Awake Craniotomy: Confronting Brain Surgery with Open Eyes

Maciej Lesniak, MD, and Anna Litchfield

A surgical procedure is a daunting experience for any patient, though thanks to general anesthesia, it's not typically a memorable one. That's not the case for patients who go through an awake craniotomy -- a unique procedure that allows surgeons to react based on feedback from the patient during removal of a brain tumor.

"I remember them waking me up using a flashlight and talking to me," Anna Litchfield, a 49-year-old patient who was operated on by Maciej Lesniak, MD, Professor of Surgery and Neurology, said in August. "I remember Dr. Lesniak saying 'Anna, are you OK?' and I remember saying 'Great, Dr. L!' out of nowhere. I never thought I'd call him Dr. L! In retrospect, I feel like my brain was thrilled that he was there operating."

Awake craniotomies are unique, complex procedures typically used to remove tumors nestled close to functional areas of the brain. Though the macabre nature of the surgery might induce shudders, the benefits for the patient are great. As the tumor is carefully removed by the surgeon, a neurologist can continuously monitor the patient's language, motor and sensory function to make sure critical parts of the brain suffer minimal damage.

Dr. Lesniak showed me very quickly that he not only understood me as a patient from an emotional point of view, but also supported my journey and the fact that I was contemplating a very scary option.

"When tumors are in what we call eloquent, functional areas, the margin of error is a millimeter," Lesniak said. "You have to ask yourself whether you feel comfortable with a patient being asleep, potentially missing that millimeter while taking out the tumor and having them wake up devastated, or minimizing that risk."

Lesniak and his team perform more awake craniotomies than any other group in the Chicago area -- more than 30 each year. Each surgery utilizes a truly interdisciplinary and experienced team of neurosurgeons, neurologists, anesthesiologists and operating room nurses who must collaborate to ensure the unusual surgery's success. Often, craniotomy candidates are referred to Lesniak from hospitals around the area and country, as the surgery can be performed only by individuals with significant expertise and experience.

"Dr. Lesniak showed me very quickly that he not only understood me as a patient from an emotional point of view, but also supported my journey and the fact that I was contemplating a very scary option," said Litchfield, who was referred to the University of Chicago Medicine from another local hospital. "I decided if there's anybody on this planet I would literally let in my head, it would be him."

For most of the procedure, the patient is kept in a state of "twilight" anesthesia, similar to what is used for colonoscopies or dental procedures. Because there are no pain fibers in the brain itself, controlling pain is not the primary issue. But anti-anxiety medication is used to keep the patient calm amid drilling noises and unusual sensations.

"It seems rather amazing that you can open up someone's skull and take out a piece of their brain while they're awake," said Steven Roth, MD, Professor of Anesthesia and Critical Care. "But we're accustomed to it, we know what to expect and what's necessary. So for people who have trained and worked in this area, it's fairly routine. I think the ability to do this has gotten easier and safer."

Still, in a procedure that can last up to eight hours, it's important to keep an awake patient calm under the very unusual circumstances.

"Often I find my role is to distract the patient from what's going on," said Leo Towle, PhD, Professor of Neurology, Surgery and Pediatrics. "We talk about their kids, their hobbies, whatever keeps them comfortable and talking during the procedure."

The conversation is more than mere small talk. Throughout the surgery, the neurologist runs tests with the patient to make sure that there is no loss of function. If a tumor is near a language area of the brain, the patient is asked to name objects from a flipbook, so that the team can listen for the sudden appearance of a speech deficit.

"They're under the drapes, asking them questions, showing them cards, asking them to count back, and I listen," Lesniak said. "It's like music: When there's a note or something that sounds off, I know that we are approaching a critical area."

Litchfield's surgery was one example of how this safety system works. With a lemon-sized mixed glioma (oligoastrocytoma) on the right side of her brain invading into the motor cortex, it was important to monitor Litchfield's ability to move the limbs on the left side of her body during the surgery. When the team observed muscle weakness developing during the resection, the surgery was immediately stopped.

Litchfield experienced some neurological deficits after the surgery, but has seen almost full recovery of normal function after rehabilitation. In a different procedure where the surgical team could not continually test the patient in such a critical area, the damage would have been permanent, Lesniak said.

"She's an example of why you do it this way," Lesniak said. "The area between functional brain and the tumor is often close, and in the case of Anna’s tumor, it was intertwined. So the minute that you run into trouble you can actually stop. While she had a little bit of a neurological problem afterwards, she's getting better from it and now she's recovering."

Anna with photograph of her grandfather

When Litchfield, a Montessori early childhood educator from Lake Forest, was first offered the awake craniotomy option, she wasn't sure she could handle the experience. To prepare herself, she asked friends (including one who served three tours in Iraq and Afghanistan) for their advice on how to partner with her fear in order to remain calm and took inspiration from her grandfather who served in World War II.

"Because it's a surgery that not many people would choose to have, you have to be very mentally prepared for what you're doing," Litchfield said. "We all have the power in ourselves to overcome the thing we fear the most. Certainly, an awake craniotomy can bring that out, you would have to be crazy to want to do it. But it has been a complete reassurance of the ability each of us has to face challenges that we never thought we would have to face, and never thought we could."

November 2011


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