Human Nature

Wake Up and Smell the Craniotomy

Yesterday, Sen. Ted Kennedy got out of the hospital. He’d been there since last week, when he had surgery to remove a brain tumor. How long he’ll live, nobody knows. The last report from his doctors was right after the operation : “Senator Kennedy was awake during the resection, and should therefore experience no permanent neurological effects from the surgery.”

Awake during brain surgery? And this helped? How?

Awake craniotomy has been around for decades and is gradually becoming more common. Kennedy’s surgery will certainly get more patients and doctors talking about it. Here’s the initial problem: Your doctors need to cut out your tumor, but it’s hard to tell where regular brain tissue stops and the tumor begins. Which parts can they cut out? Which parts can they cut through? Overall brain structure is similar from person to person, but details vary enormously.

If the operation were on your leg, the surgeons could check and map their route while you slept. That’s where most of us would like to be during surgery: out cold. I don’t know about you, but my feelings about going under the knife are pretty close to Woody Allen’s feelings about death : It’s not that I’m afraid of it; I just don’t want to be there when it happens.

But when the surgery is on your brain, you need to be there, because the feedback that will tell your doctors where to cut or not to cut isn’t strictly physical. It’s mental. According to the Boston Globe , “Kennedy’s tumor was located in a region of the brain involved with language and movement.” How can doctors find out whether snipping the next bit of tissue in their path would mess with his verbal ability? By asking him questions. “Tiny electrodes are placed on the brain to introduce an electrical current,” the Globe explains. If the electrified zone is verbally important, says a neurosurgeon , the charge “will stop their speech. You know then that’s a region you usually try to stay away from or preserve while you’re doing surgery.”

Depending on the tumor and surgeon, the test may be as simple as counting to 10 or as complex as conversation. Here’s one account from the San Francisco Chronicle a couple of years ago:

[Dr.] Perry starts flashing the pictures on the computer screen, and Hill hits them as if he’s been studying. “Window, owl, elephant, football, scissors, hammer.” Before Perry asks each question, [Dr.] Berger receives a cue to stimulate a tiny piece of brain with an electrical current … Suddenly that line is crossed. Hill starts getting confused, his brain waves spiking on an EEG monitor. He calls a door a car. Then he starts calling every picture chicken.

And here’s a British case reported by BBC News :

[Dr.] Marsh used an electrical pulse to find out where Adrian’s tumor ended and where the region of the brain that controls speech began. The pulse temporarily slurred Adrian’s speech, giving [Dr.] Marsh a clear idea of what tissue he needed to remove. Throughout the surgery, Adrian was asked to identify a series of pictures, such as a tripod, a compass and an accordion. … Marsh decided to stop the surgery after Adrian started to become muddled.

This is the hardest thing to accept about brain surgery: What’s being operated on isn’t some body part you can think about or not think about it. What’s being operated on is you . If the surgeon goofs, you don’t wake up like Ronald Reagan in Kings Row , shouting at your missing legs, ” Where’s the rest of me? ” The word me simply doesn’t mean the same thing anymore. You may never know that there ever was a “rest of me.”

This is why the surgeon in the British case warned his patient up front that

there was a risk in cutting so deep into the brain to remove as much of the growth as possible: the parts of the brain which govern speech, language or personality might be affected. “The difficulty is that you are operating very close to the regions of the brain that affect people’s thoughts, feelings and speech. It could change their personalities forever,” he said.

So take my advice: If you ever get a tumor next to the parts of your brain that think or speak, ask for the awake surgery. It’ll be pretty weird trying to answer questions or hold a conversation while you’re being zapped. But it’s better to wake up and live the nightmare for a few minutes than to sleep and live it forever.