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The Awake Craniotomy: A Patient's Experience and A Literature Review

Affiliations.

• 1 Department of Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA.
• 2 Medicine, St. George's University School of Medicine, West Indies, GRD.
• 3 Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, USA.
• 4 Internal Medicine, University of Nevada Las Vegas, Las Vegas, USA.
• 5 Department of Neurological Surgery, Arrowhead Regional Medical Center, Colton, USA.
• 6 Department of Pharmacy, Arrowhead Regional Medical Center, Colton, USA.
• 7 Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, USA.
• 8 Department of Neurosurgery, California University of Science and Medicine, Colton, USA.
• PMID: 35915692
• PMCID: PMC9338386
• DOI: 10.7759/cureus.26441

We present a case report and a literature review of the awake craniotomy procedure for mass resection, with emphasis on the historical aspects, anatomical and surgical considerations, and, uniquely, a patient's experience undergoing this procedure. This procedure is a safe and effective method for lesion resection when working in and around eloquent brain. We have described our process of guiding a patient through an awake craniotomy procedure and detailed the patient's experience in this study. We also conducted a systematic literature review of studies involving awake craniotomy over three years, 2018-2021. Lastly, we compared the methodology used by our institution and the current mostly used methods within the neurosurgical community. Several studies were identified using PubMed and Google Scholar. Awake craniotomy is a safe and effective method of achieving a high rate of resection of lesions located in and around the eloquent cortex with a low degree of postoperative neurological deficit.

Keywords: awake brain surgery; awake craniotomy; craniotomy while awake; patient experience; patient psychology.

Copyright © 2022, Patchana et al.

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Citation, DOI, disclosures and article data

At the time the article was created Henry Knipe had no recorded disclosures.

At the time the article was last revised Henry Knipe had the following disclosures:

• Integral Diagnostics, Shareholder (ongoing)
• Micro-X Ltd, Shareholder (ongoing)

These were assessed during peer review and were determined to not be relevant to the changes that were made.

• Craniotomies
• Craniotomy: types

A craniotomy is a surgical procedure where a piece of calvarial bone is removed to allow intracranial exposure. The bone flap is replaced at the end of the procedure, usually secured with microplates and screws. If the bone flap is not replaced it is either a craniectomy  (bone removed) or cranioplasty  (non-osseous surgical repair). 

Classification

There are different craniotomy approaches depending on which part of the intracranial cavity needs to be accessed 1 :

pterional (i.e. frontosphenotemporal)

subtemporal

anterior parasagittal

posterior parasagittal

retrosigmoid

medial suboccipital

lateral suboccipital

Complications

infection including bone flap osteomyelitis , subdural empyema and cerebral abscess

intracranial hemorrhage including remote cerebellar hemorrhage

scalp/subcutaneous hematomas

pseudomeningocele

tension pneumocephalus

• 1. Sinclair A & Scoffings D. Imaging of the Post-Operative Cranium. Radiographics. 2010;30(2):461-82. doi:10.1148/rg.302095115 - Pubmed
• 2. Prakash Narain Tandon, Ravi Ramamurthi. Textbook of Neurosurgery, Third Edition, Three Volume Set. (2012) ISBN: 9789350250723 - Google Books
• 3. Jane C. Rothrock, Sherri M. Alexander. Alexander's Surgical Procedures. (2011) ISBN: 9780323075558 - Google Books

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• Subdural haemorrhage
• Pterional approach (neurosurgery)
• Papillary craniopharyngioma
• Cerebral abscess
• Pott puffy tumour
• Cerebellar haemorrhage
• Remote cerebellar haemorrhage
• Pituitary adenoma/PitNET
• Craniectomy
• Adamantinomatous craniopharyngioma
• Craniotomy and evacuation of left convexity extradural haematoma
• Odontogenic epidural abscess
• Large frontal osteoma
• SMART syndrome
• Trigeminal schwannoma
• Supratentorial ependymoma
• Meckel cave meningocele
• Frontal craniotomy
• Infected bone flap post craniotomy
• Chiari 1 malformation with syrinx
• Extensive brain infarction due to occlusion of the right internal carotid artery

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Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases

• Clinical Article
• Published: 13 November 2008
• Volume 150 , pages 1241–1248, ( 2008 )

Cite this article

• X. F. Yang 1 , 2 ,
• L. Wen 1 , 2 ,
• F. Shen 1 , 2 ,
• G. Li 1 , 2 ,
• R. Lou 1 , 2 ,
• W. G. Liu 1 , 2 &
• R. Y. Zhan 1 , 2  

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Decompressive craniectomy is an important method for managing refractory intracranial hypertension in patients with head injury. We reviewed a large series of patients who underwent this surgical procedure to establish the incidence and type of postoperative complications.

From 1998 to 2005, decompressive craniectomy was performed in 108 patients who suffered from a closed head injury. The incidence rates of complications secondary to decompressive craniectomy and risk factors for developing these complications were analysed. In addition, the relationship between outcome and clinical factors was analysed.

Twenty-five of the 108 patients died within the first month after surgical decompression. A lower GCS at admission seemed to be associated with a poorer outcome. Complications related to surgical decompression occurred in 54 of the 108 (50%) patients; of these, 28 (25.9%) patients developed more than one type of complication. Herniation through the cranial defect was the most frequent complication within 1 week and 1 month, and subdural effusion was another frequent complication during this period. After 1 month, the “syndrome of the trephined” and hydrocephalus were the most frequent complications. Older patients and/or those with more severe head trauma had a higher occurrence rate of complications.

Conclusions

The potential benefits of decompressive craniectomy can be adversely affected by the occurrence of complications. Each complication secondary to surgical decompression had its own typical time window for occurrence. In addition, the severity of head injury was related to the development of a complication.

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A review on decompressive craniectomy for traumatic brain injury: the mainstay method for neurotrauma patients

Long-term survival after primary decompressive craniectomy for severe traumatic brain injury: an observational study from 1 to 17 years

Early cranioplasty associated with a lower rate of post-traumatic hydrocephalus after decompressive craniectomy for traumatic brain injury

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Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou City, 310003, Zhejiang Province, People’s Republic of China

X. F. Yang, L. Wen, F. Shen, G. Li, R. Lou, W. G. Liu & R. Y. Zhan

Institute of Brain Medicine, Zhejiang University, Hangzhou City, People’s Republic of China

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Correspondence to R. Y. Zhan .

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This manuscript reports one of the largest series of decompressive craniectomies performed in TBI that I have seen. In current day neurotraumatologic practice, the use of decompressive craniectomies is becoming more popular, despite the lack of class I evidence to support it's beneficial effect on outcome. Whist it was formally only considered in patients in whom medical management failed to adequately control ICP, many centers now perform a decompressive craniectomy at earlier stages. One of the reasons underlying this is the understanding that it is a relatively harmless operation without serious complications. This paper clearly shows that decompressive craniectomy should not be considered 'a harmless procedure'. Strengths are the large patient numbers and the clear insight into the time course of different complications. Relative drawbacks are that it concerns a retrospective study and that no conclusions concerning efficacy of decompressive craniectomy can be drawn, although reported outcome assessment at a fixed time point is at least as good, if not better than other series reporting on severe TBI.

Andrew Maas

University Hospital Antwerp

X. F. Yang and L. Wen contributed equally to this study.

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Yang, X.F., Wen, L., Shen, F. et al. Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir (Wien) 150 , 1241–1248 (2008). https://doi.org/10.1007/s00701-008-0145-9

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Received : 12 February 2008

Accepted : 19 May 2008

Published : 13 November 2008

Issue Date : December 2008

DOI : https://doi.org/10.1007/s00701-008-0145-9

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Craniotomy Explained: Process, Risks, and Recovery

Welcome to our comprehensive guide on craniotomy, a surgical procedure used to treat a range of medical conditions affecting the brain. In this first section, we will provide an overview of what a craniotomy is, why it is performed, and what patients can expect during the process.

A craniotomy is a surgical procedure in which a section of the skull is removed, providing access to the brain for medical treatment. It is performed under general anesthesia and requires a team of highly skilled medical professionals, including a neurosurgeon.

What is a Craniotomy?

A craniotomy is a surgical procedure that involves temporarily removing a portion of the skull to access the brain. This procedure is typically performed by a neurosurgeon in a hospital setting and may be done under general anesthesia.

The purpose of a craniotomy can vary depending on the patient’s condition and needs. It may be done to remove a brain tumor, control bleeding in the brain, or treat a neurological disorder.

There are different types of craniotomy, including:

A craniotomy may be a necessary procedure to diagnose or treat a variety of brain-related conditions .

Why is a Craniotomy Performed?

A craniotomy is a surgical procedure that involves the removal of a piece of the skull, also known as a skull flap, in order to access the brain. The procedure is typically performed to treat a range of neurological conditions that affect the brain, including:

• Brain Tumor Removal: A craniotomy may be performed to remove a tumor located in the brain.
• Intracranial Hemorrhage: This condition involves bleeding inside the brain, which can be caused by a head injury or other medical conditions. A craniotomy may be necessary to remove the blood and relieve pressure on the brain.
• Brain Trauma: A craniotomy may be necessary to repair damage caused by a severe head injury.
• Neurological Disorder Treatment: This includes conditions such as epilepsy, Parkinson’s disease, and other disorders that affect the brain and nervous system.

A craniotomy may also be performed to collect a tissue sample from the brain for further analysis, or to implant devices such as electrodes for monitoring brain activity.

What to Expect Before a Craniotomy

Before a craniotomy, patients will typically undergo a series of preoperative preparations and medical evaluations to ensure they are healthy enough to undergo surgery.

The specific preoperative preparation required may vary depending on the patient’s health status and the type of craniotomy they will undergo. Some common preoperative preparations may include:

• Fasting for a certain period of time before the surgery
• Stopping certain medications or supplements that may increase the risk of bleeding
• Meeting with a healthcare provider to review the surgery plan, potential risks, and expected outcome
• Completing any necessary medical tests, such as blood work, imaging tests, or electrocardiogram (ECG)

Prior to the surgery, patients will also undergo a comprehensive medical evaluation to make sure they are healthy enough to undergo anesthesia and the surgery itself. This may include:

• A physical examination and medical history review
• Anesthesia assessment to evaluate the patient’s risk for complications during surgery
• Imaging tests to assess the brain and surrounding structures, such as magnetic resonance imaging (MRI), computed tomography (CT), or positron emission tomography (PET) scans

The Craniotomy Procedure

A craniotomy is a surgical procedure that involves making an opening in the skull to access the brain. This procedure is typically performed under general anesthesia, and may take several hours depending on the complexity of the operation.

During the procedure, the patient’s head will be positioned to allow the surgical team access to the area of the brain that needs to be treated. The scalp will be shaved and clean, and a special head holder may be used to keep the head in position during the surgery.

The surgeon will then make one or more incisions in the scalp and use a special drill to create an opening in the skull. This opening is called a bone flap, and it is carefully removed from the skull and set aside for later replacement.

With the bone flap removed, the surgical team will be able to access the brain and perform the necessary treatment. This may involve removing a tumor, repairing a blood vessel, or treating an area of the brain affected by trauma.

Once the procedure is complete, the bone flap is carefully replaced and secured with small metal plates and screws. The incisions in the scalp are then closed with sutures or staples, and the patient is taken to the recovery room for further monitoring.

Types of Craniotomy

The type of craniotomy performed will depend on the specific needs of the patient and the area of the brain that needs to be treated. The surgeon will discuss the specifics of the procedure with the patient and their family prior to the surgery.

Risks and Complications of a Craniotomy

A craniotomy is a serious surgical procedure that carries some risks. Although complications are rare, it is important for patients to be aware of the potential risks and to discuss any concerns they may have with their healthcare provider before the surgery.

Surgical Risks

There are several surgical risks associated with a craniotomy, including:

Complications

Although rare, there are potential complications that can occur after a craniotomy. These may include:

• Vision or speech problems
• Memory problems
• Personality or behavioral changes
• Motor function problems

If patients experience any of these symptoms following their craniotomy, they should contact their healthcare provider immediately.

Recovery from a Craniotomy

Recovery from a craniotomy can vary depending on the individual patient and the reason for the surgery. The initial recovery period usually takes several weeks and may involve some discomfort and limitations in activities.

Following a craniotomy, patients will need to avoid activities that could put strain on the healing site, such as heavy lifting or strenuous exercise. They will also need to keep the area clean and dry to prevent infection.

It is important for patients to follow their medical team’s instructions carefully during the recovery period to ensure the best possible outcome.

Follow-up Care and Monitoring

After a craniotomy, it’s important to follow up with healthcare providers to monitor your recovery and ensure that you are healing properly. Your medical team will provide instructions for postoperative care, including medications, follow-up appointments, and any necessary rehabilitation or therapy.

Depending on the reason for your craniotomy, you may need to undergo additional medical tests to monitor your condition. This may include imaging tests, such as CT scans or MRIs, to check for any changes in your brain or to evaluate the success of the surgery.

You should also be aware of any potential complications that may arise and seek medical attention immediately if you experience any concerning symptoms, such as fever, severe headaches, or changes in vision or speech.

Regular check-ups with your healthcare providers are essential to ensure that you are healing properly and to address any concerns or questions that you may have. It’s important to be vigilant about your health and to communicate openly with your medical team throughout the recovery period.

Living with a Craniotomy

Adjusting to life after a craniotomy can be challenging, but there are many resources available to help patients through the recovery process. It is important to remember that recovery is different for everyone and can take time.

Here are some ways to help cope with life after a craniotomy:

• Attend rehabilitation sessions: Depending on the reason for the craniotomy, rehabilitation sessions may be necessary to regain certain motor or cognitive skills. These sessions can be extremely helpful for patients and may improve their overall quality of life.
• Make necessary lifestyle changes: Depending on the reason for the craniotomy, patients may need to make certain lifestyle changes, such as avoiding certain activities or taking certain medications. It is important to follow all postoperative instructions from medical professionals.
• Seek support from friends and family: Friends and family can be a great source of emotional support throughout the recovery process. Do not be afraid to reach out and ask for help when necessary.
• Join a support group: joining a support group for people who have undergone a craniotomy can be a helpful way to both give and receive support, as well as share experiences and advice.
• Practice self-care: Taking care of oneself is critical for recovery. This includes getting enough sleep, eating a healthy diet, and engaging in activities that bring joy and relaxation.

Remember to consult with healthcare providers if any concerns or questions arise during the recovery process.

Alternative Treatment Options

In some cases, a craniotomy may not be the only option for treatment. Depending on the underlying condition, there may be alternative treatments available that do not involve surgery.

Non-Surgical Options

For brain tumors that are slow-growing and not causing symptoms, a doctor may recommend watchful waiting or monitoring the tumor with regular imaging tests. Radiation therapy or chemotherapy may also be used to shrink the tumor without surgery.

For intracranial hemorrhages or brain traumas, a doctor may recommend medication and rest to allow the brain to heal on its own.

Medications

For neurological disorders such as epilepsy or Parkinson’s disease, medication can be prescribed to help manage symptoms and prevent seizures or tremors. These medications are often a long-term solution for managing the condition.

Lifestyle Changes

For conditions such as migraines or chronic headaches, lifestyle changes such as avoiding triggers, getting enough sleep, and managing stress can help reduce the frequency and severity of symptoms.

Complementary Therapies

In addition to traditional medical treatments, some patients may benefit from complementary therapies such as acupuncture, massage therapy, or meditation. These therapies can help reduce stress and promote relaxation, which can be beneficial for certain neurological conditions.

Section 11: The Cost of a Craniotomy

A craniotomy can be an expensive surgical procedure, and it’s important to understand the costs associated with it. The cost of a craniotomy can vary widely based on several factors, including the complexity of the surgery, the length of the hospital stay, and the location of the hospital. On average, the cost of a craniotomy can range from $30,000 to $150,000.

If you have health insurance, your policy may cover some or all of the costs associated with a craniotomy. However, it’s important to check with your insurance provider to understand what your policy covers and what your out-of-pocket expenses may be.

If you don’t have health insurance, the cost of a craniotomy can be even more daunting. However, many hospitals offer financial assistance programs or payment plans to help patients manage the costs of their care. It’s important to speak with a financial counselor at the hospital you plan to receive care from to learn more.

It’s worth noting that the cost of a craniotomy should never deter someone from seeking necessary medical care. Brain surgery is a serious procedure that can save lives and improve quality of life for those who need it.

Choosing a Medical Professional for a Craniotomy

Choosing the right medical professional for your craniotomy is crucial to ensure the best possible outcome and reduce the risk of complications. Here are some important factors to consider:

It is important to choose a neurosurgeon who has extensive experience performing craniotomies. Look for a surgeon who has performed a high volume of these surgeries and has a good track record of success.

Board Certification

Make sure the neurosurgeon you choose is board certified by the American Board of Neurological Surgery. This certification ensures that the surgeon has completed rigorous training and meets the highest standards of neurosurgical practice.

Hospital Affiliation

Choose a neurosurgeon who is affiliated with a reputable hospital that has a good reputation for neurosurgical care. This will ensure that you have access to high-quality facilities and resources during your surgery and recovery.

Referrals and Reviews

Ask your primary care physician, friends, and family for recommendations on neurosurgeons who they have had positive experiences with. You can also check online reviews and ratings to get a sense of a surgeon’s reputation and patient satisfaction.

Communication and Comfort

It is important to choose a neurosurgeon who you feel comfortable communicating with and who takes the time to answer your questions and address your concerns. You should feel confident and at ease with the surgeon you choose.

Insurance Coverage

Make sure to check with your insurance provider to ensure that the neurosurgeon you choose is covered under your policy. You can also discuss potential coverage options with the surgeon’s office or hospital before scheduling your surgery.

Patient Success Stories

Personal stories can provide an invaluable source of information and inspiration for patients who may be nervous about undergoing a craniotomy. Here are a few examples of individuals who have undergone successful craniotomies:

While every patient’s experience is unique, these stories offer hope and encouragement to those who may be facing a craniotomy. It is important to remember that the road to recovery may be challenging, but it is possible to overcome obstacles and regain a fulfilling life.

Research and Innovation in Craniotomy

The field of craniotomy is constantly evolving, and new research and technology are being developed to improve patient outcomes. Here are some of the latest advancements:

The Future of Craniotomy

As technology and research continue to advance, the future of craniotomy looks promising. Some of the potential future developments in this field include:

• Real-time brain imaging and monitoring during surgery
• Implantable devices that can detect and treat seizures
• Gene therapy to treat certain neurological disorders

These future developments have the potential to greatly improve patient outcomes and quality of life.

Frequently Asked Questions

Below are some frequently asked questions about craniotomy:

• Is a craniotomy a risky surgery? Yes, like any surgery, a craniotomy comes with risks such as bleeding, infection, and brain swelling. However, it is important to discuss these risks with your doctor and understand the potential benefits of the surgery.
• How long does a craniotomy take? The length of the surgery varies depending on the type of craniotomy and the reason for the surgery. Some surgeries can take several hours while others may take less than an hour.
• What is the recovery time after a craniotomy? The recovery time varies depending on the individual and the type of surgery. Generally, patients can expect to stay in the hospital for a few days and may need several weeks or months to fully recover.
• Will I have a scar after a craniotomy? Yes, a craniotomy involves making an incision in the scalp and removing a piece of the skull, which will leave a scar. However, the location and size of the scar will depend on the type of surgery and the individual’s healing process.
• What should I expect during my hospital stay? During your hospital stay, you will be closely monitored by healthcare professionals to ensure proper healing and recovery. You may have a drain in your head to remove excess fluids and may need to stay in a specific position to reduce swelling.
• When can I return to my normal activities? The timeline for returning to normal activities varies depending on the type of surgery and the individual’s healing process. Your doctor will provide specific instructions on when it is safe to resume activities such as driving, exercising, and working.

Undergoing a craniotomy can be a daunting experience, but with proper preparation and a skilled medical team, it can also be a life-saving procedure. It is important to understand the reasons why a craniotomy may be necessary, as well as the risks and potential outcomes of the surgery.

Before undergoing a craniotomy, patients should make sure they are fully informed about the process, including pre- and post-operative care. It is also important to choose a qualified and experienced medical professional to perform the procedure.

While recovery may be challenging, it is important to remain positive and focused on rehabilitation. There are many resources available to help patients adjust to life after a craniotomy, and with the right support and care, it is possible to achieve a successful outcome.

Stay informed, seek support, and trust in the expertise of your medical team. With these tools, you can navigate the process of a craniotomy with confidence and hope for a successful outcome.

Brio-Medical, Scottsdale AZ

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Awake Craniotomy For Brain Tumor

• Pituitary Apoplexy Surgery
• Subdural Hematoma
• Microsurgical Tumour Excision
• Sinus Thrombosis With Left Frontoparietal Hemorrhage

Patient Review

• Patient’s Name: Mr. Ramda Chopade
• Patient’s Age: 58
• Patient’s Gender: male
• Focal seizures and word finding difficulty.

Case Presentation

The current case study describes a patient with a large left frontal tumor in the speech area. Awake craniotomy is the appropriate technique for operating on such cases. When a brain tumor is near critical speech areas of the brain, it may be important to determine the exact location of these speech-related areas. Awake speech mapping may be carried out by applying mild electrical current to the surface of the exposed brain while the patient performs various tasks, such as reading, speaking etc. If the stimulation hinders the task, then that area of the brain is marked and preserved. Typically, the patients feel minimal or no discomfort while being awake during the surgery.

Treatment and prognosis

• Craniotomy is the only way to reliably preserve speech function during tumor resections, benefitting the patients undergoing such a procedure

Physical Examination & Tests

• Functional MRI

Post-Operative Assessment

• Vol 3, No 7 (2023)

Effectiveness of 30o Head Elevation Intervention on Head Pain Levels in Patients with Space Occupying Lesion (SOL) Intracranial Tumor Post-Op Craniotomy : Case Study

Pengaruh intervensi elevasi kepala 30 derajat terhadap tingkat nyeri kepala pada pasien dengan space occupying lesion (sol) tumor intrakranial post-op craniotomy : studi kasus.

• How to cite

Intracranial tumors are abnormal mass growths in the brain that originate from tissue that grows and divides uncontrollably. Space Occupying Lesion (SOL) is a space pressure caused by an increase in volume within the brain due to the accumulation of blood, cerebro-spinal fluid or brain tissue. A common treatment for intracranial tumors is craniotomy. According to research, about 60% of patients who undergo craniotomy experience moderate to high levels of headache pain. Non-pharmacological pain management that can be done includes deep breathing interventions with guided imagery techniques, monitoring patient hemodynamics and 30 o head elevation. The purpose of this study was to present the effect of 30 o head elevation nursing intervention on pain levels in patients with SOL intracranial tumors post craniotomy. The method in this study  used a case study design conducted in November 2022 at Sumedang Regional General Hospital. The results showed that head elevation of  30 o can reduce head pain levels because it can maximize the entry of oxygen into the intracranial and increase the return flow of blood from the brain to the heart, help activate the parasympathetic nervous system which functions to control various activities of the human body at rest and maximize relaxed conditions in patients, resulting in a stable pulse frequency, respiratory frequency, blood pressure. The intervention of elevating the head position or head elevation of 30 o is one of the many nonpharmacological therapies that are useful for improving intracranial pressure so that the headache felt by the patient improves and cerebral perfusion can be resolved.   

Keywords: SOL, Post-op Craniotomy, Head Elevation

Supplement Files

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• Aninditha, T., Nevada, V., & Sofyan, H. R. (2020). Karakteristik Klinis Tumor Intrakranial pada Dua Rumah Sakit Rujukan Nasional. Jurnal Keperawatan Indonesia, 8(3), 213–218.
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