An awake craniotomy is an operation performed in the same manner as a conventional craniotomy but with the patient awake during the procedure.
This is a preferred technique to remove tumours close to, or involving, functionally important (eloquent) regions of the brain. Performing the operation in this way allows us to test regions of the brain before they are incised or removed and also to test the patient’s function continuously throughout the operation. The overall aim is to minimise the risks of the operation.
Dr Laban trained with Henry Marsh, a pioneer of awake craniotomy, at St George’s Hospital London, UK, one of the world’s largest teaching hospital. He was selected for prestigious European Association of Neurosurgical Societies training with other luminaries in the field including Hugues Duffau. Dr Laban is a recognised expert in awake craniotomy internationally and has taught and presented on this subject in Europe, Asia and Australasia.
How is an awake craniotomy performed?
There are a variety of techniques but the one that Dr Laban most commonly uses is described here.
A craniotomy is performed under general anaesthesia. You will most likely have two intravenous lines, an arterial line and a urinary catheter inserted. Special care is taken to ensure you are comfortable during the positioning using pillows as needed. Your head is held in three-pin cranial fixation and the neuro-navigation system is used to mark the incision. A small amount of hair will be shaved along the line of the incision before it is cleaned with antiseptic solutions. Local anaesthetic will then be given around the incision. The incision is prepped and draped. Typically, a clear drape is used to enable Dr Laban to communicate freely with you and the team. Once the skull and lining of the brain are opened, you are woken up.
You will be able to see the anaesthetist, speech and language therapist and physiotherapist and talk to them. Your head will be held still but you will be able to move your arms and legs freely. Dr Laban then performs a procedure called cortical mapping. This involves stimulating the brain surface with a tiny electrical probe. If Dr Laban stimulates a motor region of the brain it may cause movement of a limb or your face; a sensory area will cause a tingling feeling; the speech areas may 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 Dr Laban removes the tumour he will continuously test your function and if anything changes he will be able to stop.
After the tumour has been removed, you may be given some sedation to keep you comfortable whilst all bleeding is stopped and the dura (membrane surrounding the brain) is closed. The bone flap is replaced and secured with mini-plates and the scalp is closed. The skin is then closed with staples and the wound is dressed and often a head bandage is applied.
Post-operative recovery is generally quicker than with a conventional craniotomy. As with craniotomy, you will be able to eat, drink and move around independently as safe. It’s likely you will be able to be discharged two or three days after the operation.
Surgical staples are removed one to two weeks following surgery depending on the site of surgery and whether there has been previous surgery at the same site. You can wash your hair two days after the operation. You should avoid dyeing your hair for three months.
Austroads guidelines state “a person should not drive for six months following supratentorial surgery or retraction of the cerebral hemispheres” for private drivers and “twelve months” for commercial drivers. This will apply to most patients who have had a craniotomy. https://austroads.com.au/drivers-and-vehicles/assessing-fitness-to-drive
All operations carry some risk. The risks of awake craniotomy include scarring, numbness around the site of the scalp incision, headaches, bleeding, infection, CSF leak or CSF disturbance, seizures or epilepsy, stroke and neurological deficit (including visual / hearing / balance / speech / swallowing / sensory / cognitive disturbance or loss, weakness and paralysis), pain, hormone disturbance (with need for long term replacement), death, symptoms remaining the same, increasing or recurring, tumour residual or recurrence, the need for further procedures, needing to abandon awake surgery (typically because of intra-operative seizures), venous thromboembolism, cardiorespiratory complications and anaesthetic risks.