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This April, Don’t Be Fooled—Be Amazed

In honor of April Fool’s Day, we’ve debunked a myth in neurosurgery, and the truth may surprise you. It may even amaze you.

Myth: A patient is always unconscious during brain surgery.

Fact: For some patients, a portion of brain surgery is done while he or she is awake. This is called “awake craniotomy” or “awake brain surgery.”

You may be wondering, why would you ever need to be awake during brain surgery? The reason is so you can help the neurosurgeon map the important regions in your brain before operating on such a delicate organ.

Yep, you read right. You help during your own surgery.

Thanks to advancements in technology and medicine, neurosurgeons can operate near important areas of the brain that were historically off limits, and patient input is key. These “eloquent” areas of the brain are regions that control vital functions like vision, speech, movement and sense of touch. Although all brains have eloquent areas in the same general place, no two brains are exactly the same. One person is bilingual, another is a musician, and these differences manifest in the layout of the brain. If one of the eloquent areas is harmed, function may be impaired.

Neurosurgeons do awake brain surgery when brain tumor or epilepsy surgery involves operating in or near these important areas of the brain. A patient may also be awake during deep brain stimulation (DBS) surgery, which is done for patients with movement disorders, like Parkinson disease.

Before surgery, a technique called brain mapping is used to determine the areas to avoid. It’s also the technique used during surgery – while the patient is awake – to help the neurosurgeon plan where to remove a tumor, operate on areas of the brain, or place electrodes. Brain mapping is done by taking detailed images of the brain before surgery, using sophisticated technology to see the brain during surgery and, of course, creating a custom map. The map helps the neurosurgeon know which areas to avoid in order to preserve brain function.

As a neurosurgeon and researcher at Columbia University Medical Center/NewYork-Presbyterian Hospital, Dr. Marc Otten specializes in awake brain surgery and brain mapping.

“My work is focused on using imaging to look inside without having to look inside,” Dr. Otten explains. “Before surgeries, we are able to see not just the problem but also map out the networks of the brain, and that allows us to plan out the safest and most effective way to approach the problem.”

Here’s how awake brain surgery is typically done:

You start off sedated, or asleep. While you are asleep, the neurosurgeon makes a cut in the scalp and creates an opening in the skull. Once the brain is exposed, you are awakened.

It’s time to map your brain.

You shouldn’t feel pain during this “awake” portion of the procedure because the brain itself cannot sense pain.

Using small, thin electrodes, the neurosurgeon stimulates the areas near the brain tumor or area causing seizures. Then he asks you to complete a task associated with the function of that area.

If, for example, the neurosurgeon probes near Broca’s area, a region that processes language, you may be asked a series of questions. The neurosurgery team listens closely to your responses. If you have difficulty forming words, the neurosurgeon knows to avoid that region and, like a cartographer, marks it on a digital map.

Other tasks you may be asked to do include counting, identifying pictures or moving a particular body part. Once the important areas are marked on the map, the neurosurgeon plans how to safely remove the brain tumor or repair the area causing seizures. Throughout the operation, this custom map serves as a guide.

But you’re not done helping. Throughout the surgery, the neurosurgeon constantly checks to make sure he is still in a safe area. He gently probes an area and re-asks you to complete tasks associated with that region’s function.

Once the surgery is over, your job is complete.

Looks like this myth is busted! The truth is some patients are awake—and assisting—during brain surgery.

Learn more about Dr. Otten on his bio page here.

patient journey

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