Who better to ask how things are going than the patient you are operating on? Iva Pocock reports
Drilling into people's heads is a very old technology. Hundreds of years ago the Aztecs were doing it to let mythical vapours out, and all without the benefits of anaesthetics. In modern medical times, advances allowed patients undergo this trauma without having to consciously endure the horror of hearing and feeling their skull being cracked open.
Nowadays anaesthetics remain an essential part of any operation on the brain, but not simply to keep patients asleep. In some cases, neurosurgeons and their medical teams are now choosing to wake up patients during surgery.
"It sounds a bit horrific but the thing is the brain itself has no pain sensation so if you have given a local anaesthetic into the lining of the brain then it's not actually painful to operate on someone's brain when they are awake," says Prof Ciaran Bolger, professor of neuroscience at the Royal College of Surgeons and a consultant at Beaumont Hospital.
In fact, the conscious input of a patient whose brain is being operated upon can make a huge difference to the outcome.
One such case is that of 47-year-old businessman Gary Stewart (see case history) who, in late September, underwent surgery to remove a brain tumour. He was the first person to undergo awake brain surgery in Ireland.
"We put him to sleep, we opened up the brain and when we were ready to take out the tumour we actually woke him up on the operating table," says Prof Bolger, who has previously done about 10 such awake operations when working abroad.
As Gary's tumour was located near the speech and motor areas on the left hand side of his brain, there was a danger that surgery would permanently damage his speech and movement.
By waking him up during surgery, Prof Bolger was able to map out in detail which areas of Gary's brain were essential for these functions, and to avoid them while cutting out the tumour.
This was done by stimulating the brain around the tumour with little electrical shocks, while asking Gary to identify a series of picture cards.
If Gary could describe an image, for example of a boat, without electrical stimulation being applied to a particular area, but could only come out with "em, em, em" when the electrodes were on, the team knew this specific area was essential for Gary's speech.
"We'd leave a little mark there to say that was part of his speech centre and we'd move away and approach the tumour from another direction," Prof Bolger explains.
The whole speech area was marked out in this way using about 30 different picture cards over 45 minutes.
A computer-guided system, using infra-red technology which is similar to that in stealth bombers, guided the team to exactly where the tumour was. "It works out where the instruments are in relation to the patient's head and then you can work out on the screen where you are in relation to the tumour, a bit like a GPS system," Prof Bolger points out.
They had to borrow essential electrodes from a hospital in Lyon, France, but are hoping to purchase this equipment costing about €20,000 shortly.
The complex operation, which took about five hours in total, required a team of medics - the chief neurosurgeon, two assistants, an anaesthetist, a psychologist and two nurses.
A lot of the skill in such an operation depends on the anaesthetist, says Prof Bolger. In this case, Dr Charlie O'Hagan, consultant anaesthetist, had to allow Gary wake up enough to communicate but not so much that he'd want to move around.
Dr O'Hagan and the psychologist were visible to Gary when he awoke, as they were under a tent-like green operating drape rising from his forehead, while the rest of the team were in theatre gear and a piece of his skull had been removed so the brain was exposed.
"It's a bit like that scene from the movie, the one after Hannibal, where he's got this head open and the guy is sitting there.
"That's literally what's happening and the brain is there but underneath the drapes the patient is awake."
Not every patient who could benefit from such surgery (Prof Bolger estimates between 20 to 30 people in Ireland could be helped with awake surgery) would be recommended for it because of the danger of people panicking when they are awoken.
"It's not everybody who's able to cope with being awake when surgery is being done on their brain," says Prof Bolger.
Gary received strong coaching before the operation. "We discussed it at length before hand. He knew exactly what we wanted to do. And then in the theatre he was very co-operative. He was very calm."
Once the tumour was accurately mapped, Gary was put back to sleep. The tumour, which was about the size of a ping pong ball, was removed over a couple of hours, and then the skull closed up.
"Then you have to wait for him to wake up from the anaesthetic and make sure that his speech and movement is okay," adds Prof Bolger. "Thankfully it was."