The Evolving Role of Awake Brain Surgery: Benefits, Risks, and Patient Experience

Advances in neurosurgery have enabled many patients to undergo brain tumor removal or epilepsy surgery while remaining awake for parts of the the procedure. Awake brain surgery (also called awake craniotomy) is increasingly used to maximize tumor removal or epileptogenic zone resection while preserving critical neurological functions such as speech, motor skills, and language.

How Awake Brain Surgery Works

1. Preoperative Mapping & Planning
   • Before surgery, the neurosurgeon works with neuropsychologists and imaging experts to map out critical brain regions (e.g. language, motor) using techniques such as functional MRI (fMRI) and diffusion tensor imaging (DTI).
   • The surgical team plans trajectories to avoid or minimize damage to eloquent brain areas.
2. Anesthesia Approach
   • Generally, patients receive sedation and pain control (local anesthesia) for skull opening. Once the brain is exposed, sedation is lightened so that the patient is awake for critical parts of mapping and resection.
   • Throughout, vital signs, brain function monitoring, and patient comfort are tightly managed.
3. Intraoperative Brain Mapping & Monitoring
   • While the patient is awake, electrical stimulation is used to test specific brain regions. The patient may be asked to talk, count, move fingers, read, or name images.
   • If stimulation causes speech arrest or weakness, the surgeon avoids that region.
   • This mapping guides the surgeon to resect as much abnormal tissue as possible while preserving function.
4. Tumor / Lesion Resection
   • Once mapping is done, the neurosurgeon proceeds to remove tumor or epileptogenic tissue, constantly checking responses from the patient.
   • Imaging (intraoperative MRI, ultrasound) and neuro-navigation assist in confirming margin and orientation.
5. Closing & Recovery
   • After removal, sedation is deepened again, and closure proceeds like standard craniotomy.
   • The patient is awakened, monitored, and undergoes neurological examination immediately after surgery.

Benefits of Awake Surgery

• Higher Safety Margin for Function
  Awake surgery allows real-time feedback from the patient, reducing the risk of postoperative deficits in speech, movement, or other cognitive functions.
• More Aggressive Tumor Resection
  Because of better functional mapping, neurosurgeons can safely push resection boundaries further in many cases, improving prognosis.
• Reduced Need for Second Surgeries
  Precise mapping can reduce residual tissue left behind, which might otherwise require additional operations.
• Faster Detection of Neurological Issues
  Intraoperative surveys allow the team to detect warnings—e.g. changes in speech or motor responses—and adapt immediately.

Risks and Limitations

• Patient Comfort & Anxiety
  Being awake in the operating room is daunting. Some patients may feel discomfort, anxiety, or fatigue; the surgical and anesthesia teams work hard to minimize these.
• Medical Contraindications
  Some patients (e.g. children, severe anxiety, certain comorbidities) may not be good candidates for awake procedures.
• Seizure Risk
  Triggering electrical stimulation may provoke seizures; the team is prepared with antiepileptic drugs and immediate intervention capability.
• Movement Risk
  Any sudden movement while operating close to critical brain structures is dangerous—communication and monitoring is essential.
• Surgical Time & Complexity
  Awake craniotomy is more complex and demands more time and coordination among neurosurgery, neuropsychology, and anesthesiology teams.

What Patients Should Expect

• Pre-surgery Counseling & Testing
  You will meet the surgical, anesthesia, and neuropsychology teams. You may rehearse tasks (e.g. naming pictures) and undergo cognitive tests.
• Clear Instructions on When and What You Will Do Awake
  The team will explain during which parts you’ll be asked to speak, move, or respond, and when sedation is used.
• Intraoperative Communication
  You’ll receive clear instructions, and there will be continuous monitoring of your comfort and vital signs.
• Postoperative Monitoring & Rehabilitation
  After surgery you’ll be closely observed for neurological deficits, and early rehabilitation or therapy (speech, physical) may begin as needed.

Awake brain surgery represents a profound shift in how neurosurgeons treat complex brain lesions—offering a synergy between maximal removal and preservation of life quality. At Dr. Tolga Dundar’s centre in Istanbul, this technique is part of a modern armamentarium for selected brain tumor and epilepsy patients, reflecting a commitment to precision, function preservation, and patient-centered care.

If you’re considering brain surgery or have questions about eligibility, feel free to reach out to schedule a consultation.