Surgery while awake
Staying conscious during brain surgery to remove blood clots or tumours can help the surgeon determine how much to remove without negatively impacting brain function.
THE brain looks much like a walnut. It has a lot of grooves and it floats in a bag of water.
This “bag” is actually a very tough membrane, comprising three layers: the dura, a thin layer underneath called the arachnoid, and the third layer on the surface of the brain called the pia.
Meanwhile, the “water” is cerebrospinal fluid in which the brain floats.
Different parts of the brain control different things.
If pressure is applied to the parts of the brain that control sensation, you might feel tingling or numbness.
If pressure is applied to the frontal lobe, which controls movement, you might start to become more forgetful and sluggish.
The slowdown of movement caused by this pressure occurs gradually, so people might say, “Oh, this is old age.”
However, this is a very subtle thing; if the brain is irritated, you can have seizures.
If blood clots press on the frontal lobe, you may experience memory or personality problems.
As a result, you may be diagnosed with a psychiatric condition like dementia.
If all these symptoms happen at once, you may be mistakenly diagnosed with a stroke.
This can be dangerous as prescribed aspirins, which are used to treat strokes, thin the blood while you might be bleeding in the head.
Blood clot pressure
One of the causes for bleeding in the brain is a chronic subdural haematoma (CSDH).
There is an estimated 10,000 new cases of CSDH per year in Malaysia.
In order to detect this condition, you have to get a CT (computed tomography) or MRI (magnetic resonance imaging) scan.
There is no other way around it. CSDH can mimic many other conditions, especially a stroke, so a brain scan is always warranted.
Blood clots are broken up by the body naturally. Brain scans allow us to tell whether a blood clot is healing naturally or if there is continuous bleeding and clotting, putting pressure on the brain.
One of my CSDH patients, Sham Tiang Kang, came from Penang to Selangor to get a diagnosis, after his wife began noticing impairment in his movement.
A CT scan showed that there was a blood clot putting pressure on part of his brain.
Due to the time-sensitive nature of CSDH, immediate surgery was recommended.
Sham agreed to undergo the brain surgery while awake, after I explained to him the benefits of this procedure.
Awake surgery allows surgeons to know how patients respond to the steps in the operation as they are conscious throughout the surgery.
This provides the surgeon with far more feedback compared to operating on an anaethetised patient.
Most surgeons are trained to perform sleep surgeries, where the patient is unconscious after being administered anaesthetic drugs.
Add to this the fact that performing awake surgery takes more time, surgeons in general tend to prefer sleep surgery.
However, I believe the responses that a patient can provide while undergoing awake surgery is far more efficient in helping the patient and ensuring better treatment.
Pros and cons
The advantages of a typical sleep operation are that it is less stressful for the patient; it is a far faster procedure; and in some cases, it is necessary as the patient is too unstable healthwise.
Operations where the patient remain conscious are overall cheaper and are significantly safer for the patient.
Along with knowing how a patient will react during the surgery, it also lowers the risk of a patient reacting badly to anaesthesia.
The procedure itself is also painless, but understandably, many patients are fearful of undergoing surgery while fully conscious.
Many times, it is the patient that refuses awake surgery, rather than surgeons refusing to perform the procedure.
As such, it is important to reinforce the message that this kind of procedure is both safer and more effective.
In fact, performing an awake surgery allows the surgeon to remove far more of the clots or tumours that might be putting stress on the brain.
Surgeons will always err on the side of caution when operating on an unconscious patient.
As the patient is unresponsive, the surgeon cannot know how much of the clot to remove before it affects the patient negatively.
If they remove too much, the surgeon may paralyse the patient, so only about 60% of the obstruction is removed during sleep surgeries.
As for the remaining 40%, the only way to remove it is if the patient is awake during the surgery.
So, as long as the patient does not want an awake surgery, there is no way to remove the remaining 40% of the clot unless very sophisticated and very expensive machines are used.
With such machines, we can operate on blood clots and tumours near the brain efficiently and safely even when the patient is asleep, but the cost is phenomenal.
The patient says
While it is impossible to have a 100% recovery rate with regards to awake surgery either, the ability to test the patient during surgery allows for the risk of complication to be significantly lower.
“During the surgery, I was fully aware of my surroundings, but I felt no pain.
“I was more nervous than scared, but being able to interact with those present throughout the procedure helped keep me calm,” said Sham during a post-surgery check-up.
“My recovery has been really great. I really dodged a bullet.
“I was discharged from the hospital the day after the surgery and only needed a few days resting to completely recover.
“All of my symptoms disappeared after the surgery; I used to have headaches because of the clot – really intense migraines – and now they’re gone.
“It has not been hard for me to assimilate back to normal life. My condition is quite good now. I am doing great.”
Sham confirmed that there have been no lasting side effects as a result of his surgery thus far.
He is now fully functional and is back to his old exercise routine, having experienced no problems with his body or range of movement. Dr Ian Low is a consultant functional neurosurgeon. For more information, email starhealth@thestar.com. my. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.