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Awake Brain Surgery

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Posted 3/8/2015

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Dr. Michele Aizenberg explains how keeping a patient awake during part of a brain tumor removal can help in preserving "eloquent" brain functions such as speech and movement. Dr. Aizenberg performs awake craniotomy surgery at The Nebraska Medical Center in Omaha, Nebraska. For more information, call 1-800-922-0000 or visit

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The benefit of doing surgery awake for a patient is that it allows us, the surgeon, to be able to completely map out the area of eloquence. The area of eloquence is something that is like motor functions, speech function, other language function and sensory function. By doing this, we can know the brain’s function in relation to the tumor. And then more safely resect the tumor or as much of the tumor as possible.

The benefit of that is that we can know the where those areas are and avoid injuring the primary areas. We want to keep the patient as functional as possible.

So I believe that by using a sleep/awake technique, the patient is going to be the most comfortable. So I explain to them that initially they will be sedated and put to sleep but not in the same fashion as with general anesthesia. And they get a special airway put in the back of their throat and everything gets completely numbed up and when everything is open and we’re ready to do the mapping and then the tumor resection, they get woken up and they should be very comfortable, if they have any discomfort, they should let us know, and but I have to say that patients rarely have any pain. The most issue that they have is really just getting tired. And so I explain all that to them and when they know what to expect, they’re not so nervous anymore.

We let people know they may feel some twitches, because we use a stimulator and that’s how we can assess where the function is. They may get some funny feelings during tumor resections; to follow how they’re doing neurologically, I have them squeeze a squeezy toy. Also to move their leg, I also put something around their foot which makes a noise, some bells actually, and we’ll have them move their food and they’re continually monitored during the resection so that if I get close to something or if there’s any change, I will know about it right away. For language, we have them count, name the months of the year for example, just speak in sentences, read objects, we show them an object and ask them to name the object with big laminated cards, and so we test visual naming, repetition, everything related to the speech areas, as complete as we possibly can under the circumstances, . So we can tell if someone has problems with speech arrest, misnaming, comprehension and things depending on where we’re stimulating.

Awake surgeries are not new; neurosurgeons have been doing them for a long time. Not a lot of neurosurgeons do them however and not a lot of neurosurgeons operate in eloquent areas. I think if you do surgeries in awake fashion, with a specific purpose of mapping out the eloquent area and protecting that area, which means that you don’t disrupt it during resection of the tumor, then you’re going to have a better neurologic outcome. Our goal is to provide that while still trying to provide maximal benefit with the tumor resection. And it’s very important in my opinion to weigh all of that in the operating room and if you think you’re going to leave someone with a permanent deficit that’s going to reduce their quality of life, that may not be a benefit to them just to remove that extra small percentage of tumor or whatever. And how much we remove of the tumor is also dependent on the tumor type; what’s appropriate and what’s not.

Anyone could be a good candidate for an awake surgery; if the tumor is located in or very near an eloquent area that we are worried about. For me, in my practice, I don’t necessarily discriminate upon age; certainly someone has to be able to cooperate and be testable, and that’s really the important thing. So if their neurologic function isn’t immutable for testing, they’re not going to be a good candidate. Someone could be 80 years old and be quite functional and have a tumor that’s in or near an eloquent area, and if they’re an appropriate surgical candidate and all things make sense, they’re a fine candidate. If someone is 10 years old and they are appropriate in terms of their neurologic function and their status, they would be okay to do awake assuming psychologically they’re okay as well. So it’s really dependent in my opinion on through the global picture of the patient, not necessarily just upon age.

So here at The Nebraska Medical Center, we now have the brain and spine cancer center, which is a comprehensive multi-disciplinary program to take care of patients with brain and spine tumors or cancers that either have occurred primarily or mestacicized, meaning spread from somewhere else. We have all of the components necessary, such as neurosurgery, oncology, radiation oncology, neuropathology, neuroradiology, neuropsychology and all of the other support services. This provides the utmost in clinical care, which is coordinated and comprehensive, which ultimately provides better care and outcomes for patients.

So another big component and important part of a big program or center such as ours here is research; and here as with other big centers we have basic science, translational science or research and clinical research and trials and so we are in the process of opening clinical trials for brain tumors. We also have basic science and translational projects that we are working on that we hope in the next few years will lead to something that we may be able to have a clinical trial for. So by providing all of the comprehensive clinical care, from all of the subspecialties of neuro-oncology, as well as the research components that I’ve just described, we have everything here in one place. So we can help move the field forward as things grow and that would be from a scientific and from a clinical standpoint.

Now that being said, if we don’t have something that we think a patient would benefit for, we have plenty of friends and colleagues in the field and we speak with them frequently and we have no problems offering something to a patient that may be outside of our institution because we feel it’s important to that we keep all of the doors open for people and let them choose what they think is appropriate for that.