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Awake Brain Surgery Helps Surgeons Remove Tumors in Sensitive Areas

Imagine having a surgeon cut into your skull while you are wide awake. Sounds like the stuff of fiction—and yet awake surgery is allowing doctors to remove complex tumors in some of the brain’s most sensitive areas.

Awake craniotomy—or brain surgery done while the patient is awake—has been around for more than 50 years, but only a handful of medical centers around the country have the expertise to perform such surgery on a routine basis

UPMC has been a leader in awake craniotomy. In fact, about 20 percent of all brain cancer surgeries performed by neurosurgical oncologists at UPMC are done while the patient is awake.

UPMC neurosurgeons have developed an awake craniotomy model that includes advanced imaging techniques to allow aggressive surgical treatment of brain cancers while preserving critical brain function, and they perform more than 60 of these surgeries each year.

How Awake Craniotomy Works

“The most important surgical principle when removing brain cancers is to provide the maximum safe resection,” says Nduka Amankulor, MD, a specialist in the surgical treatment of complex brain and spine tumors at UPMC’s Department of Neurological Surgery.

“We come to the very limit of brain tumor surgery with many cases. Remove any more tumor and we’d hurt the patient; remove any less, and we’d leave residual tumor that could have been resected.”

Knowing where that fine line is takes a multimodal imaging approach. Dr. Amankulor uses fluorescent-guided imaging and intraoperative ultrasound techniques to visualize the tumor prior to removing it. “We inject a fluorescent marker that causes the tumor to light up while we are removing it,” he says.

“And simultaneously, while the patient is awake, we stimulate the patient’s brain to identify and map the critical areas of language, motor function, and sensory function so we don’t damage them.”

A sophisticated anesthesiology team makes sure the patient does not feel any pain throughout the surgery and neurophysiologists conduct advanced neurophysiological monitoring to report critical changes in brain function to ensure that brain stimulation does not induce seizures.

“Awake craniotomies are fascinating in part because the patient becomes part of the surgical team; they can participate and help us by providing constant feedback on their neurological function,” he says.

This approach allows Dr. Amankulor to operate on brain tumors in locations that many surgeons might deem inoperable, enabling the team to offer this surgery to patients who need it. This combination of advanced imaging tools and surgical expertise provides a better chance that tumors can be completely removed.

In addition to the surgery, Dr. Amankulor emphasizes that brain tumor treatment relies on concurrent research using tissue obtained from each surgery.

Beyond Surgery: Treating Recurrent Brain Tumors

“Brain tumor treatment is more than just doing surgery—it includes all the research behind decision-making for each patient, including research that spurs development of clinical trials,” says Dr. Amankulor. “We study these tumors in the laboratory and use that information to design new trials with innovative drugs for use after surgery.”

Because brain tumors often come back, the team has used tumor samples from their surgeries to develop new therapies to treat recurrent brain tumors. This research recently led to the design of a clinical trial of an FDA-approved drug that targets a subset of brain cancers and has shown good early success.

How do patients react when Dr. Amakulor recommends awake craniotomy? Surprisingly well, he says.

“The majority of my patients say, ‘Let’s do this!’ when they understand the rationale for surgery, and most of those who undergo the surgery do very well,” he adds. “Half of my patients say they’ve seen the surgery on ‘Grey’s Anatomy’ on TV!”