The Eloquent Brain

I've heard people on the radio expressing amazement and, in some cases, a sense of "creepiness" over discussions of Ted Kennedy's awake craniotomy.

I've provided anesthesia for a few brain surgeries during parts of which the patients were supposed to be awake for assessment of neurologic function. It's not so bad. The brain itself is pain-free. It's the stuff covering it that contains pain-sensitive nerves.

We make sure patients are unaware and pain-free during the parts that actually hurt. The pinning of the head frame to the patient's head. The skin incision. The bone-cutting.

Then we wake them up by shutting off whatever drug infusion we've been using to keep them sedated. The surgeon maps out the regions comprising the "eloquent" brain - the parts of the brain that allow an individual to interact with and process the world, via senses, motion, language, memory, and purposeful use of tools. The mapping is often done with small electrodes that stimulate certain areas of the brain and evoke particular responses. Once the surgeon has a good "map" of the eloquent cortex, tumor tissue can be removed with reasonable hope of safety.

Most patients tolerate this surgery quite well. When the surgeon has completed as much tumor resection as possible, patients are usually re-sedated for surgical closure of tissue layers.

There's a neat video of excerpts of an awake crani here. At some points the screen went green for me and the image turned upside-down, but for the most part it's cool to watch. In these other videos (a little more graphic than the first - viewer discretion advised), a British surgeon brings skills, teaching, and discarded equipment to the Ukraine to perform awake craniotomies there (hat tip to SterileEye for the link). The accompanying article decries the wastefulness of medical practice in the U.K. (though I think no country is more wasteful than the U.S.) and describes how the surgeon "is struck by the wastefulness of the NHS: a drill bit he delivered to Igor has been used for ten years. In the NHS it was thrown away after a single use...The lack of equipment in Ukraine has forced the surgeons to improvise when it comes to some of the most basic surgical tools."

I like how the patient in the video at the very top of the British article, with his head secured in a head frame and a surgeon operating on his brain, wryly smiles at the camera and says, "I'll try to stay out of the doctor's way." His eloquent brain, along with its sense of humor, was doing just fine.

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Addendum 6/3/08: Katy at Funny Girl just posted what has to be my favorite neurosurgery post ever! Check it out! :)