Aaargh! Awake Craniotomy

Awake Craniotomy_450

Disclaimer: Do not read this article if you are about to undergo awake craniotomy. Not because the study I’m about to discuss has depressing results, or because I go into gory detail. But if you are nervous about your craniotomy, I am in no way going to make you feel more safe.

Brains are pretty amazing. The expanding knowledge on how the brain works is fascinating. Although I strongly suspect that the reason I find information about the brain so incredibly interesting is because it is my own brain that processes the information. I bet if my kidney had some say, I’d be all ‘ooh’ and ‘aah’ about kidneys.
It’s probably for that same reason that I am pretty freaked out by awake brain surgery/craniotomy. I’m sure neurosurgeons know what they are doing, but I’d rather not be awake whilst they’re at it. Surprisingly, not many studies have been dedicated to the psychological after effects of enduring an awake craniotomy. However, a recent study published in the Journal of Neurosurgery surveyed the psychological wellbeing of patients who had been through the procedure.
The study surveyed 16 patients a few weeks after their surgery and tested them for symptoms of Post-Traumatic Stress Disorder (PTSD) and their general quality of life with regards to their health. From 2005 to 2011 33 patients had an awake craniotomy at the University Hospital of Tuebingen, Germany. Only 16 qualified for the study, the other 17 had either ‘relocated’ or died.
You can determine the following from that information:
This is a very rare procedure; in 6 years only 33 people underwent this surgery. In other words: medics prefer to sedate you completely for the bit where the surgeon sticks his instruments directly into your brain.
The surgery comes with some risk. Over half the patients were unable to complete the survey due to relocation or death. The writers don’t separate that number into ‘relocated; and ‘dead’, but even 1 person dying on the operating table would be a 3% death rate in this instance.
All in all: an awake craniotomy is pretty damn terrifying.
The results presented by Milian et al. showed that only 2 people had experienced heightened anxiety levels during surgery.
ONLY 2!!! Call me a massive sissy, but I’d be freaked out the entire time I was screwed into a frame with my scalp flapped open, part of my skull removed and my brain out in the open air. The study describes how a multidisciplinary team is involved in the care of the patient and a neuropsychologist is present ‘from skin incision to suture’. The neuropsychologist has the job to talk to the patient and communicate any reported discomfort to the surgical team. The surgical team are hovering just above the patient’s head, so it’s safe to say they are really focussed on the job if they can’t even hear the patient go ‘I’m tilted backwards a little too much, I fear my brain will flop out of my head’. The neuropsychologist also does all the speech tests with the patient. Because the main reason for awake craniotomy is to make sure the surgeon doesn’t damage any important parts of your brain, like the speech cortex.
Because in case you didn’t know: awake craniotomies are performed to remove brain tumours. The neurosurgeon opens up your skull and then asks you to do some speech exercises. Whilst you speak to the neuropsychologist, the surgeon prods your brain with a rod that administers tiny electric shocks to the areas of your brain around the tumour. If you start slurring your speech or start having issues with your motor skills whilst you’re being zapped the surgeon knows which parts of your brain to be careful with (or even more careful, let’s assume they’re generally pretty careful with your brain besides putting a tiny taser in there)).
Apparently a common way to keep the patient’s mind occupied and to give them something to equate the annoyance they’re feeling to something they are familiar with, is telling the patient to ‘imagine your neighbour is mowing the lawn’. To me, that’s not the most mind mind-occupying image I can imagine, plus I don’t think the low hum of a lawnmower equates to having your brain exposed and operated on. But perhaps German lawn mowers are a fresh hell I’m unfamiliar with.
After surgery, only 2 patients conformed with a PTSD diagnosis, one of whom was helped with hypnotherapy and experienced no more symptoms after 12 weeks, the other had chronic PTSD. Two patients claimed they dreamt worse after the operation and 4 said they had trouble falling and staying asleep after the surgery. 3 patients avoided stimuli that reminded them of the surgery. I suppose that’s 3 people who will never read this article. Those numbers seem low to me. How did the other 12 patients sleep comfortably with a head full of sutures? Why did no more than 2 people have nightmares about the fact their skull was once opened up. How is it possible that the majority of patients felt fine, psychologically? I am genuinely amazed by these results. It really shows how amazing brains – and their owners – are, as they can manage to remain calm after and during these extreme conditions. My hat (not my scalp thankyouverymuch) goes off to the medics and nursing staff involved in this procedure, as it can only be due to their great care that patients feel safe enough to allow a surgeon to poke and zap inside their skulls whilst they chat away about their neighbour’s lawnmower.

Monika Milian et al: “Imagine your neighbor mows the lawn”: a pilot study of psychological sequelae due to awake craniotomy. Journal of Neurosurgery
Published online March 29, 2013; DOI: 10.3171/2013.2.JNS121254.

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