“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 thethird round of this and Brittany Capone, 24, is rankled by the repetition. Herirritability is actually a very good sign; it means she’s alert andcommunicating normally, regardless of the fact that she’s lying in an operatingroom at Memorial Sloan Kettering Cancer Center with a tangerine-sized flap ofher skull cut open.
Capone ishaving open-brain surgery to remove a tumor that’s dangerously close to aregion in the brain that controls speech and the ability to comprehendlanguage. And by doing the operation while Capone is awake and speaking, hersurgeon, Dr. Philip Gutin, can figure out exactly where the offending growthends 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’sability to talk.
Brittany Capone, with electrodes attached to her head that will help surgeons map where her brain tumor lies.
Awakesurgery was pioneered decades ago in epilepsy patients: surgeons would keeppatients alert enough to ensure they were destroying the tissue in the brainthat caused uncontrolled seizures. But it wasn’t until the recent introductionof brain-mapping technology—which allows doctors to create a precise digitalreplica of a person’s brain cartography—and highly sophisticated anestheticsthat more surgeons became comfortable with the idea of waking their patientswhile they operated. “There’s growing interest in awake surgery nationally andinternationally for sure,” says Gutin.
Now, it’sthe go-to surgery for many kinds of brain tumors, especially ones, likeCapone’s, located so close to the speech center. Removing it while the patientis completely sedated wouldn’t be an option anymore, says Dr. Emery Brown,professor of anesthesiology at Massachusetts General Hospital and HarvardMedical School. “That would just be wrong.”
It alsomeans Nicole Brennan, a neurodiagnostic fMRI specialist, will continue firingquestions at Capone until Gutin is satisfied that he knows exactly how far hecan go to remove her growth. “How many things in a dozen?” “Name something youwrite with.” “Name something to sit in.” Capone, whose responses so far have beenlightning fast, hesitates just a moment before saying “chair.”
Theoperating team starts buzzing. That brief pause indicates that Gutin is gettingclose to the Wernicke’s area, in Capone’s left cerebral cortex. Damage to thatarea could leave Capone unable to understand or use language for the rest ofher life.
“Name something you paint with.”
Thatsatisfies Gutin and his team. They now know where the no-go zone is, and theymark 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 twothings we are particularly cautious about,” Gutin says later, since hemiplegiaand aphasia—the inability to speak—are two of the possible outcomes. Once theydelineate where they will cut to remove the tumor, Capone’s dose of theanesthetic propofol is increased again and she’s back asleep while the growthis removed.
Capone’s surgeons probed her brain while she answered questions so they could avoid touching her language areas while they removed the growth in her brain.
Thatflexibility in controlling the patient’s awake and unconscious states comesthanks to new drugs and techniques that shorten the time anesthesiologists needto make that happen. In Capone’s case, it took around 15 minutes to wake herand just a few minutes until she was asleep again. “With today’s techniques,it’s really almost like flipping a light
,” says Dr. Robert Harbaugh,director of the neuroscience institute at Penn State and president of theAmerican Association of Neurological Surgeons. “The patient can be asleep one minute and awakethe next.”
But headmits he was a bit wary of the idea at first. Some surgeons recall rare butnightmarish stories of patients who report being awakened unintentionally whileunder general anesthesia; they can feel everything but they can’t speak or movebecause they’re paralyzed by the anesthetic. “I had some concerns initially,”Harbaugh says. “What would happen if someone became agitated, and tried to jumpoff the table?”
His fearswere unfounded, and instead, awake surgery is increasingly proving to be auseful way of helping surgeons to perform more precise, less damagingprocedures. Neurosurgeons applying or board certification are now asked aboutawake surgery techniques on their oral exam. “Even a few years ago, it was veryrare to see those cases on an oral board exam,” says Harbaugh.
And it’sexpanding beyond the brain as well. Awake surgery is used by head and necksurgeons who implant prosthetic devices to replace damaged vocal cords, forinstance. Having the patient awake and speaking helps them to place the deviceproperly and restore their ability to talk comfortably. Orthopedic surgeons alsoawaken patients when they operate on damaged spinal cords, asking patients towiggle their toes to ensure they haven’t accidentally damaged critical motornerves running along the spine.
Meanwhile,what neurosurgeons are learning through mapping and documenting theirexperiences, for example, is also informing general knowledge about where brainstructures are located and the slightly different positions they can take indifferent people.
ForCapone, the idea of being awake during her operation was more intriguing thanscary, and like most awake-surgery patients, her biggest concern was whethershe’d feel anything. With brain surgery, that’s not an issue since neurons inthe brain don’t have pain receptors, so as long as the scalp is numbedproperly, patients don’t “feel” anything the surgeons are doing in the brainitself. Headaches, when they do happen, are caused by pressure build up in theblood vessels, or inflammation of the muscles or nerves in the scalp.
In theend, the only dismay wrought by the surgery, says Capone, is the fact that shedidn’t get to watch the entire procedure on a screen in real time. “Will I getto see the tumor before you send it for biopsy?” she asks about 20 minutesafter her brain was opened. The answer was no.
There wasgood news to come, though. The small sample Gutin tested turned out to bebenign.
Caponewent home four days later, and was back at work in a couple of months. “I’mdoing great,” she says. “It’s like nothing ever happened.