Awake Craniotomy

Welcome to Dr Khurana’s Awake Craniotomy pages.

Images shown here are with the permission of Dr Khurana’s patients, for educational purposes.

• Dr Khurana: Awake Brain Surgery Team in Action (Video, 3.5 minutes, 2018)

(click to enlarge)

Panel above: This lady presented with a very large and aggressive primary brain cancer, a GBM. Her brain was swollen, and without surgery she would have lived a few weeks at most. I operated on her twice over a period of eight years, both surgeries were undertaken while she was awake, comfortable and interactive with us. Her survival from a GBM (eight years) was far more than the average survival for this tumour (1.5-2 years). Note the incision, which was photographed one week after her first surgery (green arrows). I use minimally invasive microsurgical techniques for my awakes.

What is an awake craniotomy?

Awake craniotomy is a neurosurgical art that uniquely combines training, advanced technology and microsurgical techniques and, perhaps most important of all, meticulous teamwork, preparation and communication. During some designated part of the operation, the patient is gently awoken by the team in order to be interactive with, and neurologically testable by, members of the team during the surgery. Via the techniques I use, typically:

• Only a small amount of scalp hair is shaved;
• The incision and craniotomy are of a ‘minimal’ footprint as safely possible;
• The patient can NOT hear or feel the ‘drilling’ part of the craniotomy (we have surveyed numerous consecutive awake craniotomy patients of mine to verify this; British Journal of Neurosurgery 2011).
  

Its key advantages are:

• Enhanced safety via awake testing during the procedure [THIS CAN LOWER PERMANENT COMPLICATION RATES];
• Facilitating removal of more tumour volume especially for lesions in “high-price real estate” of the brain [THIS CAN ENHANCE SURVIVAL];
• Avoidance of prolonged inhalational anaesthesia (use of short-acting intravenous anaesthetics instead)

Why is an awake craniotomy carried out? i.e., What is its main advantage?

Awake craniotomy is carried out or recommended to be carried out in SOME neurosurgical patients. Its purpose (i.e., the purpose of the patient being awake during the critical part of the operation) is to make the operation safer (i.e., reduce the likelihood of a neurological impairment or “deficit” in that particular patient). CERTAIN or “SELECT” PATIENTS with brain tumours or vascular malformations involving highly eloquent(i.e., highly functionally important) parts of the brain may benefit from an awake craniotomy because the neurosurgeon can be assured of the neurological progress of the patient in real-time.

The collage below (from an original study by Dr Khurana and colleagues, published in the British Journal of Neurosurgery in 2011) shows corresponding pre- and post-operative images from a series of awake craniotomies carried out by Dr Khurana for a variety of complex brain conditions including:

It is now well established that the MORE VOLUME a surgeon resects/removes of a brain cancer (glioblastoma multiforme, anaplastic astrocytoma, or a metastasis) or a “low grade” brain glioma (e.g., WHO grade II astrocytoma or oligodendroglioma), the better the prognosis is for that patient. However, the surgical goal must be for “maximal safe resection” – i.e., the surgeon should remove the most he or she can without permanently harming the patient.

In the setting of an awake craniotomy, a neurosurgeon can potentially be more aggressive with the condition (such as a brain cancer) knowing that the patient is awake and responsive and stays neurologically intact as the tumour removal or resection proceeds while the patient is simultaneously functionally tested by other members of the team.

Therefore, the key advantage of awake craniotomy over its traditional anaesthetised/fully asleep counterpart is that it can facilitate a surgeon reducing the risk of permanent neurological complications while increasing the extent/volume of the mass’ resection, through real-time neurological feedback (via micro-electrical stimulation of the brain and awake patient clinical testing) as the surgery proceeds.

Thus, many lesions that would otherwise be deemed ‘higher risk’ of permanent deficit or only partially resectable or “for biopsy only” owing to their location, may be more amenable to safer and more complete surgical resection using this approach.

Are there any disadvantages of awake craniotomy?

There are no significant downsides to this approach if all of the three criteria mentioned above are met. Any chance of a seizure, airway difficulty or pain/discomfort are reduced by the appropriate measures undertaken by a well-trained team.