The patient lies on his side on the operating table, alert and chatting with the anesthesiology team about his love for St. Louis Blues hockey and reality shows, and about which team he favors in the upcoming Super Bowl.
Washington University neurosurgeon Eric Leuthardt, MD, interrupts.
“Tim, how are you doing?” he asks.
“Great,” the patient says wryly. “Just living the dream.”
“Glad to see you have your sense of humor,” Leuthardt replies, as he returns to the task at hand: tweezing strands of tumor tissue from the patient’s exposed brain.
The patient is one of about 15 patients a year who undergo awake craniotomy surgery performed by Washington University neurosurgeons at Barnes- Jewish Hospital. Though it may seem shocking to wake a patient in the middle of surgery—especially a major surgery on a vital organ—awake craniotomy is a valuable treatment for brain tumors and intractable seizures in carefully selected patients.
“With awake craniotomy, patients derive better outcomes,” says Leuthardt, director of the Center for Innovation in Neuroscience and Technology, Department of Neurological Surgery. “We’re able to accomplish a more aggressive surgery in sensitive areas while preserving function.”
In a standard open craniotomy, part of the patient’s skull is removed so surgeons can access the brain. It’s a common procedure for removing many brain tumors, repairing acute brain hemorrhages or trauma and removing clots or tissue causing seizures. Patients remain fully anesthetized—asleep—during these procedures.
The difference with awake craniotomy is that after the patient’s skull is opened and before surgeons begin cutting or manipulating brain tissue, the patient is brought out of sedation to consciousness in order to interact with the surgical team.
Awake craniotomies are primarily performed on patients who have lesions near the areas of the brain that control speech and motor function.
Eric Leuthardt, MD, uses a special probe to check his exact position within the patient’s brain.
While removing or destroying troublesome tissue, surgeons need to ensure that they’re not inadvertently damaging healthy tissue. The most reliable way to do this is to wake the patient up, ask him or her to answer questions and perform simple tasks, and then monitor the responses.
“This procedure can give the surgeon the best balance between safely avoiding critical areas in the brain while at the same time being maximally aggressive towards the tumor,” Leuthardt says.
At Barnes-Jewish Hospital, several advanced technologies are available to supplement this technique, making awake craniotomy even safer and more precise.
For instance, awake craniotomies are performed in the hospital’s intraoperative magnetic resonance imaging (MRI) suite.
This suite is one of about 20 in the United States equipped with a high-field-strength MRI magnet, which allows surgeons to produce real-time MRI scans during surgery. Surgeons can then consult the images to make sure they’ve removed as much tumor tissue as safely possible.
Washington University neurosurgeons also use stereotactic navigation, a system that works like a GPS to guide them through the patient’s brain.
The day before surgery, the patient has an MRI to map certain points in the brain. The map is displayed on a screen during the operation, and surgeons check their exact position within the brain by touching the area with a special probe.
Leuthardt also uses sophisticated brain-mapping techniques, some of which he developed, to pinpoint areas of the brain that control very specific behaviors.
One technique involves laying a thin plastic sheet studded with a grid of sensors directly on the brain’s surface. The sensors detect minute electrical charges as they travel along pathways in the brain during a seizure or while the patient is speaking or moving.
A computer program turns the data collected by the sensors into a map that can guide surgeons precisely to the area causing seizures or steer them away from healthy tissue surrounding a tumor. But sophisticated technology is ultimately just a complement to the skill and experience the surgical team must bring to the procedure. The volume of awake craniotomies performed at a center translates into better outcomes, and the Washington University neurosurgeons are experienced at surgery close to the motor and sensory cortexes.
Providing anesthesia for awake craniotomies also presents a special challenge, says Leuthardt. Typically, a patient who is asleep during surgery has a breathing tube inserted to keep the airway clear and open. A patient who is awake and talking can’t be intubated, so the anesthesia team must be especially vigilant.
And although the brain itself has no pain receptors, the patient must be kept as calm and pain-free as possible during the surgery, especially as the scalp is cut and a portion of skull is removed. However, the patient can’t be so sedated that he or she can’t respond to the surgeon.
“It’s certainly more difficult than a regular procedure,” Leuthardt says.
But awake craniotomy can pay off in both short-term and long-term benefits for the patient.
In the long run, patients with difficult brain tumors can have an extended and improved quality of life when the maximum amount of tumor is removed. In the short run, patients often spend less time recovering in the hospital.
The day after his surgery, the Blues-loving patient is alert and sitting up in the Barnes-Jewish neuro-intensive care unit. He’s drinking a milkshake and talking with his family when Leuthardt stops by.
“Still doing OK?” Leuthardt asks.
The patient flashes a smile and gives his doctor a thumbs up.
Refining the Technique
To remove a tumor near important brain regions governing speech or motor control, neurosurgeons must first identify these areas and map their locations. For half a century, this mapping has been performed by directly stimulating brain tissue with one bipolar electrode while the patient is awake, talking and performing tasks.
According to Eric Leuthardt, MD, director of the Center for Innovation in Neuroscience and Technology, Department of Neurological Surgery, this direct stimulation technique is considered the gold standard for mapping and monitoring brain function during this type of procedure, known as awake craniotomy. “The electrode temporarily stuns a little area of the brain, so you can see what would happen if you were to remove it,” Leuthardt says. “If the patient stops talking, or if he stops moving or jerks his hand, you can identify the areas that control motor and speech.”
Leuthardt calls the technique useful but not perfect.
“It’s inefficient and cumbersome, and it carries the risk of causing seizures,” he says. “So we’ve been developing a number of new techniques to identify brain function, both before and during surgery.” Before the patient enters the operating room, Leuthardt and other neurosurgeons can perform a type of MRI scan that maps the locations of the brain’s networks in a resting state.
Unlike task-based MRI mapping, the patient does not need to actively participate in the testing. The MRI scan maps the resting brain before surgery, and Leuthardt has another tool to map networks during the surgical procedure. With an electrode array that sits on the surface of the exposed brain, he can passively record electrical signals from different parts of the brain while the patient is under anesthesia.
Ultimately, one goal of these new technologies is to limit the need for awake craniotomy. Though Leuthardt says an awake procedure provides the best method to eliminate the tumor while protecting healthy brain tissue, it’s still a lot for patients to go through.
“It’s stressful for people to be awake during these surgeries,” he says. “Now, we can listen to the brain do its thing without passing electricity into it. As a result, we have a good idea of what’s where before they even wake up in the OR. I still do the gold standard—awake stimulation— but these additional capabilities have the potential to make awake brain mapping safer and more efficient.”
To learn more, and watch a video of an awake craniotomy, visit BarnesJewish.org/awake.
Mgonjwa amelala upande wake kwenye meza ya upasuaji, akifikiria na kuzungumza na timu ya anesthesiology juu ya upendo wake kwa St. Louis Blues, mchezo wa mpira wa magongo, na juu ya timu ambayo anapendelea katika Super Bowl ijayo. Upasuaji wa neva wa Chuo Kikuu cha Washington Eric Leuthardt, MD, anakatiza. "Tim, unaendeleaje?" anauliza. "Ni vizuri sana", mgonjwa huyo asema kwa uchungu. "Ninafurahi kuona una hisia yako ya ucheshi", Leuthardt anajibu, wakati anarudi kwa kazi iliyo karibu: pinching nyuzi za tishu ya uvimbe kutoka kwa ubongo wa mgonjwa uliofunuliwa. Mgonjwa huyo ni mmoja wa wagonjwa 15 wanaofanyiwa upasuaji wa kupasua kichwa kila mwaka na madaktari wa Chuo Kikuu cha Washington katika Hospitali ya Barnes-Jewish. Ingawa inaweza kuonekana ya kushangaza kuamsha mgonjwa katikati ya upasuaji - hasa upasuaji mkubwa kwenye kiungo muhimu - upasuaji wa kichwa cha macho ni matibabu yenye thamani kwa uvimbe wa ubongo na mshtuko usioweza kushughulikiwa kwa wagonjwa waliochaguliwa kwa uangalifu. "Kwa kutumia upasuaji wa kichwa wakati wa usingizi, wagonjwa hupata matokeo bora", anasema Leuthardt, mkurugenzi wa Kituo cha Ubunifu wa Sayansi ya neva na Teknolojia, Idara ya Upasuaji wa neva. "Tunaweza kufanya upasuaji mkali zaidi katika maeneo nyeti huku tukihifadhi utendaji wake". Katika upasuaji wa kawaida wa kufungua fuvu la kichwa, sehemu ya fuvu la kichwa la mgonjwa huondolewa ili madaktari wa upasuaji waweze kufikia ubongo. Ni utaratibu wa kawaida wa kuondoa uvimbe mwingi wa ubongo, kurekebisha kutokwa na damu kwa ubongo au majeraha na kuondoa makundi ya damu au tishu zinazosababisha mshtuko wa akili. Wagonjwa hubaki wakiwa wamelazwa kabisa - wakiwa wamelala - wakati wa taratibu hizi. Tofauti na upasuaji wa kichwa wa mgonjwa akiwa amelala ni kwamba baada ya mfupa wa kichwa kufunguliwa na kabla ya madaktari wa upasuaji kuanza kukata au kuharibu tishu ya ubongo, mgonjwa hutolewa kutoka kwa usingizi hadi ufahamu ili kuingiliana na timu ya upasuaji. Upasuaji wa kichwa unaofanywa wakati wa kuamka hufanywa hasa kwa wagonjwa walio na majeraha karibu na sehemu za ubongo zinazodhibiti usemi na utendaji wa magari. Eric Leuthardt, MD, hutumia kipimaji maalum kuchunguza nafasi yake halisi ndani ya ubongo wa mgonjwa. Wakati wa kuondoa au kuharibu tishu zenye kusumbua, madaktari wa upasuaji wanahitaji kuhakikisha kwamba hawaharibu tishu zenye afya bila kukusudia. Njia bora ya kufanya hivyo ni kumamsha mgonjwa, kumwomba ajibu maswali na kufanya kazi rahisi, kisha ufuatilie majibu. "Utaratibu huu unaweza kumpa daktari wa upasuaji usawa bora kati ya kuepuka kwa usalama maeneo muhimu katika ubongo wakati wakati huo huo kuwa na nguvu zaidi dhidi ya uvimbe, "Lyuthardt anasema. Katika Hospitali ya Barnes-Jewish, teknolojia kadhaa za hali ya juu zinapatikana ili kuongeza mbinu hii, na kufanya upasuaji wa fuvu la kichwa ukiwa macho uwe salama zaidi na sahihi zaidi. Kwa mfano, upasuaji wa kichwa wakati wa usingizi hufanywa katika chumba cha hospitali cha upasuaji cha kupima picha kwa kutumia sumaku (MRI). "Kama sehemu ya ""seti ya MRI"" ya kisasa, kitengo hiki cha upasuaji kina uwezo wa kugundua MRI ya nguvu ya uwanja wa juu, ambayo inaruhusu madaktari wa upasuaji kutoa uchunguzi wa MRI wakati halisi wakati wa upasuaji." Madaktari wa upasuaji wanaweza kisha kuchunguza picha ili kuhakikisha kwamba wameondoa tishu nyingi za uvimbe kwa usalama iwezekanavyo. Wataalamu wa upasuaji wa neva wa Chuo Kikuu cha Washington pia hutumia mfumo unaoitwa stereotactic navigation, ambao hufanya kazi kama GPS ili kuwaongoza kupitia ubongo wa mgonjwa. Siku moja kabla ya upasuaji, mgonjwa hufanyiwa MRI ili kuchunguza sehemu fulani za ubongo. Ramani hiyo huonyeshwa kwenye skrini wakati wa upasuaji, na madaktari-mpasuaji huchunguza mahali hususa pa ubongo kwa kugusa eneo hilo kwa chombo cha pekee. Leuthardt pia hutumia mbinu za hali ya juu za kuchora ramani za ubongo, ambazo baadhi yake aliendeleza, ili kutambua maeneo ya ubongo ambayo husimamia tabia maalum sana. Mbinu moja inahusisha kuweka karatasi nyembamba ya plastiki iliyofunikwa na gridi ya sensorer moja kwa moja juu ya uso wa ubongo. Vifaa hivyo vinaweza kugundua umeme unaosonga kwenye ubongo wakati wa mshtuko wa moyo au wakati mgonjwa anapozungumza au kutembea. Programu ya kompyuta inageuza data zilizokusanywa na sensorer kuwa ramani ambayo inaweza kuwaongoza madaktari wa upasuaji kwa usahihi kwenye eneo linalosababisha mshtuko au kuwaelekeza mbali na tishu nzuri inayozunguka uvimbe. Lakini teknolojia ya hali ya juu ni mwishowe tu nyongeza ya ujuzi na uzoefu timu ya upasuaji lazima kuleta kwa utaratibu. Upasuaji wa kichwa unaofanywa katika kituo cha upasuaji wa akili una matokeo bora, na madaktari wa upasuaji wa neva wa Chuo Kikuu cha Washington wana uzoefu wa upasuaji karibu na korti za motor na sensory. Leuthardt anasema kwamba kutoa anesthesia kwa ajili ya upasuaji wa kichwa wakati mtu amelala pia ni changamoto kubwa. Kwa kawaida, mgonjwa anayelala wakati wa upasuaji huingizwa bomba la kupumua ili njia ya kupumua iwe wazi na wazi. Mgonjwa ambaye ni macho na kuzungumza hawezi kuwa intubated, hivyo timu anesthesia lazima kuwa hasa tahadhari. Ingawa ubongo hauna vipokezi vya maumivu, mgonjwa lazima aendelee kuwa mtulivu na asiyekuwa na maumivu wakati wa upasuaji, hasa wakati ngozi ya kichwa inapokatwa na sehemu ya fuvu la kichwa ikiondolewa. Hata hivyo, mgonjwa hawezi kutuliza sana hivi kwamba hawezi kujibu daktari-mpasuaji. "Ni hakika ni ngumu zaidi kuliko utaratibu wa kawaida", Leuthardt anasema. Lakini upasuaji wa kichwa ukiwa umekaa unaweza kuwa na manufaa kwa mgonjwa kwa muda mfupi na kwa muda mrefu. Kwa muda mrefu, wagonjwa wenye uvimbe mgumu wa ubongo wanaweza kuwa na ubora wa maisha uliopanuliwa na ulioboreshwa wakati kiasi cha juu cha uvimbe kinapoondolewa. Kwa muda mfupi, mara nyingi wagonjwa hutumia muda mfupi zaidi kupona hospitalini. Siku moja baada ya upasuaji wake, mgonjwa anayependa muziki wa blues yuko macho na ameketi katika kitengo cha Barnes-Jewish cha utunzaji wa neva. Yeye ni kunywa milkshake na kuzungumza na familia yake wakati Leuthardt huacha na. "Bado unaendelea vizuri?" Leuthardt anauliza. Mgonjwa huyo anatabasamu na kumtia daktari wake kibali. Ili kuondoa uvimbe karibu na maeneo muhimu ya ubongo yanayohusu usemi au udhibiti wa magari, madaktari wa mfumo wa neva lazima kwanza watambue maeneo hayo na kuamua mahali pake. Kwa nusu karne, ramani hii imefanywa kwa kuchochea moja kwa moja tishu ya ubongo na elektroni moja ya bipolar wakati mgonjwa yuko macho, akizungumza na kufanya kazi. Eric Leuthardt, Mkurugenzi wa Kituo cha Ubunifu katika Neuroscience na Teknolojia, Idara ya Upasuaji wa Neurolojia, anasema kuwa mbinu hii ya kuchochea moja kwa moja inachukuliwa kuwa kiwango cha dhahabu cha ramani na ufuatiliaji wa kazi ya ubongo wakati wa utaratibu huu unaojulikana kama craniotomy ya macho. "Electrode hiyo hufadhaisha kwa muda eneo dogo la ubongo, hivyo unaweza kuona nini kingeweza kutokea ikiwa ungeiondoa", anasema Leuthardt. "Kama mgonjwa anaacha kuzungumza, au akiacha kusonga au kutikisa mkono wake, unaweza kutambua maeneo ambayo kudhibiti motor na hotuba. ""Leuthardt anadai mbinu muhimu lakini si kamilifu." "Ni isiyo na ufanisi na ngumu, na ina hatari ya kusababisha mshtuko wa moyo", anasema. "Kwa hiyo tumekuwa tukitengeneza mbinu mpya za kutambua utendaji wa ubongo, kabla na wakati wa upasuaji. ""Kabla ya mgonjwa kuingia kwenye chumba cha upasuaji, Leuthardt na madaktari wengine wa neva wanaweza kufanya aina ya MRI ambayo hupanga maeneo ya mitandao ya ubongo katika hali ya kupumzika." Tofauti na ramani ya MRI inayotegemea kazi, mgonjwa hahitaji kushiriki kikamilifu katika upimaji. MRI ya ubongo huonyesha ubongo uliokuwa umepumzika kabla ya upasuaji, na Leuthardt ana chombo kingine cha kuchora ramani ya mitandao wakati wa upasuaji. Kwa kutumia electrode iliyo juu ya ubongo, daktari anaweza kurekodi ishara za umeme kutoka sehemu mbalimbali za ubongo wakati mgonjwa akiwa chini ya anesthesia. Hatimaye, lengo moja la teknolojia hizi mpya ni kupunguza uhitaji wa upasuaji wa fuvu la kichwa wakati wa usingizi. Ingawa Leuthardt anasema utaratibu wa kuamka hutoa njia bora ya kuondoa uvimbe wakati wa kulinda tishu ya ubongo yenye afya, bado ni mengi kwa wagonjwa kupita. "Ni jambo lenye kusumbua kwa watu kuwa macho wakati wa upasuaji huu", anasema. <unk>Sasa, tunaweza kusikiliza ubongo ukifanya kazi yake bila kuupatia umeme. Matokeo yake, tuna wazo nzuri la nini <unk> ni wapi kabla hata kuamka katika OR. Bado ninafanya kiwango cha dhahabu cha kuchochea macho lakini uwezo huu wa ziada una uwezo wa kufanya ramani ya ubongo wa macho kuwa salama na yenye ufanisi zaidi. Ili kujifunza zaidi, na kutazama video ya craniotomy ya macho, tembelea BarnesJewish.org/awake.