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Awake Craniotomy - A Comprehensive Guide

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Awake craniotomy is a conscious, awake brain surgery technique used to treat low-grade gliomas near vital speech, movement, or feeling regions.

Medically reviewed by

Dr. Rahul Pramod Patil

Published At May 8, 2024
Reviewed AtMay 8, 2024


A method known as "awake craniotomy" or "awake brain surgery" is performed while the patient is conscious. It is usually used to treat brain tumors, especially low-grade gliomas close to vital speech, movement, or feeling regions. To gain access to the brain, a portion of the skull must be temporarily removed from the patient without causing them any pain. A local anesthetic is utilized to numb the muscles, skin, and bone to get to the brain. A team approach headed by a neuroanesthesiologist and skilled neurosurgeon is necessary for this extremely complex treatment. A neuropsychological examination is needed before performing an awake craniotomy on any patient. This approach transforms brain surgery practice by enabling precise targeting of the damaged area and real-time monitoring.

This article explores the history, development, advantages, step-by-step instructions, patient preparation and selection, anesthetic alternatives, hazards, complications, and recovery process of awake craniotomy patients. The potential for achieving neurosurgical precision with this method is enormous.

What Is the History and Development of Awake Craniotomy?

Although awake craniotomy has been around since the early 1900s, it was not until the 1980s that it became widely accepted as a viable neurosurgery technique. As a result of their recognition of the need for better tumor resection and functional mapping, the "asleep-awake-asleep" approach was developed.

However, when anesthetic and intraoperative monitoring improved, the "awake-awake-awake" approach became preferred. This method minimizes the danger of neurological injury by keeping the patient conscious of the treatment, enabling neurosurgeons to engage with them and map out important brain areas.

Since then, awake craniotomy has developed into a highly regarded method for a range of neurosurgical operations, such as functional mapping, tumor removal, and epilepsy surgery.

What Are the Benefits and Advantages of Awake Craniotomy?

Awake craniotomy has several important advantages. First, it makes exact brain mapping possible, especially in brain regions responsible for essential abilities like speech, movement, and vision. Second, by identifying and avoiding important areas with the patient during surgery, one can lower the likelihood of postoperative impairments.

Awake craniotomy also allows for direct patient feedback, guaranteeing the best possible tumor removal and preservation of function. Additionally, this method has been demonstrated to shorten hospital stays and surgical times, promoting quicker recovery and lowering medical expenses. Moreover, awake craniotomy presents a unique opportunity for scientific investigation, enabling researchers to examine brain activity during live operations.

What Is the Step-By-Step Guide for Awake Craniotomy?

  • A comprehensive preoperative evaluation is performed to ascertain the patient's wellness for an awake craniotomy before the procedure is carried out.

  • When it is decided it is appropriate, local anesthetic is applied to numb the skull and scalp before the surgery starts.

  • Then, a tiny portion of the skull called the bone flap is removed to gain access to the brain.

  • The patient is agreeable and stays awake for the entire surgery, conversing with the surgical team.

  • Functional MRI (magnetic resonance imaging) and direct cortical stimulation are two intraoperative monitoring techniques used to map out functional limits and identify key brain areas.

  • The neurosurgeon locates the tumor or damaged area and then gently removes or treats it.

  • After the procedure, the incision is closed, and the bone flap is reattached.

  • After that, the patient is closely watched during their healing process.

How to Select and Prepare Patients for Awake Craniotomy?

Not every patient is a good fit for an awake craniotomy. Eligibility is largely determined by factors like the tumor's location and size, co-occurring medical problems, and patient participation. To ensure the patient can tolerate the psychological and physical demands of the surgery, a thorough preoperative evaluation is carried out to evaluate the patient's neurological and cognitive functioning. To reduce anxiety and get the patient ready for the unusual experience of being awake during brain surgery, psychological therapy may be given. Furthermore, the anesthesiologists and the surgical team work together to create a customized anesthetic strategy that guarantees patient comfort and a cooperative state.

What Are the Anesthesia Options for an Awake Craniotomy?

During an awake craniotomy, anesthesia is still given to the patient to guarantee their comfort and cooperation, even though they are still conscious. Several different anesthetic procedures, such as regional anesthesia, monitored anesthesia care (MAC), and local anesthesia, can be used.

While MAC uses sedatives and analgesics to keep the patient calm and pain-free, local anesthesia includes injecting numbing drugs into the scalp and skull. Regional anesthetics, such as scalp and nerve blocks, can also deliver focused pain relief. The anesthesiologist's competence, the surgical needs, and the patient's preferences all play a role in the anesthetic option.

What Are the Risks and Complications of Awake Craniotomy?

Awake craniotomy has some risks and complications, similar to any surgical treatment. These include bleeding, convulsions, infection, leakage of CSF (cerebrospinal fluid) fluid, and neurological impairments. However, dangers have been greatly reduced by improvements in surgical methods, careful planning, and intraoperative monitoring. Furthermore, the advantages of awake craniotomies, such as enhanced tumor removal and preserved function, often surpass the drawbacks. The patient and the surgical team collaborate closely to guarantee the patient's comfort and safety throughout the process.

What Is the Recovery and Post-operative Care for Awake Craniotomy?

Patients are closely followed in the post-anesthesia care unit (PACU) after an awake craniotomy, and then they are moved to a regular hospital room. Neurological evaluations, wound care, and pain control are crucial aspects of post-operative care. Physical and occupational therapy may be started to help with the patient's recovery and rehabilitation. The length of the hospital stay varies based on the procedure's complexity and the patient's state. Most patients heal quickly and can return to their regular activities within a few weeks, with regular follow-up appointments to check their progress.


Neurosurgery has undergone a revolution due to awake craniotomy, which reduces the possibility of neurological impairments while allowing for precise tumor removal and functional mapping. One may anticipate more advancements in the method as technology develops, opening up access to a larger patient pool and improving surgical results. Awake craniotomy's future rests in combining it with cutting-edge technologies like artificial intelligence, virtual reality, and intraoperative imaging. Neurosurgeons can push the limits of what is now feasible in neurosurgery thanks to these improvements, which will further improve the procedure's safety and precision. The industry has reached a significant milestone with awake craniotomy, and the potential for bettering patient outcomes is amazing.

Dr. Rahul Pramod Patil
Dr. Rahul Pramod Patil



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