Saudi neurosurgeon performs awake brain surgery to treat epilepsy

King Faisal Specialist Hospital & Research Centre in Saudi Arabia has been offering awake craniotomy, an exceptionally advanced brain surgery procedure, for several years. Middle East Health speaks to Afnan Alkhotani, MD, Associate Consultant in Neurosurgery at King Faisal Specialist Hospital & Research Centre, Jeddah, about the awake craniotomy procedure, indications for the procedure, as well as the challenges and potential complications of the intervention. Dr Alkhotani is subspecialized in Stereotactic Functional, Pain and Epilepsy Neurosurgery.

Middle East Health: What are the main indications for performing an awake craniotomy, and what types of brain conditions or tumours are typically addressed with this procedure?

Dr Afnan Alkhotani: An awake craniotomy is a remarkable surgical intervention specifically designed for the treatment of brain conditions residing within eloquent areas. Eloquent areas refer to the regions of the brain that are intricately involved in vital functions, in stark contrast to the silent counterparts. These functions encompass critical components such as speech centres within the dominant hemisphere, motor abilities encompassing facial expressions, limb movements, and the perception of bodily sensations.

Primarily employed for the resection of tumours, epileptic foci, and specific vascular or congenital malformations, the technique of awake craniotomy offers an unparalleled opportunity for surgeons to meticulously map the intricate landscape of the brain. By actively engaging the patient during the procedure, the surgical team can effectively identify and delineate the boundaries of these crucial functional areas, allowing for their preservation while adeptly removing tumours located in their proximity.

This innovative approach stands as a testament to the remarkable progress and sophistication achieved in the realm of neurosurgery. By delicately balancing the imperative of eradicating diseased tissue with the paramount importance of safeguarding essential brain functions, the awake craniotomy reflects the commitment of medical professionals to redefine the boundaries of possibility in their pursuit of enhanced patient outcomes and improved quality of life.

Middle East Health: What are the main challenges and risks associated with performing awake craniotomy compared to traditional craniotomy under general anaesthesia?

Dr Afnan Alkhotani: Performing an awake craniotomy presents a multitude of challenges and risks when compared to the traditional craniotomy under general anaesthesia. These challenges include:

• Patient cooperation: Maintaining patient cooperation throughout the surgery is essential but can be challenging. Some patients may experience anxiety or discomfort during the procedure. To address this, thorough explanation, rehearsal, and mental preparation are undertaken to ensure the patient understands and feels as comfortable as possible.
• Psychological impact: The unique nature of an awake craniotomy, wherein patients can hear and see parts of the surgery, can have a significant psychological impact. The patients may experience fear or distress during the procedure. To mitigate this, a comprehensive neuropsychological baseline assessment before surgery and appropriate follow-up care can help alleviate anxiety and fear.
• Pain management: While local anaesthesia numbs the scalp and dura, effective pain management and anxiety medications are crucial to ensure the patient’s comfort and cooperation. Adequate measures are taken to ensure that the patient is not experiencing unnecessary pain or discomfort during the procedure.
• Intraoperative seizures: Brain tumours or lesions can trigger seizures during surgery, which can impair consciousness and patient cooperation. Sensitive electrical recorders are employed to detect seizures before they spread, and topical irrigation with cold water can be utilized to abort the seizure if necessary.
• Neurological deficits: The primary goal of an awake craniotomy is to minimize the risk of postoperative neurological deficits, such as weakness or sensory changes, compared to traditional craniotomy. However, despite meticulous care, there is still a chance of post-operative weakness, which can be attributed to the disconnection of brain cell fibres, cellular swelling, or direct injury. Every effort is made to assess and protect critical brain areas, but the potential for complications remains.
• Surgical precision: A high degree of surgical precision is required during an awake craniotomy to avoid damaging vital motor, sensory, and language functions. Surgeons employ emerging technologies and utilize all available resources to accurately delineate the diseased areas and ensure minimal disruption to critical brain functions.

Middle East Health: How do you ensure patient comfort and cooperation during an awake craniotomy, especially considering the potentially stressful and invasive nature of the solutions include?

Dr Afnan Alkhotani: Awake craniotomies require patient comfort and cooperation. Some advisable solutions:

• Pre-operative education about the procedure, what to expect, and why their participation is important. This reduces emotional stress and boosts cooperation.
• While awake, the patient receives local freezing to numb the skin incision. Sedatives also calm the patient and reduce anxiety.
• The surgical team clearly communicates with the patient throughout the procedure. Patients should voice their concerns; the head position should be as comfortable as surgically possible, where the patient can swallow sips from an ice ship if his/her feels too dry to vocalize. Some may need voice augmentation microphones.
• Awake craniotomy can stress patients. Patients may receive psychological support before, during, and after the procedure. Counselling or other methods may help manage anxiety.
  
  By implementing these strategies, healthcare professionals can prioritize patient comfort and ensure their active participation in the awake craniotomy process. Through a multidimensional approach encompassing education, communication, and psychological support, the surgical team can navigate the challenges of the procedure while fostering an environment of empathy and care for the patient’s well-being.

Middle East Health: Can you explain the process of brain mapping during an awake craniotomy and its significance in preserving critical brain functions while removing tumours or treating epilepsy?

Dr Afnan Alkhotani: The process typically begins during the clinic visit, days before the surgery. Evaluation by the process of brain mapping during an awake craniotomy is a meticulous and critical step in preserving crucial brain functions while removing tumours or treating epilepsy. The significance of brain mapping lies in its ability to identify and delineate the boundaries of functional areas within the exposed brain, enabling surgeons to navigate and operate with precision.

The process typically begins well before the actual surgery, during the clinic visit. During this evaluation phase, the patient undergoes an assessment by an anaesthesiologist, and if necessary, any blood thinners they are taking may be temporarily stopped. Additionally, necessary laboratory tests and structural or functional imaging studies are requested to aid in surgical planning.

On the day of the surgery, the patient’s scalp is numbed with local anaesthesia. The head is then secured in a three-point head holder to ensure stability during the procedure. The patient is informed about the vibrations that may be felt during the drilling of the skull bone. It is important for the patient to keep their mouth slightly open to avoid teeth clenching, and the infiltration of local anaesthesia into the dura can help alleviate mild headaches.

Once the dura, the protective covering of the brain, is opened, the surgeon proceeds with brain mapping. This involves stimulating different areas of the exposed brain using a mild electrical current. The stimulation helps elicit specific responses or movements from the patient, providing valuable information about the functional areas being activated.

For example, when the right motor area is stimulated, the patient may experience twitches or movements in the left-sided limbs or face. Similarly, stimulating a language area in the dominant hemisphere of the brain may cause the patient to have difficulty speaking or understanding words. By mapping these responses, the surgeon can precisely identify the boundaries of critical brain regions and avoid inadvertently damaging them during the surgical procedure. This meticulous approach minimizes the risk of postoperative neurological deficits or impairments by choosing the safest path of surgical resection.

In addition to direct electrical stimulation, other adjunctive techniques may be employed for brain mapping during an awake craniotomy. These may include neuronavigation, which uses imaging data to precisely locate tumour boundaries, diffusion tensor imaging (DTI) to assess white matter tracts and connectivity, functional magnetic resonance imaging (fMRI) to identify language and motor areas, or electrocorticography (ECoG) to monitor brain activity during the procedure.

By combining these sophisticated mapping techniques, surgeons can achieve an enhanced understanding of the individual patient’s brain organization, ensuring a more targeted and precise approach to surgical intervention. The integration of brain mapping during an awake craniotomy underscores the commitment to preserving critical brain functions while
effectively addressing tumours or treating epilepsy, leading to improved patient outcomes and quality of life.

Middle East Health: What are the most common neurological complications that can arise during or after an awake craniotomy, and how are they managed or minimized?

Dr Afnan Alkhotani: During or after an awake craniotomy, some common neurological complications that can arise include seizures, neurological deficits, or infections.

• Seizures can occur during the procedure due to stimulation of the brain tissue which can be aborted with direct cold solution irrigation. Also, to minimize the risk of seizures, antiseizure medications may be administered before and during the surgery.
• Damage to critical brain structures during surgery can cause neurological deficits. Pre-operative brain mapping reduces the risk of neurological deficits. Functional mapping helps the surgeon avoid damag- ing critical brain areas.
• Any craniotomy carries a risk of infections. Sterile surgery practices reduce infection risk. Antibiotics can also be given before, during, and after the procedure to reduce infection risk.
• In addition to these complications there is the potential for pain, bleeding,
  and swelling. Painkillers, close monitoring, and postoperative care manage these.
  
  Close attention to infection control, diligent monitoring, and utilizing advanced mapping techniques allows for a more precise and meticulous surgical approach, minimizing the risks and maximizing the benefits of this specialized procedure.

Middle East Health: How do you handle communication with the patient during the procedure to ensure their safety and provide necessary feedback about potential changes in neurological function?

Dr Afnan Alkhotani: Ensuring effective communication with the patient during an awake craniotomy is vital for their safety and to provide necessary feedback regarding potential changes in neurological function. The following methods are employed to facilitate communication and maintain patient well-being:

• Speech Mapping: To assess language function, the patient may be asked to perform tasks such as counting, naming objects, or reading aloud while specific brain areas are stimulated. This allows the surgical team to evaluate potential changes in speech and language function and make informed decisions accordingly.
• Motor Mapping: The patient may be instructed to move their fingers or toes while specific brain areas are stimulated. This enables the surgical team to assess motor function and detect any alterations that may occur during the procedure.
• Verbal Communication: Throughout the surgery, the surgeons engage in ongoing conversation with the patient. The patient is encouraged to actively communicate and promptly report any changes in sensation, motor function, or speech they may experience. This real-time feedback allows the surgical team to address concerns immediately and make necessary adjustments to ensure patient safety.
• Neurological Assessments: The surgical team continuously monitors the patient’s cognitive function, motor strength, sensation, and speech during the procedure. Any changes in these parameters are evaluated promptly. In the event of unexpected deficits, further evaluation, such as an instant CT scan, may be requested to assess the situation and rule out major bleeding or complications.

• Anaesthesia Management: While the patient is awake during the craniotomy, local anaesthesia is administered to numb the scalp and skull, ensuring their comfort and minimizing pain.
  
  By employing these communication strategies and closely monitoring the patient’s neurological status throughout the procedure, the surgical team can maintain patient safety, promptly address and stabilize any changes in function,

Middle East Health: What specific technologies or techniques do you employ to monitor the patient’s neurological function in real time during an awake craniotomy?

Dr Afnan Alkhotani: During an awake craniotomy, several technologies and techniques are employed to monitor the patient’s neurological function in real time. These monitoring methods play a crucial role in ensuring patient safety and the effectiveness of the procedure. Here are some specific technologies and techniques utilized:

• Electrocorticography (ECoG): Electrodes placed on the surface of the brain record electrical activity. ECoG helps identify brain function and detect any seizure activity that may arise during the surgery.
• Electromyography (EMG): EMG measures muscle electrical activity. It is used to monitor facial muscles during the procedure, allowing for the detection of any potential damage to the facial motor cortex.
• Motor Evoked Potentials (MEP): MEP involves stimulating specific brain areas and monitoring the corresponding muscle responses. This technique assesses the integrity of the motor pathways and aids in the detection of any surgical damage.
• Somatosensory Evoked Potentials (SSEP): SSEP involves stimulating peripheral nerves and monitoring the electrical responses in the brain. SSEP is used to assess the integrity of sensory pathways throughout the surgery and identify any abnormalities.
• Intraoperative MRI (iMRI): Real-time brain imaging is conducted during the surgery using an MRI machine. This technology provides immediate feedback on tumour removal and helps identify any potential complications or residual tumour tissue.
• Awake Brain Mapping: This technique involves stimulating specific regions of the brain while the patient is awake. It allows for the identification and preservation of critical language and motor regions, ensuring their protection during tumour removal or other surgical interventions.
• Continuous Neuromonitoring: Various parameters such as blood pressure, heart rate, oxygen levels, and intracranial pressure are continuously monitored throughout the procedure. Any significant changes in these parameters may indicate potential complications and allow for prompt intervention.
  
  Middle East Health: What kind of team dynamics and coordination are required for ensuring a successful awake craniotomy procedure, considering the need for close collaboration between neurosurgeons, anaesthesiologists, and other healthcare professionals?
  
  Dr Afnan Alkhotani: Successful awake craniotomy procedures rely on strong team dynamics and close collaboration among healthcare professionals involved, including neurosurgeons, anaesthesiologists, neurophysiologists, and nurses. The following practitioners are crucial for ensuring a well-coordinated and successful procedure:
  
• Neurosurgeons: Neurosurgeons lead the surgical team, performing the procedure, identifying the target area, and implementing surgical techniques. They work closely with the anaesthesiologists to determine the appropriate level of sedation required for the patient’s comfort and cooperation. Effective communication between the neurosurgeon and anaesthesiologist is essential throughout the procedure.
• Anaesthesiologists: Anaesthesiolo- gists play a pivotal role in managing pain, sedation, and the overall well-being of the patient. They closely monitor the patient’s neurological function in collaboration with the neurophysiologists. Anaesthesi- ologists must strike a delicate balance be- tween providing adequate sedation to keep the patient calm and cooperative while en- suring they remain awake and responsive.
• Neurophysiologists: Neurophysiologists are responsible for monitoring the patient’s neurological function in real time during the awake craniotomy. They utilize techniques such as EEG (electro-encephalography), EMG, and SSEP to assess brain and nervous system function. Their findings and observations are communicated promptly to the neurosurgeon and anaesthesiologist, enabling them to make informed decisions during the procedure.

• Nursing staff: The nursing team plays a crucial role in supporting both the patient and the surgical team. They monitor vital signs, ensure patient comfort, and assist during the surgery. Effective communication and coordination between the nursing staff, neurosurgeon, anaesthesiologist, and neurophysiologist are essential for seamless patient care.

Middle East Health: Can you briefly discuss any recent advancements or emerging technologies that have helped overcome some of the challenges associated with awake craniotomy, improving patient outcomes or reducing procedure-related complications?

Dr Afnan Alkhotani: Awake craniotomy has indeed witnessed significant advancements and the integration of emerging technologies, leading to improved patient outcomes and a reduction in procedure-related complications:

• Intraoperative and functional MRI: The utilization of intraoperative and functional MRI during awake craniotomy represents a noteworthy advancement. Real-time imaging allows surgeons to visualize the tumour and surrounding brain tissue, facilitating precise identification and pres-ervation of critical brain areas responsible for speech, movement, and sensation. This enables more effective tumour resection while minimizing damage to vital functional brain tissue.
• Neurophysiological monitoring: The emergence of neurophysiological monitoring techniques has greatly contributed to enhancing patient safety and reducing postoperative neurological deficits during awake craniotomy. By placing electrodes on the patient’s scalp or brain, surgeons can monitor electrical activity, allowing for the real-time assessment of the patient’s brain responses during the surgery. This proactive monitoring approach enables timely adjustments and interventions to safeguard vital brain functions.
• Advancements in anaesthesia: The continuous improvement of anaesthesia practices has significantly enhanced the safety and comfort of awake craniotomy procedures. Local anaesthetics, sedatives, and analgesics are employed to minimize pain and anxiety during the procedure, facilitating a state of wakefulness and cooperation while ensuring the patient’s overall well-being.
  
  By leveraging these innovations, health- care professionals continue to push the boundaries of possibility, achieving greater success in treating brain conditions while prioritizing patient safety and well-being.

Middle East Health: What is the history of awake craniotomy at KFSH&RC and can you tell us about some of the successful cases of awake craniotomy at KFSH&RC?

Dr Afnan Alkhotani: At King Faisal Specialist Hospital & Research Centre (KFSH&RC), the practice of awake craniotomy has been firmly established for several years. Recognizing the
numerous benefits of this procedure in specific cases, we began offering it as an option to patients who would derive significant advantages from its implementation.

One remarkable success story from KFSH&RC involved a 20-year-old girl with a tumour located in the region of the brain responsible for speech and language function on the left side. By performing an awake craniotomy, we meticulously mapped her brain, precisely locating the tumour while meticulously preserving her speech function. This altered the surgical plan, allowing us to choose a safer entry point, resulting in the successful removal of the entire tumour with minimal to zero damage to the surrounding healthy tissue. Following the procedure, the patient experienced a favourable recovery, with preserved speech and language function intact.

Another notable case at our centre involved a patient suffering from epilepsy, with seizures originating from the left side of the brain. During the awake craniotomy, we employed cortical mapping techniques to identify the precise location of the epileptic focus, enabling us to successfully resect the abnormal tissue. This intervention led to a substantial reduction in the frequency and severity of the patient’s seizures, significantly improving their overall quality of life without compromising the integrity of the surrounding vital brain structures.

These cases exemplify the positive outcomes and improved quality of life achieved through the implementation of awake craniotomy at KFSH&RC. We have consistently demonstrated exceptional results, which can be attributed to our experienced and well-supported team, state-of-the-art technology, and patient-centred approach. These factors synergistically contribute to making this transformative advancement readily accessible, ensuring optimal patient care and outcomes.