Navigating Awake Brain Surgery: A Comprehensive Guide to Essential Insights

Awake brain surgery may be beneficial in cases where the surgical target is located near or within critical functioning areas of the brain. Such cases may require real-time mapping and monitoring of specific brain functions during the surgery.

Some conditions where awake brain surgery may be needed include: 

• Brain Tumor in Eloquent Area: In tumors located in the areas that are responsible for critical functions such as speech, motor control, or sensory perception, awake brain surgery may be needed. It helps in minimizing damage to essential brain tissue during tumor removal.
• Epilepsy Surgery: When seizures are located in specific regions of the brain, awake brain surgery may be used to identify and remove seizure focus ⁽⁵⁾. Mapping during surgery would help ensure critical functions are preserved.
• Intracranial Aneurysms in Functional Areas: Aneurysms situated in areas of the brain associated with critical function may require awake surgery.
• Deep Brain Stimulation for Movement Disorders: Awake brain surgery is employed in procedures involving the placement of electrodes for deep brain stimulation, particularly for conditions like Parkinson’s disease, essential tremor, or dystonia. Mapping surgery helps in identifying optimal electrode placement to modulate abnormal brain activity.
• Functional Neurosurgery for Psychiatric Disorders: Some psychiatric disorders such as obsessive-compulsive disorder or major depressive disorder, may be treated with deep brain stimulation. Awake brain surgery allows for the mapping and placement of electrodes to modulate specific brain circuits.
• Resection of Brain near Language Centers: Lesions near the language centers of the brain may need awake surgery to prevent language deficits.
• Brain Resection in Pediatric Cases: In pediatric cases where the location of the lesion requires careful preservation of brain functions, awake brain surgery may be considered.

Awake brain surgery is a valuable technique that allows neurosurgeons to tailor the approach to the unique anatomy and functional organization of each patient’s brain.

As with any other surgical procedure, there may be complications from awake brain surgery as well ⁽⁶⁾. The main complication of risk is having a seizure.

Seizures are most commonly known to occur during cortical mapping ⁽¹⁾. Most of the seizures occur for a brief period and resolve themselves. Cold, sterile water or medication can be applied by the surgeon to help stop seizures.

Other complications include: 

• Air embolism
• Airway complications
• Hypertension
• Nausea and vomiting
• Not being able to map the brain during cortical mapping.

There is also a risk of not having awake brain surgery for people with brain tumors. If treatment is not given the tumor may continue to grow, leading to permanent brain damage.

Before going ahead with the surgery, a person needs to speak with a healthcare professional to know what to expect before and after the surgery. 

People need to continue with their daily activities before going ahead with awake brain surgery. Any previous medications should be taken regularly unless stopped by the surgical team. If taking any steroid, antiepileptic medication, or antihypertensive medication, they should be taken as recommended.

It is important to meet the healthcare professional to prepare for the operation. Specific medications may be prescribed to be taken before surgery.

Solids can be consumed until 6 hours before the surgery. Fluids should be consumed until 2 hours before the procedure. 

Mild sedatives are given intravenously in the person’s arm through a vein. This might help make a person feel comfortable. Fluid output is monitored through a catheter, which can also help avoid needing comfort breaks.

Local anesthesia may be given when operating on the skull to access the brain. The head is held in place with the help of clamps. An image guidance system with a monitor is used to find the precise location of the tumor. Before giving any incision, the surgeon ensures whether the person feels pain or not.

Once access to the brain is made, cortical mapping is used to check the functions of different areas. This may include the person performing specific tasks involving ⁽⁷⁾: 

• Speech
• Language
• Movements, such as those of fingers or toes 

After cortical mapping is completed, a large part of the tumor is removed by the surgeon. The person continues to complete tasks as they do so.

After removing the tumor, the access point is closed and the skull is stitched up. The person is then taken to the recovery room. The person feels fatigued post-operation. 

The vital signs of the person are monitored for 2 hours after awake brain surgery ⁽⁸⁾. The recovery takes place in the high-dependency ward or the intensive care unit (ICU).

Analgesics are given to manage pain. After the person is discharged from the ICU, the doctor discusses the result, diagnosis, and any further action.

A study done in 2021 suggested that among 469 people who underwent awake craniotomy, 1.7% had permanent side effects after surgery ⁽⁹⁾.

Awake brain surgery represents a remarkable advancement in the neurosurgery technique, providing a unique and tailored approach to address complex conditions affecting the brain. The procedure can balance imperative surgical intervention with the preservation of critical brain functions, minimizing the risk of postoperative neurological deficits.

The surgery involves the removal of brain tumors and the treatment of other conditions. The person is typically awake during the procedure so that they can talk to the surgeon. This allows the surgeon to accurately map the sections of the brain. This process is called cortical mapping. The tumor is removed without affecting the areas of the person’s brain.

The evolution of awake brain surgery reflects ongoing advancements in neuroimaging, neurophysical monitoring, and understanding of brain function.