Neurosurgery - Awake Craniotomy with Intra-operative Functional Mapping (IOFM)

This leaflet has been designed to introduce patients to what is involved in awake brain surgery and mapping of brain areas involved in sensory, motor and language skills. If you have any questions after reading this information in this booklet please do not hesitate to contact the

Neurosurgeon on: ................................................................................................

or your Neuropsychologist on: .................................................................................................

The Awake Craniotomy Team

A Neurosurgeon will oversee your individual patient pathway. They will explain to you and your family the proposed plan for surgery. It is the neurosurgeon who will perform the surgery to remove the brain tumour and carry out electro-stimulation of brain areas to map your motor and thinking skills during the surgery. The same neurosurgeon will then follow you up following surgery.

A Neuropsychologist will complete pre and post-surgical assessments of your thinking skills and quality of life.
The neuropsychologist will also complete an fMRI scan with you and analyse the fMRI data.
 
The neuropsychologist will be with you during the surgery and will assess your motor and thinking skills whilst the neurosurgeon carries out electrostimulation of brain areas. The same Neuropsychologist will follow you up following surgery.

A Neuroanesthetist familiar with specialist awake craniotomy techniques will be responsible for your comfort and safety during the procedure.

A Neuroradiologist may be involved in the acquisition and analysis of the fMRI data.

Neuro-Oncology Clinical Nurse Specialist’s act as key workers throughout the patient pathway.

The Neuro-oncology Multi- Disciplinary Team (specialist nurses, clinical oncologists, neuropathologists, neuroradiologists, neurologist and other professionals allied to medicine) support the patient pathway including confirmation of a brain tumour diagnosis and ongoing treatment of patients with brain tumour.

What will happen before your surgery?

Pre-surgical Assessment

A Neurosurgical Consultation will take place prior to your surgery. During this visit your neurosurgeon will explain your proposed treatment plan and answer any questions regarding the procedure.

A pre-operative Anaesthetic Assessment will take place to assess your physical fitness for the procedure.

You will have a Pre-operative brain scan before your surgery (Brain Lab scan) which will be used as a navigational tool to guide us to the exact area of your tumour.

Neuropsychological Consultation:

Before your surgery a clinical neuropsychology assessment will be completed to identify any changes you may be experiencing relating to the brain tumour.

This includes a formal assessment of thinking skills through ’paper and pen’ tasks, for example, speech.
Neuropsychological assessment helps to identify strengths and weaknesses in your thinking skills and how these relate to the brain tumour. This informs the surgical team about any potential risks that surgery may have to thinking skills.

This information may help you to make a fully informed decision about your surgery.

Functional MRI

You will complete a specialised brain scan, an fMRI (functional Magnetic Resonance Imaging). fMRI can identify brain areas that are involved in motor and/ or language skills. fMRI provides information about where areas involved in movement and speech are located in your brain and how close these vital areas are to the brain tumour.

fMRI confirms the side of your brain responsible for language. fMRI can assist the neurosurgeon to judge how much of the brain tumour may be safely removed and decide the best approach to the surgery. You will complete the fMRI scan with the Neuropsychologist.

You will also meet the Neuropsychologist the week of your surgery to familiarise you with the tasks you will be doing during the surgery and to prepare you for the awake surgery.

This includes any emotional support you may need before, during and following your surgery.

Awake Craniotomy with Intra-Operative Functional Mapping (IOFM)

Awake craniotomy (awake brain surgery) with functional brain mapping is a multi-disciplinary approach to brain surgery for the treatment of brain tumour.

Awake Craniotomy: What does it involve?

Intra-operative functional mapping (IOFM) allows the Neurosurgeon to identify essential brain areas for language and movement during the surgery. This ensures that as much of the brain tumour is removed as possible whilst protecting your speech and movement and quality of life following surgery.

‘Awake craniotomy’ is a Misleading term as you may not be awake for the entire procedure. The Neuroanaesthetist looking after you will administer either a general anaesthetic or sedation, in combination with a local anaesthetic injections to the scalp for the first part of the surgery. This is when the Neurosurgeon removes the bone flap in order to get access to the brain.

You will be gently woken up during the tumour resection stage during which we will need your co-operation. The brain itself has no pain receptors, so you will not feel any pain. However, you will not be able to move your head as this would have been fixed to a frame earlier and you will not be able to see the surgery behind you. You will be able to see and speak to the Neuroanaesthetist and Neuropsychologist at all times.

During brain mapping (IOFM) the surgeon will apply an electric stimulation to the brain to temporarily stop function in that area. At the same time the Neuropsychologist will assess your movement and language skills to identify areas of the brain that need to be avoided during the tumour resection.

Awake speech mapping involves applying mild electrical current to the surface of the exposed brain while you will be asked to complete different tasks, such as reading, moving your hand or leg, counting 1-10 etc. If the stimulation interrupts the task, then that area of the brain is marked and will not be taken out.
 
When as much of the tumour as possible has been removed, you will either be sedated or given a general anaesthetic for the final stage of the surgery when the surgeon replaces the bone flap and closes up.

What will happen after surgery?

You will be reviewed following surgery by your:

Consultant Neurosurgeon: .........................................................................................................

Clinical Neuropsychologist: ..........................................................................................................

Neuro Oncology Clinical Nurse Specialist: ...........................................................................................................

Following your surgery you might need some further treatment including radiotherapy or chemotherapy depending on the type and grade of your tumour.

Risks

Although the risks of this procedure are much less than if you were fully asleep, it is still brain surgery with its associated risks,
i.e. infection, haemorrhage, stroke, seizures, risk of medical complications and small risk to life.

A proportion of patients experience temporary changes in their speech and language skills following surgery. This may last for a few days, but for some patients can continue for a few months following surgery. This will be discussed with you in more detail during your pre-operative neuropsychology consultation.

Summary

In summary, our aim is to remove as much of your tumour as is safely possible. There is increasing evidence that undergoing awake craniotomy with functional mapping increases the chance of improving and controlling your symptoms (especially seizures), whilst also achieving longer tumour control and improving long- term prognosis.

Useful Links, Associations & Contacts

Brain Tumour UK
www.braintumouruk.org.uk

Samantha Dickinson Brain Tumour Trust
www.braintumourtrust.co.uk

BASIC (Brain and Spinal Injury Charity)
www.basiccharity.org.uk

Epilepsy Action
www.epilepsy.org.uk/info/nonep.html

National Society for Epilepsy
www.epilepsynse.org.uk/pages/info/leaflets/factsnea.cfm

Neuro Oncology Clinical Nurse Specialist’s at Salford Royal Hospital, Stott Lane, Salford.
0161 206 2073 or 0161 206 0613