Living with a brain tumour: Undergoing an awake craniotomy

The aim of this leaflet

This leaflet explains what an awake craniotomy involves and the reasons why we have recommended this form of neurosurgery for you.

What does an awake craniotomy mean?

A craniotomy is an operation where an incision is made in your scalp (the skin on your head), followed by the temporary removal of part of your skull bone. This piece of bone is removed in order to gain access to your brain tumour. Once your operation is complete, the surgeon replaces the section of bone and closes your scalp wound with stitches or surgical staples.

Sometimes, the procedure is performed when the patient is awake for part, or all, of the procedure. This is known as an awake craniotomy. These operations are usually performed when tumours are found close to, or within, parts of the brain that are important in helping control speech, language or movement functions.

Why do I need an awake procedure?

Although every patient is unique, areas of your brain that are vital in controlling your speech, language and the movements of your arms and legs are found in roughly the same location in each person. This location can sometimes be seen on MRI images (scans) of your brain.

If your tumour is within, or near, this area, we sometimes recommend you undergo an awake craniotomy. This is to ensure we take every possible step to help minimise any risks to you, such as causing permanent damage to mobility or speech.

Are awake craniotomies common?

We regularly perform a craniotomy as an awake procedure. Although it is routine for us, we fully understand that this is a major undertaking for you. We have done many of these. We know how to help you, allay your fears and to make the experience as comfortable as possible.

We have built in safety measures to ensure that anaesthesia and surgery goes smoothly. We only offer this procedure if the risks of undertaking an awake craniotomy are less than the perceived benefits to you.

Are there any particular risks?

Your neurosurgeon will talk through any specific risks relating to you. This largely depends on the size and location of your tumour and any previous medical history of relevance. Before you sign a consent form, all risks will have been detailed for you to consider.

It is important to remember that surgery has been recommended as the safest option for you. It is likely that without surgery, your tumour would continue to grow and may very well cause permanent damage to these vital parts of your brain as it grows. So whilst there are risks with undergoing neurosurgery, equally there are risks with delaying, or not proceeding with surgery.

We have listed some of the more common risk factors associated with awake craniotomies. If you are concerned about any of them, please speak to your neurosurgeon, anaesthetist or specialist nurse:

• Nausea and/or vomiting
• Agitation
• High blood pressure
• Seizures (fits)
• A need to convert to general anaesthetic.
  • This may happen if you develop problems with your breathing during the operation or if any of the previously listed complications become difficult to manage.
• Brain swelling with stroke-like symptoms.
  • As with any operation, swelling will get worse before it gets better. This swelling will put pressure on the brain which in turn may cause side-effects including loss of movement on one side or speech problems. This risk is slightly higher with someone undergoing an awake procedure.

What is the role of neuropsychology?

Prior to your awake craniotomy, a one hour neuropsychology appointment will be scheduled. You will likely meet with the psychologist that will be monitoring your speech whilst you are awake in your surgery. In the appointment, they will discuss your cognition (thinking skills) and you will complete several tasks: a simple picture naming task, counting and recalling days of the week. They will also discuss how best to support you during your surgery to ensure you are as comfortable as possible.

What is electrical/cortical mapping?

This is where your surgeon pinpoints the exact areas of your brain that control your speech, language and movements. It also helps the surgeon to see how close your tumour is from these areas, as everyone’s anatomy is slightly different.

A small electrical current (stimulus) is passed through this area of your brain. At the same time you will be asked to perform basic tasks by the psychologist you have previously seen such as naming simple objects on a photo, counting to 20 or gently

moving one of your arms or legs. You will not feel the electrical stimulus, but you may experience some difficulties in performing some of the tasks. This is normal and lets the surgeon know where they can and cannot operate. Depending on your reaction to the stimulus, your surgeon will know if it is safe to proceed with removing all or part of your tumour. This procedure is sometimes also referred to as cortical mapping.

During awake surgery, the electrical mapping is done with you awake, talking to the doctor and neuropsychologists. This is done with your safety in mind so that we know what your alert reactions are.

Will I feel pain during the operation?

Every effort is made to make this a pain-free operation. Your brain does not have any pain receptors, so you will not feel any pain during the time the surgeon is operating on it. This is one of the main reasons we are able to do this form of surgery while you are awake.

Before you go into the operating theatre, you will be given drugs to make you feel sleepy and relaxed. These are given to you via a drip in your arm in the anaesthetic room, which is located immediately next to the operating suite.

Once you are lightly sedated, your neurosurgeon will inject some local anaesthetic into your scalp and facial nerves. This is known as a scalp-block. This will stop your nerves from sending and registering any pain signals when the incision is made into your skin. The local anaesthetic may sting for a few seconds as the surgeon is injecting it, but it will very quickly subside.

If at any time you feel uncomfortable or get slight twinges of pain, you must inform the anaesthetist who will give you some more local anaesthetic.

What happens if I suffer long term side-effects?

Unfortunately, some side effects may be permanent despite our best efforts to ensure otherwise. Should you need further rehabilitation as a result, we will arrange for this to be undertaken at a centre closest to your home.

In some instances, you may still be able to go home, with adequate out-patient access to rehabilitation services such as Physiotherapy, Occupational Therapy or Speech Therapy. Each case is different so please contact us for advice and support if you have any questions or concerns.

Am I awake throughout the whole operation?

Your neurosurgeon will discuss all options with you and your family or carer as required. In most cases, you will be asleep via a general anaesthetic for the first part of the procedure and only woken up once the skull bone has been removed and your brain tumour exposed. You will then remain awake for the remainder of the procedure. Pain relief and nerve blockers will be administered meaning you will not feel any pain. The brain itself has no pain receptors.

The size and location of your tumour and any other relevant health problems you may have will dictate which option is deemed safest and best for you. Please speak to your neurosurgeon or specialist nurse if you have any concerns or questions. You will find all relevant numbers at the back of this leaflet.

Am I put back to sleep once the tumour is out?

No. You will remain awake or lightly sedated for the rest of the surgery. It is important to appreciate that you will not be completely asleep while procedures are happening to you. You will feel relaxed and comfortable, and you are likely to have a complete memory of all events for the whole awake craniotomy operation. This is expected and normal. Once surgery is completed, and as much of the tumour as possible has been removed, the skull bone will be put back in place and the wound will then be closed.

What will happen on the day of surgery?

On the morning of your operation, an anaesthetist will see you and ask you questions about your general health, allergies, previous surgeries, and any past reactions to different drugs. You will get the opportunity to ask any questions you may have about the anaesthetic.

Before you are collected from the ward, you will be asked to put on a hospital gown. For your safety, we ask you remove hairpins, nail polish, make-up and jewellery.

Dentures, partial plates, glasses, contact lenses and hearing aids can be worn until you arrive in the anaesthetic room where sometimes they may need to be removed. If removed, they will be placed in a patient property bag and labelled with your details. This bag will then accompany you back to your ward.

When you arrive at the theatre reception area, you will be met by the surgeon and other operating department personnel. They will explain again what will happen during the awake craniotomy procedure.

What about my hair?

Your surgeon will shave a strip of your hair off. Usually this is a couple of centimetres in diameter. How long the scar is depends on the size/location of your tumour. We do not recommend your shave your hair before the procedure as this increases the risk of infection. Please discuss any such requirements directly with your surgeon.

Will I have a scar?

You will be left with a scar, but the incision is normally placed behind your hair line. As your hair re-grows it will cover the scar. After a year or so, your scar will fade to a thin line.

Does the bone in my skull rejoin up after the operation?

Like any other broken bone, the skull will heal itself with time. Normally this takes six to eight weeks. The ‘window’ of your skull bone created during your surgery is secured in place via titanium plates or clips. These clips are MRI safe.

What if I need to cough or use the toilet?

We want you to be as comfortable as possible during your operation. We believe the more prepared you are for your surgery, the more relaxed you will be about it. If you feel you need to cough or sneeze then let the surgeon or anaesthetist know and they will stop for a minute to allow this to happen. As you have been given some sedation, you may even fall asleep during part of the operation, which is perfectly fine.

In order to monitor your kidney function and fluid balance, we may need to insert a urine catheter into your bladder before the operation. As you are lightly sedated when this is done, you will most likely not even remember having it inserted! The catheter will be removed as soon as you are mobile on the ward.

Will I be able to see what is going on?

No. In order to keep a sterile field during the operation, a surgical drape is placed around your head. You will not be able to see what is going on as the surgeon will be working behind this drape. There will be a nurse or doctor present for you to see and talk to at all times.

You will hear some unfamiliar noises, such as the noise of the drill or suction catheter. These noises do not last long and are similar to those heard at the dentist. Please let the nurse or doctor know if there is any particular noise you are worried about – they will keep you informed of what is happening.

What happens if I nod my head during surgery?

Once your scalp-block is working and when you are still lightly sedated, a clamp is placed onto your head. This clamp stops your head from moving during the operation. It has to be secured to your skull bone in three places by pins which are tightened.

As you have had a full nerve block of your scalp, this procedure should be pain-free, but you may feel a little pressure whilst the clamp is being secured. If necessary, extra pain relief will be given intravenously in order to ensure you feel no pain.

Once you are positioned on the operating table, the head clamp will then be fixed to a frame at the end of the operating table. You will therefore not be able to move your head at all. This is done mainly to keep your head still whilst the surgeon is operating and to a lesser extent to prevent you from nodding or shaking your head in response to questions.

Contact details

Please do not hesitate to contact us on any of the below numbers if you have any questions or concerns regarding any aspect of your neurosurgical care. We are here to help.

Neuro Oncology Specialist Nurses (direct dial with answering machine): 01223 256246or via Addenbrooke’s contact centre 01223 245151 via mobile phone for urgent calls Mon-Fri, 8am-4pm

Team Secretary (direct dial with answering machine): 01223 216780