Rock Stars in the OR
Awake craniotomies inspire a special performance by two brain tumor survivors.
Awake Craniotomy
An awake craniotomy is a brain tumor surgery where you are awake during part of the procedure. The surgery team can then interact with you, allowing them to identify and preserve key parts of the brain while removing the tumor.
What diseases are treated with awake craniotomy?
Awake craniotomies are used to treat patients with tumors in the parts of the brain that control speech, language, movement and sense of touch. Common tumors that grow in these areas include gliomas such as glioblastoma, astrocytoma and oligodendroglioma. Patients with any type of tumor in these locations may be eligible for an awake craniotomy, though.
Who are candidates for awake craniotomy?
An awake craniotomy is a major surgery. In addition to having a tumor in one of these important parts of the brain, you must be in good overall health to undergo this procedure.
If the location of the tumor and your health make you a candidate for an awake craniotomy, you will be evaluated by a neuropsychologist. These doctors specialize in identifying, diagnosing and treating changes in a person's ability to think, personality, behavior and mood. The neuropsychologist will give you a cognitive test to find out how your brain is performing and what parts may be impacted by your tumor. This test can help determine if an awake craniotomy is right for you.
You must also be willing to be awake during brain surgery. Your care team will work to ensure your comfort, but an awake craniotomy can be psychologically and physically more stressful than surgeries where you are completely asleep. Some patients decide not to have an awake craniotomy to avoid this stress.
What happens during an awake craniotomy?
If your care team recommends an awake craniotomy, there are several steps you’ll go through during the procedure.
- Anesthesia: A specially trained neuro-anesthesiologist will give you anesthesia, so you will be asleep during the first part of the surgery. You will also get local anesthesia to the part of the scalp surrounding the incision.
- Accessing the tumor: The surgeon will open the scalp and remove a part of the skull bone over the tumor. This lets the surgeon access the brain and the tumor. The surgeon will use specialized devices to keep the size of the cut as small as possible. The surgeon will also inject local anesthesia into the covering of the brain, called the dura, to help prevent any pain.
- Waking the patient: The neuro-anesthesiologist will slowly wake you up from the anesthesia. You will not experience any pain when you wake up. You will be able to speak and to move your arms and legs.
- Testing and mapping: Once you are fully awake, you will be asked to perform simple tasks. These can include counting backwards, naming objects projected on a screen, completing sentences and moving your limbs. You may even be asked to perform tasks from your daily life, such as playing a musical instrument. While performing these tasks, the neurosurgeon will use an electric current to stimulate parts of the brain near the tumor. If you cannot perform a task during the stimulation, the surgeon will know that spot is responsible for the function being tested. This process lets the surgeon map the functions of the brain over and around the tumor. Testing and mapping can take anywhere from 10 minutes to several hours.
- Tumor removal: During this step, the surgeon will use MRI images of the tumor and information from the testing and mapping to remove as much of the growth as possible without harming the functional parts of the brain. During and after the tumor is removed, the surgeon will test you to ensure you have your normal functions.
- Closing the incision: The surgeon will close the dura, replace the skull and close the skin. During this part of the surgery, you will be either awake but sedated or fully asleep.
After the procedure, you will stay in the hospital for several days. You should be able to walk the day after surgery and return to most normal activities after several weeks. Full recovery can take several months.
What are the side effects of awake craniotomy procedures?
As with any surgery, there are potential risks and side effects associated with awake craniotomy, including:
- Bleeding
- Infection
- Post-surgery seizures
- Impairment of movement or speech: While awake craniotomy is designed to prevent these changes, in some cases the patient’s speech or movement is still impacted. These changes may be temporary or permanent.
If you experience any side effects, talk to your care team. They can help you manage the neurological and physical effects of an awake craniotomy.
Awake craniotomy at MD Anderson
Awake craniotomies are complex procedures that require a team of experts. At MD Anderson, your care will include doctors who specialize in complex brain surgeries and preserving your quality of life.
The surgery itself is performed by an MD Anderson neurosurgeon. Our neurosurgeons are widely viewed as among of the best in the nation. They perform more than 2,000 procedures a year. Among these are hundreds of highly complex procedures like awake craniotomies. This gives our neurosurgeons incredible skill and expertise to call on when performing your surgery.
The surgery team will also include a dedicated neuro-anesthesiologist. This doctor is specially trained in managing anesthesia for brain surgery patients. The neuro-anesthesiologist will help you sleep at the start of the surgery, then slowly and carefully wake you up for the brain testing and mapping.
The team also includes a neuro-psychologist, who will perform the pretreatment assessment and will help test your neurological functions during the procedure.
And at MD Anderson you will be surrounded by the strength of one of the nation's largest and most experienced cancer centers. From support groups to integrative medicine care, we have all the services needed to treat not just the disease, but the whole person.
Guitarist’s awake craniotomy video strikes a chord with drummer facing similar diagnosis
When Adrian Rivas needed brain surgery, his doctors suggested he not only be awake in the middle of his procedure but that he also play the drums while they removed the tumor. Adrian was stunned.
“My initial thought was ‘I’m not going to agree to do this’ because I just can’t imagine how it would be possible for somebody to be awake during that kind of procedure,” Adrian says.
He had astrocytoma, a type of brain tumor that grows from cells in the nervous system.
“I didn’t have any major symptoms or family history,” Adrian says of his unexpected diagnosis. “I went for a run and, when I got out of the shower, I had a seizure.”
Seizures can be a sign that a tumor is growing in a critical location. In Adrian’s case, the tumor was in the part of the brain that controls motor function and, more importantly, his hands.
Adrian works from home and relies on his fingers to type, so keeping this function was essential for his job. And, as an avid drummer since age 12, he didn’t want to lose his ability to play. There is no known musical part of the brain, so that made it difficult to pinpoint exactly how surgery would affect it.
In cases where patients like Adrian have tumors near parts of the brain that control speech and movement, doctors suggest an awake craniotomy. This is where the patient is woken up during surgery to help locate and test critical functions in real-time to reduce the risk of neurological injuries and paralysis.
Now, neurosurgeon Sujit Prabhu, M.D., wanted Adrian to wake up mid-surgery so he could play his drums.
This had only been done once before at MD Anderson. And the previous patient’s story would come to change Adrian’s mind.
MD Anderson’s first awake craniotomy with an acoustic guitar
In 2018, Robert Alvarez played his guitar in the operating room while undergoing brain surgery.
Up until that day, none of the 80 to 90 awake craniotomies performed at MD Anderson each year had included a musical instrument in the operating room. But Prabhu had wanted to try it with Robert to map out parts of his brain as he and his team of neurosurgeons probed the areas surrounding the tumor while Robert played his guitar. Like Adrian, Robert had wanted to ensure he could continue to play music after his brain surgery.
The surgery went smoothly, and Robert’s musical ability remained intact.
A change of tune about an awake craniotomy
At the time, MD Anderson had produced a YouTube video chronicling Robert’s surgery, which has since received more than 27 million views. Perhaps one of the most important was Adrian’s.
When Prabhu shared the video with Adrian, it struck a chord. He saw the surgery through the eyes of someone with a similar passion for music and a similar fear of losing that ability. That made going through with his own awake craniotomy an easy decision.
“I saw how easy it was and how everything was well planned out,” Adrian says. “Robert seemed calm and comfortable, and Dr. Prabhu made the music a priority.”
On Sept. 1, 2022, Adrian underwent the 6-hour surgery.
“As soon as I got there, I didn’t feel a thing,” he recalls. “I woke up and had the practice pad in front of me, and it just felt like a regular day.”
The neurosurgery team paid close attention to Adrian’s rhythms while removing the tumor.
Paying it forward after an awake craniotomy
More than a year after surgery, Adrian is doing well. He’s working remotely and has set up a recording studio in his home. He hopes his story will inspire others.
“I’m just hoping my case can help improve surgeries and also help somebody else that might be going through this,” says Adrian, who often gets asked what it was like to play during brain surgery. “It’s not until these functions are gone that you realize it could all be taken away. Robert’s story certainly helped me, and I’d like to pay it forward. That’s really the goal for me.”
And Robert is grateful his experience has helped improve people’s lives. “It’s hard and it’s scary,” he says. “But music is my soul, and I’m glad my experience motivates people like Adrian to do something positive.”
A harmonious meeting
Now fully recovered from their awake craniotomies, Adrian and Robert recently met in person. It gave Adrian a chance to get to know the man who made an enormous impact on his decision.
It was also a chance for both of them to thank the care team who helped preserve their talents.
When they met on Feb. 13, 2024, Adrian and Robert had a jam session at MD Anderson. For Prabhu and the entire neurosurgery team, seeing Robert and Adrian perform together reinforced the importance of their work.
“It’s wonderful to see them thriving and persevering in their passions. It brings me back to why we’re doing this and whom we’re helping,” Prabhu says. “These guys are my rock stars.”
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