Awake Craniotomy (Brain Surgery)

What is an awake craniotomy?

An awake craniotomy is open brain surgery to remove tumours or a section of the brain where seizures occur. These brain sections are often within, or close to, critical regions of your brain. These regions typically control important bodily functions or your sensory and linguistic skills.

It is important that you are conscious during parts of the procedure so that your surgeon can monitor your neurological functions closely. Although you will be awake, you will not feel any discomfort because a local anaesthetic will be applied to fully numb the area, and sedation will be provided.

Why do you need an awake craniotomy?

An awake craniotomy is especially beneficial for some brain tumours and epilepsy. The procedure allows the team to:

Identify critical areas of the brain to avoid during the surgery
Remove or treat brain tumours that are within or near critical regions of the brain

If not for awake craniotomy, certain conditions may be considered inoperable due to the risks of damaging critical areas of the brain.

Who should not undergo an awake craniotomy?

An awake craniotomy may not be suitable for a patient who is unable to communicate during the surgery. This may be due to severe symptoms of an existing condition, such as severe sleep apnoea.

Without responsive feedback from the patient during the procedure, the surgical team will not be able to map their brain accurately. This will affect the outcomes of the surgery.

Your doctor will help to determine if you are a suitable candidate for this procedure.

What are the risks and complications of an awake craniotomy?

Your doctor will explain the degree of risk in your case, as it depends on a number of factors. These include the severity of your condition, the size and location of the tumour and your general health.

Complications may include:

Memory loss
Fits or seizures
Speech or learning difficulties
Coordination and balance impairments
Cerebrospinal fluid (CSF) leak
Muscle weakness
Brain swelling
Meningitis

Generally, the incidence of serious complications causing a permanent stroke or death is low. The risks of surgical and medical complications are also thought to occur less frequently in awake craniotomy.

How do you prepare for an awake craniotomy?

Before your surgery, your doctor may order several tests such as:

Blood tests
Electrocardiogram (ECG) test

You will also have an anaesthetic review in the ward with an anaesthetist. During this review, you can ask any questions you have about pain relief during the surgery.

Closer to your surgery, your anaesthetist or surgeon will advise you on how to prepare. In general, you may drink fluids up to 2 hours before your surgery and eat solid foods up to 6 hours before your surgery.

What can you expect in an awake craniotomy?

You will be fully conscious during parts of the procedure so that your surgeon can monitor your neurological functions closely. As you will be under anaesthesia throughout the procedure, you should not feel any pain.

Communication with your surgeon is crucial for the team to assess the effectiveness of the surgery as it is progressing, and to ensure that important functions are not compromised.

Estimated duration

An awake craniotomy typically takes between 4 – 8 hours in total. Depending on the severity of your condition, your awake time in the surgery could range from 45 minutes to several hours.

Before the procedure

Before surgery, your specialist may ask you to identify pictures and words on cards or a computer so that your answers can be compared during surgery.

During the procedure

You will be given sedatives to make you sleepy for parts of your awake craniotomy. To facilitate the surgery, your head will be kept in a fixed position. Your surgeon will use an image guidance system to locate the tumour in your brain and mark your scalp. Some of your hair around the incision will be shaved.

Your surgeon will then remove part of your skull to reach your brain. You will remain sedated (asleep) during this part, and also when your surgeon reattaches your skull at the end of the surgery.

Once your brain is exposed, your anaesthetist will stop administering the sedatives so that you can wake up and provide feedback. Your surgeon will perform a procedure called cortical mapping where they stimulate the brain surface with a tiny electrical probe.

When they stimulate...	You may experience...
A motor region of your brain	Twitches in your limb or face
A sensory area	A tingling feeling
A speech area	Difficulty speaking very briefly

During this stage, you may be guided through a series of instructions or asked to respond to questions. This enables the team to:

Confirm the critical parts of your brain before proceeding to remove the tumour.
Lower the risk that your vision, movement or speech abilities may be damaged during the surgery.

Your surgeon will continue engaging with you as they remove the tumour, and stop if your level of functioning changes.

Once the surgeon has removed as much of the tumour as possible, the team will stop all bleeding and close the dura (thick membrane surrounding the brain) with sutures.

They will replace your bone flap with mini-plates and close your scalp. They will then close your skin, dress your wound and apply a head bandage.

After the procedure

Your surgeon may request a magnetic resonance imaging (MRI) scan to confirm that the tumour has been completely removed.

You will be monitored in the intensive care unit for a while. Most likely, you will spend another 2 – 3 days in the hospital to rest and recover.

Care and recovery after an awake craniotomy

For the first few weeks after surgery, you may feel tired more easily and take frequent naps. As much as possible, you should aim to do gentle exercises (such as walking) every day.

Generally, you should be able to return to work and other normal activities after a few weeks as directed by your specialist.

You should have a follow-up appointment with your doctor about 5 – 10 days after your surgery to check the incision. Your doctor will check on your recovery and answer any questions you may have. They will discuss with you your options for future care. Many patients follow their surgery with radiation therapy and chemotherapy.