A team of surgeons and doctors huddle around the patient, the collective concentration encompassing the room. As they meticulously perform the brain surgical procedure, the sound of a violin fills the room.
And the violin is being played by the patient's hands.
Does this sound like science fiction? Because it’s reality. While they were operating on Dagmar Turner (to remove a tumor), surgeons woke her up to make sure they didn’t impact the areas of her brain that were necessary for her to play the violin. When she played her instrument, they could identify the areas that were actively working to help her perform the action, such as the area of the brain that controls precise coordination and precise hand movements.
This miraculous procedure is called an awake craniotomy. It is a surgical technique that is most commonly used in the removal of brain tumors such as metastatic brain tumors or gliomas. Awake craniotomies are performed in patients with tumors in or near critical brain areas such as the motor or speech cortex. The most common areas operated on include the motor cortex located in the prefrontal gyrus (Brodmann area 4), the sensory cortex located in the postcentral gyrus (Brodmann areas 3,1,2), and the language cortex (Broca’s and Wernicke’s area). Amazingly, the awake craniotomy procedure is also useful for deep brain stimulation surgery classically for Parkinson's disease and other central movement disorders, Alzheimer's disease, and psychiatric disease. Furthermore, it has uses in stereotactic brain biopsy and ventriculostomy, and interventional pain procedures such as pallidotomy and thalamotomy.
Surprisingly, the history of neurosurgery and specifically awake craniotomies dates back over a century. Sir Victor Horsley, in 1886, first performed an awake craniotomy to localize the epileptic focus with cortical electrical stimulation. Even before this, archaeological records show that during ancient times, patients were treated for seizures with trepanation (a surgical intervention in which a hole is drilled or scraped into the human skull). Susruta, an ancient Indian physician, known as the father of surgery and plastic surgery, was the first known physician to achieve a successful entrance of the skull. After Sir Victor Horsley, Wilder Penfield began early versions of awake craniotomies to treat patients with epilepsy. He and Andre Pasquet published their landmark paper on the surgical and anesthetic aspects of surgery after the administration of local anesthesia and intermittent sedation and analgesia. This technique was able to be reproduced, and it became an accepted surgical technique worldwide to treat epilepsy. In addition, Wilder Penfield was a pioneer because he applied the awake craniotomy technique for the first time to some patients with brain tumors as well. Renowned neuroscientist Dr.Henry Marsh is another leading figure in the development of the modern awake craniotomy. Although the findings of this procedure date to historic times, it hasn’t gained popularity until the 21st century, and even until this past decade.
It is fascinating to take a deeper look into the steps of this procedure. Let’s take the example of a patient with tumors near the speech/language processing or motor control areas. Before surgery, your neurosurgeon or a speech-language pathologist would ask them to identify pictures and words on cards or on a computer so that your answers can be compared during surgery. Their physician would also be responsible for determining whether or not the patient is a good candidate for the surgery, and would explain the benefits and drawbacks.
Next, during the first portion of the surgery, the anesthesiologist will give the patient some medication to sedate them for parts of your awake brain surgery. The neurosurgeon will apply local anesthesia to the patient’s scalp to ensure their comfort. During the procedure, a section of the skull is removed to gain access to the brain. Now, after the part of the skull has been removed, the anesthesiologist stops giving sedatives to wake the patients up. At this point, brain mapping is done by a whole team of diverse professionals. For example, the brain mapping team at the University of California San Francisco’s Brain Tumor Center includes neurosurgeons, neuroanesthesiologists, speech and language specialists, psychologists, and neurologists. During this step, the neurophysiologist will stimulate different relevant parts of the brain by applying small electrical currents to the areas around the tumor. The patient is kept awake during the removal of the tumor, and the neurophysiologist continues to interact with the patient during this removal. Lastly, while reattaching the skull at the end of the surgery, the patient is sedated again.
From a patient’s perspective, the procedure is painless, and recovery is not drastically different than other common surgical procedures.
Biomedical innovations like awake craniotomies are examples of the phenomenal leaps that humanity is making in healthcare. And it’s all because of people like HOSA members who dedicate themselves to finding ways to serve and treat the whole world. If you are someone who is interested in exploring and creating biomedical innovations like these, then Exploring Medical Innovation, Biotechnology, and Medical Innovations are competitive events that HOSA offers that may be perfect for you!
Check out the event guidelines here.