Awake Craniotomy Successfully Performed at Rajagiri Hospital

KOCHI:
Rajagiri Hospital, Aluva, made a scientific victory with the successful conduct of ‘Awake Craniotomy’ surgery. Awake craniotomy is a complicated multi-disciplinary procedure in which the patient undergoes a totally painless surgery on his brain while he remains awake or can communicate with the operating team.
This rare surgery was conducted on a 57 year old patient, who was admitted with a past history of anepisode of a peculiar type of seizure following sleep deprivation. While conversing with the relatives, the patient suddenly stopped speaking and started starring for a few seconds –a phenomenon called speech arrest.
As the  patient had one more episode of such seizure, he was evaluated at an outside centre with a magnetic resonance imaging of the brain. This revealed a low grade tumor of the inferior frontal gyrus, a specialized eloquent area of the brain concerned with speech.
He was advised conservative treatment with anti-epileptic drugs. On evaluation at Rajagiri Hospital a few months later, it was found that the tumor had turned into high grade and warranted immediate surgery for its removal.
There was imminent threat of losing the speech function permanently following surgery, as the tumor was close to the Broca’s area, where the speech is usually generated. Hence it was decided to conduct an awake craniotomy to monitor the speech during tumor removal.
What is an awake craniotomy?
An awake craniotomy is an operation performed in the same manner as a routine craniotomy but with the patient awake during the procedure. This is a preferred technique for operations to remove lesions close to, or involving, eloquent (functionally important) regions of the brain.
This allows a Neurosurgeon to identify functional regions of the brain before they are incised or
removed and enable to test patient’s function throughout the procedure. The overall aim is to minimise the risks of losing these functions during such surgery.
In the operating room, the patient is given medicines to make him relaxed and painfree. The neuronavigation system is then used to mark out the incision and a very small amount of hair is shaved along the line of the incision before it is cleaned with antiseptic solutions.
A special combination of local anaesthetic is injected at specific points on the scalparound the head to make it numb. Drapes are placed around the wound so that the patient is able to talk to the neuropsychologist and speech therapist while the surgery is in progress.
In addition, he will be able to move his arms and legs freely during the operation. During the surgery, the surface of brain was simulated with increments of pulsed bipolar current (cortical stimulation) and the patient was made to talk continuously by asking questions about himself and his job.
After this initial introduction, special tasks of speech like counting numbers and naming (by showing pictures and objects) were initiated. While stimulating a particular area in the exposed brain, he was found to develop speech arrest and thus the speech area was identified.
This procedure is called Brain mapping. Navigation was also used and the tumor location was assessed. Using an advanced tumor-fluorescence microscope (First centre in Kerala state to have this microscope), the capsule of the deep tumour was identified and total excision was carried out.
Immediately after the surgery, the patient came out of sedation and started talking. Patient recovered well and has started taking normal diet. Postoperative imaging confirmed total tumor excision. He has now been mobilised and discharged home.
The rare surgery was done by the neurosciences team including Dr.Jagath Lal Gangadharan (Neurosurgeon), Dr.Annie Thomas, Dr.Sachin George (Anaesthetists), Divya K Thomas (Neuropsychologist), Sara Paul (Speech Therapist), Salini Sasidharan, Sreenath K.S.(Neurophysiologists) and Dr. Rakesh Hari (Registrar).