Awake craniotomy for brain tumors: 8 questions

Imagine being able to talk to your doctors during brain tumor surgery without pain and give them immediate feedback while they operate. That’s exactly what happens during an awake craniotomy.

A craniotomy is a type of surgery where a piece of the skull is temporarily removed to access the brain. In an awake craniotomy, the patient is woken up during surgery. MD Anderson doctors perform more than 100 awake craniotomies every year.  

This highly specialized surgical procedure requires a team approach led by an experienced neurosurgeon and a neuroanesthesiologist. To learn more, we spoke to neurosurgeon Jeffrey Weinberg, M.D., and neuroanesthesiologist Shreyas Bhavsar, D.O.

What’s the benefit of being awake during brain tumor surgery?

Our goal is to remove as much of the tumor as possible, as safely as possible. When a tumor is near an area of the brain that controls critical functions — such as speech, language or movement — an awake craniotomy is the best way to identify and safely preserve those abilities.

We know where certain functions are generally located on the brain’s surface. But below the surface, bundles of nerves pass through the brain to the spinal cord and throughout the body. We have to map these nerves to understand which ones are connected to key functions so that we can avoid them as we remove the tumor. Damaging critical nerves could cause permanent disability.

We also use other tools to map brain function, but mapping nerves during an awake craniotomy is the only way to obtain immediate feedback during surgery.

Which patients are candidates for awake craniotomies?

Patients with tumors in the parts of the brain that control these key functions are candidates for an awake craniotomy. Tumors that often form in these areas include gliomas like glioblastoma and oligodendroglioma. The type of tumor does not qualify (or disqualify) patients for the procedure, though. The location of the tumor is what matters.

The patient also has to feel comfortable with the idea of waking up and participating during brain surgery.

A patient with severe symptoms or anxiety may not be able to effectively contribute to the neurological exams during surgery. A neuropsychological evaluation can help determine the severity of any deficits and if the patient would be a good candidate for this procedure. 

How is it possible to wake up during brain surgery without feeling pain?

Brain tissue doesn’t have any pain fibers, so while you may feel pressure or vibrations from the surgery, you shouldn’t feel pain. We use a local anesthetic (similar to those used at a dentist’s office) to numb the nerves in muscles, skin, bone and dura (the tissue between the bone and the brain) that the surgeon has to cut through.

What should I expect when I wake up during surgery?

When you wake up, you’ll hear the neuroanesthesiologist reassuring you. You won’t be able to move your head, but the neuroanesthesiology team will make you as comfortable as possible and stay with you the entire time.

How long will I be awake?

You could be awake for 45 minutes to several hours. Exactly how long depends on how big your tumor is, where it’s located, the tumor’s relationship to the brain, the function we are trying to preserve and the type of symptoms you had before surgery.

What happens while I’m awake? 

While you’re awake, you’ll be an essential participant in the most critical part of the surgery. You’ll help map your brain function through a series of simple neurological exams. The neurosurgeon will stimulate part of your brain near the tumor with a low electrical current. At the same time, the neuroanesthesiologist and/or neuropsychologist will give you some simple verbal and functional tasks to see if the stimulation impacts your neurological function.

For example, you may be shown a tablet with pictures of common objects. If you suddenly can’t name an object or can’t get any words out at all, the neurosurgeon will know the area being stimulated at that moment is critical to speech. The surgeon can then avoid that area while removing the tumor.

Even when you’re not actively mapping, you’ll talk to the neuroanesthesiologist and neurosurgeon, who are in constant communication throughout the surgery. This is important for ensuring a safer surgery, with the best possible outcomes. 

When will you put me back to sleep?

In most cases, your doctors will keep you awake through the removal of the tumor. This lets them test your functions during and after removal, allowing them to determine if any of these abilities have been impacted. When it is time to close the wound, you’ll either be sedated or fully asleep.

How can I prepare for an awake craniotomy?

Before surgery, you’ll get imaging exams that help identify the tumor’s relationship to important nerve pathways. Doctors use this information to develop a surgical plan just for you.

You’ll also have several appointments with your neurosurgeon and neuroanesthesiologist. We’ll explain the surgery step-by-step and answer questions from you and your family. We can even show you a video of a patient undergoing the surgery so you’ll have a better idea of what to expect.

We’ll also take time to get to know you and learn what’s important to you. This will let us talk about things you care about during surgery, which will help you stay awake and participate in the surgery longer. It’ll also help us build trust, which is important for a surgical procedure like this. We’re most likely to get the best possible outcome when you feel safe, supported and fully engaged. So don’t be afraid to ask questions and share your concerns at appointments and while you’re awake during your craniotomy.

Request an appointment at MD Anderson online or call 1-844-313-2796.