Awake brain surgery: preserving the mind while treating the brain

Awake brain surgery, also known as awake craniotomy, is one of the most significant advances in modern neurosurgery—designed not just to treat disease, but to protect the functions that define a person’s identity. When brain lesions are located close to areas controlling speech, movement or sensation, the challenge for surgeons is not only to remove the lesion safely, but to ensure the patient’s quality of life remains intact.

This specialised technique is typically recommended for patients with a space-occupying lesion or tumour near the brain’s eloquent areas—regions responsible for critical functions such as speaking, understanding language, and voluntary movement. Since general anaesthesia is associated with a higher risk of complications related to neurologic function, awake brain surgery can provide neurosurgeons with an opportunity to observe critical neuronal function as it occurs in real-time so as to provide greater accuracy and improve results.

What the procedure entails

Despite common fears, awake brain surgery is not painful. The brain itself does not have pain receptors. During the procedure, the scalp and surrounding tissues are numbed using local anaesthesia, and the patient is kept relaxed and comfortable. The only time during a surgical procedure that a patient will be awake and aware of their surroundings will be when brain mapping (initial assessment of functional areas of the brain) is taking place, which occurs only at key times throughout the surgical procedure.

Once brain mapping has been completed, and throughout the surgery, the patient will be asked to perform simple tasks such as talking, counting, moving arms or legs, or answering questions. From these tasks, the surgical team can monitor the slightest change in the patient’s speech, voice, or limb motion, indicating that the surgical team is close to a critical area of function. This provides continuous live feedback to the surgical team to remove to be able to remove the lesion while preserving necessary neural pathways.

Teamwork is key

Awake brain surgery necessitates a great amount of teamwork and coordination amongst a range of health professionals including neurosurgeons, anaesthetists, neurologists, speech and language therapists, psychologists, and specialised nursing staff.

Prior to surgery, patients have extensive pre-operative counselling and psychological testing to allow them to be well prepared and confident prior to undergoing the procedure.

Busting misconceptions

Awake brain surgery is often surrounded by misunderstanding. A common misconception is that patients will be in pain or that they will be scared during the operation. In actuality, patients remain comfortable because of the use of local anaesthetic and sedation. A second misconception is that patients being awake during the process increases their risk of having complications. However, real-time feedback from the patient actually decreases the likelihood of speech or movement deficits after surgery. Some believe awake brain surgery is performed in all brain operations: this is not accurate. It is selectively used, only when lesions are close to critical functional areas.

With proper patient selection and an experienced multidisciplinary team, awake brain surgery is a safe, well-established technique that prioritises both survival and quality of life.

A recent case involved a young woman with a space-occupying lesion located close to her speech and motor centres. Given the high risk of functional impairment, awake brain surgery was chosen. During the procedure, she was asked to speak and sing, allowing continuous monitoring of her speech pathways while the lesion was carefully removed. The surgery was successful because the patient did not lose her speech and movement after the operation.

Redefining successful surgeries

Awake brain surgery redefines the definition of “successful” in neurosurgery both with regard to medical outcomes and quality of life. An awake brain surgery allows neurosurgeons not only to remove the tumours, but also gives patients back their independence, dignity and ability to live a fulfilled life.

(Dr. Rathijit Mitra is a neurosurgeon with CK Birla Hospitals, CMRI, Kolkata. Drrathijit.mitra@Ckbirlahospitals.com)