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Awake Craniotomy

  • Friday, 04 September 2009 21:44
  • Last Updated Friday, 25 November 2011 01:42

An awake Craniotomy is an operation performed in the same manner as a conventional craniotomy (see document) but with the patient awake during the procedure. This is a preferred technique for operations to remove lesions close to, or involving, eloquent (functionally important) regions of the brain. This allows us to test regions of the brain before they are incised or removed and allows us to test patient’s function continuously throughout the operation. The overall aim is to minimise the risks of such operations.

HOW IS AN AWAKE CRANIOTOMY PERFORMED?

There are 2 main techniques used. Some surgeons use a technique of anaesthesia called sleep-awake-sleep. As the name suggests, you will first be put to sleep under full general aneasthesia whilst the first stage of the operation is performed (opening of the head). Then you will be woken up for the testing of the brain (see below) and the removal of the tumour. Finally, you will be put back to sleep for the closure of the wound.

More often nowadays, your surgeon may advise a full-awake procedure. In the anaesthetic room you will have a drip inserted with some drugs that make you feel comfortable and relaxed. In theatre, the neuronavigation system will then be used (as previously described) to mark out the incision and a very small amount of hair shaved along the line of the incision before it is cleaned with antiseptic solutions and then local anaesthetic is inserted around the incision. This will sting a little for a few seconds and then go numb.

We will then place some drapes around the wound but you will be able to see the anaesthetic team and talk to them and be able to move your arms and legs freely during the operation. The operation then continues and you will hear some noises and the drilling sound briefly.

When the brain is exposed we will perform a procedure called cortical mapping. This involves stimulating the brain surface with a tiny electrical probe. If we stimulate a motor region of the brain it may cause twitching of a limb or your face; a sensory area will cause a tingling feeling; the speech areas will prevent you from speaking very briefly. By mapping out the important regions of the brain first we can aim to avoid and protect them during the operation. Whilst we remove the tumour we will continuously test your function, and if anything changes we will be able to stop.

This does not eliminate the risks of surgery but does likely reduce them.

After the tumour has been removed, all bleeding is stopped, the dura is closed with sutures, the bone is replaced with 3 mini-plates and the scalp is closed. The skin is closed with staples, the wound is dressed and often a head bandage is applied.

WHAT HAPPENS AFTER SURGERY?

Post-operative recovery is generally much quicker as you will not have had a general anaesthetic. You will likely only have a single drip and will not have any other lines or a catheter. You can eat, drink and mobilise as soon as you feel able to and will be able to be discharged on the same day as your operation or the following day if you are able. If you are having day-case surgery you will need a CT scan of the head 4 hours after surgery and can be discharged 6 hours post-op provided all is well.

WHAT HAPPENS AFTER DISCHARGE?

After any major operation it takes a few weeks to recover fully. For the first couple of weeks you may have some headaches that you should be able to control with simple painkillers that you will be given. You will feel more tired than usual and will need to rest when you feel tired. However, you should do a little more simple exercise each day such as taking walks.

Your surgeon will usually arrange to see you in the outpatient’s clinic about 5 to 7 days after surgery to check on your recovery and also to give you any results from biopsies from the operation. He will also advise you on your further care and answer any other questions that you have. Your clips or stitches will probably be removed in the clinic too.

WHAT SHOULD YOU NOTIFY YOUR DOCTOR OF AFTER SURGERY?

Headaches that are progressively worsening
Fitting
Fever
Wound problems (increasing pain, swelling, discharge)
Development of new or worsening symptoms (weakness, numbness, etc)
Increasing drowsiness
Rash

If you are at home you could discuss your symptoms with your GP, call your neuro-oncology specialist nurse (if you have one) or contact your surgeon and his team at the hospital through the neuro-oncology MDT coordinator.

WHAT ARE THE RISKS OF AWAKE CRANIOTOMY FOR A Brain Tumour?

The risks of awake surgery for a brain tumour are the same as those for conventional surgery but there is also a small risk of seizures during surgery that might require conversion to general anaesthetic in rare circumstances.

Every operation carries a risk. Overall, complications following a craniotomy are uncommon and the degree of risk depends on a number of factors, for example, the size, location and type of the tumour, your general medical health and age. Your surgeon will explain to you the particular risks associated with your operation and give you an indication of the likely chance of complications occurring. Complications include, but are not exclusive to, the following:

Temporary or permanent neurological deficit (stroke e.g. Paralysis of limbs or loss of speech)
Haematoma (blood clot)
Brain swelling
Infection
Fits
CSF leak (leakage of fluid from around the brain)
General medical complications
Deep Vein Thrombosis (clot in leg veins)
Pulmonary embolism (clot from legs passing to lungs)
Pneumonia
Heart attack
Urinary tract infection

Some of these complications might be serious enough to warrant further surgery and some can be life threatening. Overall, as a general guide, the incidence of serious complications causing permanent neurological deficit (stroke) or death is less than 5%.

Overall the risks of general complications of surgery, such as Deep vein thrombosis and urinary or chest infection, are thought to occur less frequently because you will not have a general anaesthetic.

This article has been written by Mr Paul L Grundy BM(Hons) MD FRCS(SN), Consultant Neurosurgeon, Wessex Neurological Centre & Spire Hospital, Southampton, UK


On Tuesday 26th May 2009 Mr Grundy performed an awake craniotomy live on channel 4 as part of a week long series about surgery. The patient, Peter Chaisit-Charles, had a suspected tumour in his brain. For the last four years he suffered from Epilepsy, with his Lesion causing abnormal electrical activity in the brain. Recently it started to affect his short term memory too. The tumour was growing in the left Temporal Lobe – the area of the brain that controls our speech and language functions. If the tumour had continued to grow, Peter could have lost part of his ability to talk.

Whilst we at Bt Buddies understand that watching scenes from this programme might be distressing to some, others may find it useful so below is a list of clips available and links to those clips. If you have any questions or would like further information about awake craniotomies after watching the clips please This e-mail address is being protected from spambots. You need JavaScript enabled to view it and we will do our best to help.

*Warning, the following links contain details and clips of surgical operations*


1. Opening the Scalp

2. Removing the skull bone disc

3. Exposing the brain

4. Mapping the region

5. Cutting into the temporal lobe

6. Dissecting tumour while testing speech

7. Completing the dissection

8. Replacing the skull bone disc

9. Closing up

 


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