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AWAKE CRANIOTOMY

From Barnes-Jewish Hospital and Washington University Physicians, Innovate, Spring 2012, written by Kathryn Holleman, posted June 25, 2012

The patient lies on his side on the operating table, alert and chatting with the anesthesiology team about his love for St. Louis Blues hockey and reality shows, and about which team he favors in the upcoming Super Bowl.

Washington University neurosurgeon Eric Leuthardt, MD, interrupts.

“Tim, how are you doing?” he asks.

“Great,” the patient says wryly. “Just living the dream.”

“Glad to see you have your sense of humor,” Leuthardt replies, as he returns to the task at hand - tweezing strands of tumor tissue from the patient’s exposed brain.

The patient is one of about 15 patients a year who undergo awake craniotomy surgery performed by Washington University neurosurgeons at Barnes- Jewish Hospital. 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 intractable seizures in carefully selected patients.

“With awake craniotomy, patients derive better outcomes,” says Leuthardt, director of the Center for Innovation in Neuroscience and Technology, Department of Neurological Surgery. “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 access the brain. It’s a common procedure for removing many brain tumors, repairing acute brain hemorrhages or trauma and removing clots or tissue causing seizures. Patients remain fully anesthetized—asleep—during these procedures.

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 brought out of sedation to consciousness in order to interact with the surgical team.

Awake craniotomies are primarily performed on patients who have lesions near the areas of the brain that control speech and motor function.

While removing or destroying troublesome tissue, surgeons need to ensure 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 tasks, and 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 are available to supplement this technique, making awake craniotomy even safer and more precise.

For instance, awake craniotomies are performed in the hospital’s intraoperative magnetic resonance imaging (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 scans during surgery. Surgeons can then consult the images 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 a GPS to guide them through the patient’s brain.

The day before surgery, the patient has an MRI to 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 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 sophisticated technology is ultimately just a complement to the skill and experience the surgical team must bring to the procedure. The volume of awake craniotomies performed at a center translates into better outcomes, and the Washington University neurosurgeons are experienced 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 be intubated, so the anesthesia team must be especially vigilant.

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 he or she can’t respond to the surgeon.

“It’s certainly more difficult than a regular procedure,” Leuthardt says.

But awake craniotomy can pay off in both short-term and long-term benefits for the patient.
In the long run, patients with difficult brain tumors can have an extended and improved quality of life when the maximum amount of tumor is removed. In the short run, patients often spend less time recovering in the hospital.

The day after his surgery, the Blues-loving patient is alert and sitting up in the Barnes-Jewish neuro-intensive care unit. He’s drinking a milkshake and talking with his family when Leuthardt stops by.

“Still doing OK?” Leuthardt asks.

The patient flashes a smile and gives his doctor a thumbs-up.
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Copyright 2013 Washington University School of Medicine