the surgery and sedated during the initiation and completion of the operation. The sedation is stopped by the neuroanaesthesiologist when the neurosurgeon is prepared to separate and remove the tumor.

(III)           Or, you will be injected with general anaesthesia and a nerve block that will render you unconscious. However, you will be woken up when it is time to resect the tumor from the brain. Post removal, the patient is put to sleep once again.

While the surgery goes on, the area surrounding the tumor cells will be stimulated by using small electrodes. In order to locate those areas of the brain structure that need to be avoided, a speech pathologist will ask you a few questions or your surgeon may ask you  to perform tasks such as counting, identifying images or raising a finger. These responses from you will help the team to ascertain that no functional area has been disturbed from its normal role. Identification of important brain areas is done via brain mapping, which is akin to a window for checking the brain.

Detailed images from a three dimensional computer assist the surgeon in removing the tumor. In some cases, stereotactic radiosurgery is also performed during ‘awake’ craniotomy. The neuroanaesthesiologist makes sure that you experience no pain during the surgery. Other vital signs of breathing and blood pressure are closely monitored for any variations.

Major advancements in skull surgery have improved results in tumor removal. Large, open brain surgeries are a thing of the past and are soon to be replaced by newer techniques that cause minimal scarring and preserve brain function.

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