Hovering Between Worlds: Awake During Brain Surgery

Hovering Between Worlds: Awake During Brain Surgery
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There are certain areas in which conventional medicine excels, and the ability to perform brain surgery to remove tumors is one of them. This is particularly true in the case of awake brain surgery, also known as intraoperative brain mapping, which is performed while the patient is sedated but awake.

Awake brain surgery is typically performed to treat epileptic seizures or remove tumors without clear borders that have spread throughout the brain. Because the tumors are often close to brain regions responsible for controlling vision, language and movement, it would be too dangerous to attempt to remove them while the patient is completely under anesthesia, as doing so could result in a significant loss of function.1

Awake brain surgery allows neurosurgeons to remove or shrink tumors that may otherwise be inoperable, while preserving the patient’s speech and other skills. In the video above, you can watch a particularly remarkable case, in which a woman not only remained awake during brain surgery but played her violin throughout — ensuring she wouldn’t lose this skill that she held near to her heart.

Musician Plays Violin During Brain Surgery

Violinist Dagmar Turner, 53, was diagnosed with a brain tumor in the right frontal lobe, which is near the area that controls fine movements of her left hand.2 As a musician who plays with the Isle of Wight Symphony Orchestra, Turner was concerned about losing the ability to play the musical instrument, so she asked her doctor if she could play the violin during the procedure.

Surgeons at King’s College Hospital in London agreed. Dr. Keyoumars Ashkan, her neurosurgeon, told Time:

“We knew how important the violin is to Dagmar, so it was vital that we preserved function in the delicate areas of her brain that allowed her to play … We managed to remove over 90% of the tumor, including all the areas suspicious of aggressive activity, while retaining full function in her left hand.”3

Before the surgery, doctors mapped brain areas that were active when Turner played the violin. She was awoken in the middle of the surgery to play the violin and “ensure the surgeons did not damage any crucial areas of the brain that controlled Dagmar’s delicate hand movements,” according to a statement from the hospital.4

“The thought of losing my ability to play was heart-breaking but, being a musician himself, professor Ashkan understood my concerns,” Turner told Time. “He and the team at King’s went out of their way to plan the operation — from mapping my brain to planning the position I needed to be in to play.”5

Guitarist Also Plays During Brain Surgery

In a similar case, South African musician Musa Manzini also played a musical instrument during brain surgery to remove a tumor.

Playing the guitar requires complex interactions in the brain, and by playing during the surgery, “It increased the margin of safety for us, in that we could have real-time feedback on what we were doing,” Dr. Rohen Harrichandparsad, one of the neurosurgeons involved in the procedure at Inkosi Albert Luthuli Central Hospital in Durban, told The Guardian.6

The surgery was a success, with 90% of the tumor being removed and Manzini’s ability to play the guitar preserved. Other cases have also made headlines, including a musician who played a saxophone during brain surgery in 2015 and an opera singer who sang during a brain operation in the Netherlands in 2014.7

Computer Images Create a Map of the Brain

There are a number of considerations that go into deciding whether awake brain surgery is the best option. In his book, “Do No Harm: Stories of Life, Death, and Brain Surgery,” British neurosurgeon Henry Marsh wrote, “Often it is better to leave the patient’s disease to run its natural course and not to operate at all.”8

According to Johns Hopkins, other considerations include the patient’s general health, as awake brain surgery isn’t performed in people who are obese or have sleep apnea. The patient must also be able to stay calm during the surgery and respond to the neurosurgeon, and the tumor must be able to be removed without causing damage to critical areas of the brain.9

The patient may be awake for the entire procedure or could be sedated or put to sleep at the beginning and end of the procedure and be awake only in the middle. The neurosurgeon then uses small electrodes to stimulate the brain, and, to locate functional areas of the brain to avoid, will ask the patient to perform different tasks such as speaking, counting or playing an instrument.

Computer images of the brain help with this, creating a map of functional areas of the brain. Marsh wrote:10

“Brain surgery is dangerous, and modern technology has only reduced the risk to a certain extent. I can use a form of GPS for brain surgery called Computer Navigation where, like satellites orbiting the Earth, infrared cameras face the patient’s head. The cameras can ‘see’ the instruments in my hands which have little reflecting balls attached to them.

A computer connected to the cameras then shows me the position of my instruments in my patient’s brain on a scan done shortly before the operation. I can operate with the patient awake under local anaesthetic so that I can identify the eloquent areas of the brain by stimulating the brain with an electrode.

The patient is given simple tasks to perform by my anaesthetist so that we can see if I am causing any damage as the operation proceeds.”

Still, even under the best circumstances, there is a risk of leaving a person severely disabled if even a small area of the brain becomes unintentionally damaged.

Even Marsh wrote, “Despite all this technology neurosurgery is still dangerous, skill and experience are still required as my instruments sink into the brain or spinal cord, and I must know when to stop … And then there is luck, both good luck and bad luck, and as I become more and more experienced it seems that luck becomes ever more important.”11

Benefits of Being Awake During Brain Surgery

There are practical benefits to being awake during brain surgery, including cost. “The total inpatient costs for awake craniotomies were lower than surgery under GA [general anesthesia],” researchers wrote in the journal Neurosurgery.12 While total inpatient expenses per patient for awake craniotomy came in at $34,804, this rose to $46,798 for surgery under general anesthesia.

Further, the incremental cost per quality-adjusted life years for the awake craniotomy group was $82,720 less than the general anesthesia group. Awake brain surgery also required fewer days in the hospital — 4.12 days for the awake craniotomy group compared to 7.61 days for the general anesthesia surgery group.

“This study suggests better cost effectiveness and neurological outcome with awake craniotomies for perirolandic gliomas,” the researchers noted.13 Another of the primary benefits is avoiding the risks that come along with general anesthesia, which can be significant.

Research published in the journal Anesthesiology compared the effectiveness of local versus general anesthesia for hip fracture surgery and found the local anesthesia was associated with better outcomes, with researchers writing, “Regional anesthesia is associated with a lower odds of inpatient mortality and pulmonary complications among all hip fracture patients compared with general anesthesia.”14

Awake Brain Surgery Outcomes and Shortcomings

Research into outcomes of awake brain surgery have also suggested positive outcomes. In a review of medical records for 35 patients who had awake right hemisphere brain operations, 68.7% of those with seizures became seizure-free and 77.7% of those with moderate to severe headaches improved significantly.

“There were also improvements in speech and language functions in all patients who presented with speech difficulties,” the researchers noted, adding, “When combined with intraoperative cortical mapping, both speech and motor function can be well preserved.”15

That being said, most research into awake brain surgery has focused on preserving language and motor function, while the monitoring of other cognitive functions has been less explored.

In a systematic review of 360 studies, tests to assess memory, calculation, emotions and other cognitive functions were reported in only a minority of cases, as were tests for visuospatial domain and motor and sensory functions. On the contrary, tests to assess language functions were widely reported.

“There is a need for development of tests or paradigms for assessment of other cognitive functions so that the broad spectrum of cognition can be monitored during awake brain surgery,” researchers explained16 and, indeed, there remains much to be learned about the human brain as a whole, let alone how it responds to interventions like surgery. As with all surgery, there remain risks for awake brain surgery, which include:17

Changes in vision Seizures Difficulty with speech or learning
Loss of memory Impaired coordination and balance Stroke
Swelling of the brain Too much fluid in the brain Meningitis
Leaking spinal fluid Weak muscles

Brain Tumor Signs and Symptoms

In the U.S., an estimated 700,000 people are living with a primary brain tumor and 87,000 more will be diagnosed with one in 2020.18 Common symptoms of a brain tumor include:

Loss of balance Memory loss and language issues
Mood and/or behavior changes Nausea and vomiting
One-sided weakness or numbness Persistent headaches
Seizures Vision changes

EMF exposure, including cellphone use, contributes to chronic illness including brain tumors, and you’d be wise to reduce your exposure to cell towers, cellphones, microwaves, “smart” products, Wi-Fi and wireless products. Increased peroxynitrites from cellphone exposure will damage your mitochondria, and your brain is the most mitochondrial-dense organ in your body.

This is but one risk factor for brain tumors, which often occur without a known cause. Other risk factors may include radiation exposure, family history and a weakened immune system, as well as potentially infection with certain viruses or exposure to certain chemicals such as vinyl chloride, pesticides and petroleum products.19

As much as possible, be proactive in using a healthy lifestyle to support and protect your health and remember, too, that even your brain is capable of being regenerated.

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