Brittany Capone had a brain tumor removed while she chatted with her doctors. New breakthroughs in awake surgery are opening up a world of possibilities for doctors. Here’s what it’s like for the patient
“Brittany, name the days of the week.”
“Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday.”
“What do you shave with?”
“What color is grass?”
“What color is the sky?”
“Blue. You just asked me these questions.”
It’s the third round of this and Brittany Capone, 24, is rankled by the repetition. Her irritability is actually a very good sign; it means she’s alert and communicating normally, regardless of the fact that she’s lying in an operating room at Memorial Sloan Kettering Cancer Center with a tangerine-sized flap of her skull cut open.
Capone is having open-brain surgery to remove a tumor that’s dangerously close to a region in the brain that controls speech and the ability to comprehend language. And by doing the operation while Capone is awake and speaking, her surgeon, Dr. Philip Gutin, can figure out exactly where the offending growth ends and the area of the brain called the Wernicke’s center begins. This way, Gutin can see how close he can cut without permanently affecting his patient’s ability to talk.
Awake surgery was pioneered decades ago in epilepsy patients: surgeons would keep patients alert enough to ensure they were destroying the tissue in the brain that caused uncontrolled seizures. But it wasn’t until the recent introduction of brain-mapping technology—which allows doctors to create a precise digital replica of a person’s brain cartography—and highly sophisticated anesthetics that more surgeons became comfortable with the idea of waking their patients while they operated. “There’s growing interest in awake surgery nationally and internationally for sure,” says Gutin.
Now, it’s the go-to surgery for many kinds of brain tumors, especially ones, like Capone’s, located so close to the speech center. Removing it while the patient is completely sedated wouldn’t be an option anymore, says Dr. Emery Brown, professor of anesthesiology at Massachusetts General Hospital and Harvard Medical School. “That would just be wrong.”
It also means Nicole Brennan, a neurodiagnostic fMRI specialist, will continue firing questions at Capone until Gutin is satisfied that he knows exactly how far he can go to remove her growth. “How many things in a dozen?” “Name something you write with.” “Name something to sit in.” Capone, whose responses so far have been lightning fast, hesitates just a moment before saying “chair.”
The operating team starts buzzing. That brief pause indicates that Gutin is getting close to the Wernicke’s area, in Capone’s left cerebral cortex. Damage to that area could leave Capone unable to understand or use language for the rest of her life.
“Name something you paint with.”
That satisfies Gutin and his team. They now know where the no-go zone is, and they mark it on the digital mapping system that, sort of like a neural GPS, documents every inch of Capone’s brain. “The motor and speech areas are two things we are particularly cautious about,” Gutin says later, since hemiplegia and aphasia—the inability to speak—are two of the possible outcomes. Once they delineate where they will cut to remove the tumor, Capone’s dose of the anesthetic propofol is increased again and she’s back asleep while the growth is removed.
That flexibility in controlling the patient’s awake and unconscious states comes thanks to new drugs and techniques that shorten the time anesthesiologists need to make that happen. In Capone’s case, it took around 15 minutes to wake her and just a few minutes until she was asleep again. “With today’s techniques, it’s really almost like flipping a light switch,” says Dr. Robert Harbaugh, director of the neuroscience institute at Penn State and president of the American Association of Neurological Surgeons. “The patient can be asleep one minute and awake the next.”
But he admits he was a bit wary of the idea at first. Some surgeons recall rare but nightmarish stories of patients who report being awakened unintentionally while under general anesthesia; they can feel everything but they can’t speak or move because they’re paralyzed by the anesthetic. “I had some concerns initially,” Harbaugh says. “What would happen if someone became agitated, and tried to jump off the table?”
His fears were unfounded, and instead, awake surgery is increasingly proving to be a useful way of helping surgeons to perform more precise, less damaging procedures. Neurosurgeons applying or board certification are now asked about awake surgery techniques on their oral exam. “Even a few years ago, it was very rare to see those cases on an oral board exam,” says Harbaugh.
And it’s expanding beyond the brain as well. Awake surgery is used by head and neck surgeons who implant prosthetic devices to replace damaged vocal cords, for instance. Having the patient awake and speaking helps them to place the device properly and restore their ability to talk comfortably. Orthopedic surgeons also awaken patients when they operate on damaged spinal cords, asking patients to wiggle their toes to ensure they haven’t accidentally damaged critical motor nerves running along the spine.
Meanwhile, what neurosurgeons are learning through mapping and documenting their experiences, for example, is also informing general knowledge about where brain structures are located and the slightly different positions they can take in different people.
For Capone, the idea of being awake during her operation was more intriguing than scary, and like most awake-surgery patients, her biggest concern was whether she’d feel anything. With brain surgery, that’s not an issue since neurons in the brain don’t have pain receptors, so as long as the scalp is numbed properly, patients don’t “feel” anything the surgeons are doing in the brain itself. Headaches, when they do happen, are caused by pressure build up in the blood vessels, or inflammation of the muscles or nerves in the scalp.
In the end, the only dismay wrought by the surgery, says Capone, is the fact that she didn’t get to watch the entire procedure on a screen in real time. “Will I get to see the tumor before you send it for biopsy?” she asks about 20 minutes after her brain was opened. The answer was no.
There was good news to come, though. The small sample Gutin tested turned out to be benign.
Capone went home four days later, and was back at work in a couple of months. “I’m doing great,” she says. “It’s like nothing ever happened.