Awake Craniotomy

What is awake craniotomy?

An awake craniotomy is a specialised type of brain surgery in which the patient remains conscious during part of the procedure. It is primarily used when a lesion, such as a brain tumour or epileptic focus, is located near areas that control vital functions including speech, movement or vision. This technique is also employed in the treatment of arteriovenous malformations, cavernomas, low-grade gliomas and certain functional neurological conditions such as movement disorders and chronic pain, where precise mapping of brain function is essential to preserve important abilities.

Unlike a standard craniotomy, which is typically performed under general anaesthesia, an awake craniotomy allows real-time monitoring of brain activity. The surgical team may ask the patient to speak, move or respond to instructions while the surgeon stimulates or removes tissue near critical brain regions. This approach helps to guide the procedure and reduce the risk of long-term neurological deficits by ensuring that key functional areas are identified and preserved during surgery.

How does awake craniotomy work?

Awake craniotomy involves the temporary removal of part of the skull to access the brain while keeping the patient conscious during key stages of the operation. The procedure begins with local anaesthetic and light sedation to ensure that the patient remains calm and free of pain. Once the brain is exposed, the patient is gently awakened and asked to carry out simple tasks such as speaking, moving a limb or following instructions.

This interactive approach allows the neurosurgeon to electrically stimulate specific areas of the brain and accurately map regions that control essential functions such as language, movement, sensation and vision. This functional mapping helps the surgical team avoid damaging critical areas during procedures such as tumour resection, epilepsy surgery and the treatment of vascular or functional brain disorders. Once the necessary surgical work is complete, sedation may be resumed while the skull is carefully closed.

What are the uses of awake craniotomy?

Awake craniotomy is used in specific situations, including:

• Tumours near functional brain areas: When a tumour is close to regions responsible for speech, movement or vision, functional mapping is used to identify and preserve these critical areas while maximising safe tumour removal.
• Epilepsy surgery and functional mapping: During procedures to control seizures, mapping helps identify and protect areas responsible for language, motor control and other essential functions.

Awake craniotomy provides real-time feedback, which greatly improves the accuracy and safety of surgery in delicate or high-risk brain areas.

What are the risks associated with awake craniotomy? 

Awake craniotomy is generally considered safe when performed by an experienced team. However, as with any surgical procedure, there are potential risks and safety considerations:

• Infection: There is a small risk of infection at the surgical site, which is managed with sterile technique and antibiotics if needed
• Bleeding: Bleeding within the brain or at the surgical site may occur, although this is uncommon
• Seizures: Brain stimulation during the procedure may trigger a seizure, but the surgical team is prepared to manage this safely.
• Swelling or pressure: Temporary swelling around the surgical area can lead to headaches or neurological symptoms.
• Neurological changes: Some patients may experience temporary or, rarely, permanent changes in speech, movement or memory, depending on the brain area involved.
• Emotional distress: Being awake during surgery can cause anxiety or distress, although this is minimised through psychological support and anaesthetic management.
• Airway risks: Maintaining a clear airway while the patient is awake can be more complex than during procedures under general anaesthesia.

These risks are carefully managed through detailed preoperative assessment, close monitoring during surgery and ongoing support throughout recovery.

What are the limitations of awake craniotomy?

While awake craniotomy offers significant benefits in preserving brain function, it has certain limitations and is not suitable for every patient or every type of brain surgery.

Its limitations include:

• Patient suitability: Not all patients are suitable for awake procedures, particularly those with high anxiety, communication difficulties or certain medical conditions.
• Extended duration: The procedure may take longer than a standard craniotomy due to the need for intraoperative testing and patient interaction.
• Emotional and psychological stress: Being awake during brain surgery can be challenging for some patients despite careful preparation and support.
• Specialist requirements: The surgery requires a highly skilled team, including experienced neurosurgeons, anaesthetists and support staff trained in awake procedures.
• Technical limitations: In rare cases, mapping may not clearly identify functional areas, which can limit the effectiveness of the approach.

Awake craniotomy remains a valuable technique in selected cases, but the decision to proceed depends on careful assessment by the neurosurgical and anaesthetic teams.

How can you prepare for awake craniotomy?

Preparing for an awake craniotomy involves careful planning by the medical team and active participation from the patient. You may be asked to go through the following in the days leading up to the procedure:

• Medical evaluation: Attend pre-operative assessments, including brain imaging, blood tests and anaesthetic review.
• Medication review: Inform your doctor of any current medications, especially those that affect bleeding or consciousness.
• Functional testing: You may undergo speech, language or motor assessments to help the team plan intraoperative brain mapping.
• Discussion of expectations: Speak with your surgeon and anaesthetist about the steps involved and what you may experience while awake.
• Emotional preparation: You may be referred to a psychologist or support team to help manage anxiety and prepare for the awake portion of surgery.
• Fasting: Follow specific guidance on when to stop eating and drinking before surgery.
• Consent and planning: You will be asked to give informed consent and may need to practise simple tasks that you will be asked to perform during surgery.

What can you expect during awake craniotomy?

An awake craniotomy is carried out in stages to ensure that the patient remains safe, comfortable and able to cooperate. The procedure typically follows these steps:

• Initial sedation and monitoring: You will receive light sedation to help you relax, and your vital signs will be monitored continuously.
• Scalp anaesthesia and positioning: The scalp will be numbed with local anaesthetic, and you will be positioned on the operating table in a way that provides access to the surgical site while keeping you stable and comfortable.
• Opening the skull: A small part of the skull will be removed to expose the brain. You will remain sedated or asleep during this part.
• Waking phase: Once the brain is exposed, sedation will be reduced so that you can become fully awake and responsive.
• Functional testing: The neurosurgeon will ask you to speak, move your limbs, or carry out simple tasks while stimulating parts of the brain. This helps identify and protect critical areas during tumour removal.
• Communication and reassurance: You will be supported by the team throughout the procedure, with regular reassurance and encouragement.
• Completion of surgery: After tumour removal, sedation may be increased again while the skull is closed and the wound is stitched.

What can you expect after awake craniotomy?

Recovery after an awake craniotomy varies depending on the individual and the area of the brain involved. Most patients are monitored closely in hospital for the first few days. You can generally expect the following:

• Observation and monitoring: You will be taken to a recovery area or high-dependency unit, where your neurological function, vital signs and surgical site will be closely monitored.
• Mild symptoms: Headache, tiredness, nausea or some swelling at the incision site are common and usually improve within a few days.
• Speech or movement changes: Temporary difficulties with speech, coordination or memory may occur, depending on the tumour location. These are often mild and improve with time.
• Imaging: A postoperative scan may be performed to check the outcome of the surgery and ensure there are no complications.
• Physiotherapy or rehabilitation: Some patients may require support from a speech therapist, occupational therapist or physiotherapist during recovery.
• Hospital stay: Most patients remain in hospital for several days to allow for recovery and assessment before returning home.
• Follow-up care: You will be given instructions for wound care, activity restrictions and follow-up appointments with your surgical team.

Will I feel pain during an awake craniotomy?

No, you should not feel pain during an awake craniotomy. Local anaesthetic is used to numb the scalp, and sedation is given to help you stay relaxed. Although you may feel some pressure or hear sounds, discomfort is kept to a minimum.

How long does an awake craniotomy take?

An awake craniotomy usually takes between four to six hours. This includes preparation, brain mapping, tumour removal and closure. The exact time depends on the complexity and location of the tumour.

Will I be awake throughout the entire awake craniotomy?

No, you will not be awake for the entire awake craniotomy. You will be sedated at the beginning and end. You will be gently woken during the part of the surgery where brain function needs to be assessed.