Talking with your neurosurgeons during brain surgery may seem terrifying or like science fiction. But actually, as two patients share, it was a necessary part of making their surgeries successful. Dr. Rohan Ramakrishna joins Dr. Stieg to talk about how awake craniotomies provide a critical real-time assessment into the inner workings of the brain.
Dr. Stieg: In the process of performing brain surgery, a neurosurgeon often has a patient under something called general anesthesia, but there are occasions when the patient must be awake and fully conscious during the surgery so that the surgeon can communicate with the patient to make sure sensitive parts of the brain are not being compromised. This amazing procedure is called an awake craniotomy. Dr. Rohan Ramakrishna, a neurosurgeon at Weill Cornell Medicine / NewYork-Presbyterian Hospital specializing in awake craniotomies joins me today along with his patient, Mario Moore. Mario is an artist who had a seizure which led to the discovery of a brain tumor. Welcome Rohan and Mario. Mario, I'd like you to take us back a few years before your seizure. What you described was giving a lecture but not being able to remember the words. What was your experience during that event?
Mario Moore: So I'm a visual artist and I was giving a lecture at Winston-Salem State University and I believe it was in 2015, I was giving a lecture to a class and I'm talking about my work and talking about my paintings and things like that. And I was coming to about the end of the lecture and there were words that I was, that I had in my mind that I wanted to say and I couldn't, I just couldn't say them. So literally what I had to do was talk around those words and I'm sure to the students after the lecture that they probably looked kind of confused or like, I don't know what that last part, what it's about. I thought it was me being nervous, but eventually I found out it was, it was more to it.
Dr. Stieg: So Rohan, can you give us a little bit of background on what really went on and why you felt like you needed to do an awake craniotomy in this situation?
Dr. Ramakrishna: Well, as Mario mentioned, he had had some telltale signs of language dysfunction prior to being diagnosed with a brain tumor. In addition, he had had a seizure and when the imaging evaluation for this was completed, it was clear he had a tumor and a part of the brain called the superior temporal gyrus on the left side. Now this part of the brain is almost always intimately associated with language function and there was some swelling associated with the tumor. So it was immediately obvious that this lesion was in fact responsible for not only seizure but his language dysfunction because of the proximity of language areas to the tumor. That's why I recommended an awake craniotomy so that we could find those areas and take the tumor out safely.
Dr. Stieg: Had you gotten a functional MRI scan beforehand to confirm that as well?
Dr. Ramakrishna: Uh, yes. And he had language areas intimately associated with the tumor.
Dr. Stieg: So Mario, you're sitting in Dr. Ramakrishna's office, and he says, "I want to do an awake craniotomy." What was your first reaction?
Mario Moore: My first reaction was I had no idea what it was. The second reaction was I'd never had surgery before, which also led me to have no idea what it was. And then when I realized what he was talking about, I immediately thought of a scary movie. It's like, this is, this is something that people actually do. But when Dr. Ramakrishna actually explained it more, I understood the process and I knew he was really good at it from just, I'm talking to him and doing some research on my own. So it seemed to be the best way to remove the tumor. You know, of course I was still a little like, "Oh, this is, this is kind of out of this world." But I understood what was needed to be done.
Dr. Stieg: Rohan, as a surgeon proposing this to Mario, what was your perception of his response and how did you deal with that?
Dr. Ramakrishna: I think Mario, being a young otherwise healthy guy was appropriately taken aback by the thought of having surgery. Certainly anyone being told they're about to have brain surgery for a tumor will be anxious. But he handled the news and the proposed solution really quite well. I think he did what all patients should do, which was ask the right questions. He came very prepared to the office visit with a number of questions he wanted to ask. He did more research once he left the office and so I think he was as prepared as he could have been prior to the procedure.
Dr. Stieg: So Rohan, can you describe what kind of a patient we might not want to use an awake craniotomy? What are the limitations of this technique?
Dr. Ramakrishna: Well, the technique works best when the surgeon, and the neuropsychologist, and the patient all speak the same language as their first language. You can imagine that if patients speak English as a second language or don't speak English at all, it can be very challenging to interpret language errors in the operating room because of the complexities of understanding the nuance between languages. Similarly, if someone has language deficits as a result of their tumor or hemorrhage, for example, that can make understanding language errors in the operating room very difficult. So, in general, we try and optimize our patients for an awake craniotomy by having them meet with the neuropsychologist preoperatively so that they understand what exactly is going to happen during the procedure. But also so that we can tailor our awake craniotomy testing so that it's most efficient during the operating room.
Dr. Stieg: Our second patient, Rachel Lindquist Stahmer had suffered a traumatic head injury during a soccer game and was having a brain scan when she was a teenager. In Florida. Your whole situation was rather unexpected as well. A little bit differently than Mario's. You had already by the time you came to New Jersey, had already gone through several operations under general anesthesia before you and I met. Can you talk about that and how that affected your interactions with me?
Rachel Lindquist Stahmer: I had my first surgery when I was 16 in Florida, so I think out of all of my surgeries that was the scariest for me because I was so young and didn't understand exactly what was happening. I had another surgery in my early twenties and I thought that that was going to be the end of my surgery. It turns out that the cavernous angiomas were growing more in my brain. When I was 16 my first neurosurgeon told me those were what I was born with and that's what I had. When I came to you in 2011 in that in the emergency room, I wasn't expecting to have another surgery, but I guess I was prepared.
Dr. Stieg: So for our listeners, when I first saw Rachel, she had arrived in our emergency room in NewYork-Presbyterian Hospital with several, what we call cavernous malformations, which are aberrant blood vessels within the brain that can leak or can cause seizures. One of the cavernous malformations was indeed close to her speech area called Broca's area, much like Mario, a critical place that controls speech. We knew in a way craniotomy was in order and I'm sure you remember
that day. Rachel, can you recount our conversation when I proposed this to you?
Rachel Lindquist Stahmer: Yes, I remember it. So the one on the Broca's area was something that had bled previously, but we were just watching. I never thought that we would be operating on that particular one either. I thought it was an inoperable area. You told me that I needed to have a functional MRI after I had a few bleeds. I got the functional MRI and I saw that most surgeons that did surgery in the Broca's area, it was an awake craniotomy. So I told my husband, I think that Dr. Stieg might be telling us that I'm going to have an awake brain surgery. So the way I handle that, I watched a brain sort of, alive, awake brain surgery on YouTube. And I know that sounds a little crazy that somebody would watch it, but just coming from my other surgeries, I wanted to be more prepared. And when I came to your office, you introduced me to Dr. Ramakrishna also. And as scared as I was, I was ready.
Dr. Stieg: And I think we should explain to our listeners that the patient feels absolutely no pain during an awake craniotomy. In fact, the patient feels just about nothing since the physical brain itself has no pain fibers and no sensitivity. The patient is awake because the surgeon wants to hear directly from them. And so do we.
Dr. Stieg: Mario, can you talk us through the before surgery process when you were put through the series of benchmark tests?
Mario Moore: Yeah, so I had an appointment with the neuropsychologist. Basically what he did, I was in the room and my girlfriend was also also with me and he had a series of postcards and he basically went over what would happen in the operation room, which was that he would present to me a series of three of the, that would have simple line drawings of like a cup or a knife, watch and things like that. And then he had a series of postcards that had sentences and I had to fill in the line with a word. So as we did this, you know, pre-op test, he was going through some of the images and I was sitting there and a lot of it, I really could not say what what it was. I knew the way the image worked, I knew what it was and that knew like what its use was. But I couldn't say the word to define the image. What was interesting though, my girlfriend was sitting right next to me and she actually thought that I just didn't know it. Like it wasn't a a brain tumor thing. She was like, do you really not know what those things mean? But eventually, uh, during the operation, uh, I actually did really well with the postcards and the sentences. And then, we went on to have a full conversation.
Dr. Stieg: Did that help your girlfriend understand the gravity of your problem?
Mario Moore: It did. It did. I think as she was sitting there, I think she kind of began to tear up a little bit just to understand what was really happening because it's not something that you can see, per se, or something that was like readily available for everybody to witness that knew me in my life. So I think it kind of provided the gravity of what was happening inside.
Dr. Stieg: That's real important. Family members go through these processes almost as seriously as the patient does and it's important for them to, to understand that. Rohan, do you want to describe why the pre-testing and all that is important for you? Get into the operating room?
Dr. Ramakrishna: Sure, Dr. Stieg. I think it's critical that patients undergoing awake procedures meet preoperatively with the neuropsychologist. It serves a number of functions. First, it familiarizes the patient with what exactly will happen in the operating room. So there are no surprises or anxiety. And second, it establishes a baseline of language function with the neuropsychologist. This is also critical because if someone has a baseline level of language dysfunction, we can tailor the tests that we do interoperatively so that the procedure is much more efficient and effective and not anxiety inducing in our patients.
Dr. Stieg: So Rohan, can you specifically describe to the listeners what we're really doing in the operating room when we're doing functional mapping of the human brain.
Dr. Ramakrishna: Once the patient has been put into that twilight state where a specific cocktail of medications are given, such that the patient can be awake but still breathe on their own, we start the procedure by making the incision and taking off the bone. Once we've opened up the lining of the brain and they're staring at the brain itself, we first have to figure out if there's any seizure activity going on in the brain. And so taking an electrical stimulator, which we use for the brain mapping procedure, we carefully stimulate the brain at ever-increasing intensities until we can generate a type of mini seizure. This is a sign that tells us that further stimulation, at above this intensity might cause a seizure interoperatively. And so once we know the stimulation that will be safest for that patient, we can then really awake the patient from the twilight anesthesia and begin the mapping procedure.
Dr. Ramakrishna: Now there's two types of mapping procedures. There's language mapping and there's motor mapping. In language mapping, it sounds just like it; it means just what it sounds. And that is, we go around the brain as the patient is going through a series of language tests and stimulate the brain. If we stimulate a part of the brain that is critical for language function, either the production of speech or the comprehension of speech, the patient will not be able to engage properly in the language task. Tasks can be anything from counting where we say count from one to 10 and if we stimulate the right part of the brain, they won't be able to count anymore. Similarly, we may ask them the question, "What does a king wear on his head?" And if we stimulate the right part of the brain there, they will not be able to understand what we've asked them and respond with. gibberish. Similarly, we may ask them to repeat a very simple phrase like, "No ifs, ands, or buts." And if we stimulate the appropriate part of the brain there, they won't be able to repeat back to us what we said despite the fact that they understood, what we asked them to do. So that in a nutshell is what language mapping is. And then of course we take nothing for granted. Even once we've mapped out the brain and have started to remove the lesion, whether it's a cavernous malformation or a tumor, we keep the patient talking during the operation. And so in that way, it gives us live in the moment feedback about how what we're doing is affecting their language function. The other part of mapping that we often do is called motor mapping. And this is slightly different in that we're trying to find where in the brain, the part that controls motor function, which is the movement of your arm and leg, is located. It's very similar to language mapping and that we use an electrical stimulator, stimulate a part of the brain. And when we do it, it causes the patient's arm or leg or face to move. And we monitor this not only by visualization of the movement, but by neurophysiologic monitoring where they can see movement in the muscles even if the leg isn't actually visibly moving. So that in a nutshell is language and motor mapping.
Dr. Stieg: Rachel, after we started the surgical procedure and then awakened you for the removal of the cavernous malformation, what was your experience as we awakened you and you started speaking with the neuropsychologist?
Rachel Lindquist Stahmer: When I woke up, I heard people calling my name. I was speaking with the neuropsychologist. I was very comfortable. I didn't feel any pain. I was, he asked me what I wanted to speak about to make feel. I think more comfortable and I spoke about vacation and then a lot of the same questions from the functional MRIs.
Dr. Stieg: I think that Dr. Ramakrishna and I can both assert that while we were taking out the cavernous malformation, you were just joyously singing about this miraculous vacation that you had with your husband. Can you describe what your recovery was like? Was it different with an awake
craniotomy versus having had general anesthesia?
Rachel Lindquist Stahmer: Yes. It was very different. Actually. I know that I said to you before that if I have to have another surgery and I had to pick one, I would choose the awake craniotomy. When I came out of the surgery, I didn't feel as nauseous. I felt more composed. I felt better, I felt more awake. I didn't feel as drowsy and exhausted as I did compared to the asleep craniotomy.
Dr. Stieg: Rachel, I'm really happy that you tolerated the awake craniotomy much better and I certainly hope that we won't have to do another surgery. That being said, Dr. Ramakrishna, can you explain why she probably felt better after the awake craniotomy versus general anesthesia?
Dr. Ramakrishna: In general anesthesia, you're getting a deep induction of medication that really slows brain activity. With an awake technique, you're getting the minimal amount of sedation required so that you can tolerate the incision, but not feel much pain. And so because you're getting much less sedation and narcotic medication, the aftereffects, or the hangover experience is dramatically reduced. So that's why I think patients often feel that the awake procedure is much more tolerable from a recovery standpoint than general anesthesia.
Dr. Stieg: Rohan thank you for helping us better understand the reasons why awake craniotomies provides such a critical window into the functioning of our patient's brains in real time. And a very special thanks to Mario and Rachel for sharing their remarkable stories.