Brain surgery on awake patient requires a team approach.

Byline: The Health Files by Tim Christie The Register-Guard

THE MEDICAL TERM is "awake craniotomy."

What it means is, you're put to sleep for brain surgery and then, after your skull is cut open and your brain exposed, the anesthesiologist wakes you up, and the neurosurgeon asks you a bunch of questions as he probes different parts of your brain.

It sounds worse than it is. Most patients don't feel any pain and don't even remember being awakened.

Janette Whiting, a 48-year-old Eugene woman, has a vague recollection of waking up during brain surgery a year ago at Oregon Health & Science University.

Whiting has a benign, or slow-growing, tumor on the right side of her brain, which was diagnosed in 1999.

"This just came out of the blue," she said.

Whiting and her husband, Michael, live in Santa Clara and have two children and grandchildren. Whiting worked in school kitchens for 12 years in the Bethel School District before taking a disability retirement because of the tumor.

The tumor was causing her to have seizures about once a week. She'd find herself in a store, clutching onto a shopping cart, as her left arm and left leg would jerk uncontrollably.

"I didn't do much by myself because I was so afraid," she said.

Doctors in Eugene told her the tumor was inoperable because it had grown into the ridges of her brain. She was taking seizure medication, and doctors kept upping the dose. Finally, she and her husband went to Portland and got a second opinion from Dr. Johnny Delashaw, a neurosurgeon at OHSU.

Delashaw told her he thought he could cut out most of the tumor, which would take pressure off her brain and make her less susceptible to seizures.

Then he told her the anesthesiologist was going to wake her up so he could ask her questions mid-surgery.

"He took a lot of time talking about it," she said. "We felt really comfortable with him. I would say I went in fat, dumb and happy. I had no qualms about it at all. I felt really safe."

The job of anesthesizing Whiting fell to Dr. Renata Rusa, a neuro-anesthesiologist at OHSU. She put Whiting to sleep at the start of the surgery, gently awakened her in the middle, then put her back under for the end of the surgery.

A successful awake craniotomy requires a patient who is emotionally stable and can handle being awakened during surgery, a gentle surgeon and supportive anesthesiologist, Rusa said.

"It really is a team effort," she said.

Delashaw knew from imaging studies where Whiting's tumor was, but he didn't know how close it was to vital brain functions, such as speech or movement, Rusa said. If he took out too much of the tumor next to one of those vital functions, Whiting could lose the ability to speak or be paralyzed.

As the surgeon places electrodes on different areas of the brain, he asks the patient to count to five by ones, or recognize certain objects, or to squeeze a hand or move two fingers. The responses allow the surgeon to "map" the brain and avoid cutting into critical areas.

Rusa's done about a dozen awake craniotomies at OHSU in the past four years. Still, she approaches each one with a "heightened level of anxiety," compared to garden-variety surgeries.

"I still approach each one of these procedures with a bit more attention," she said. "Every person responds differently to medication. The goal of this anesthesia is to have a smooth awakening."

When the surgery began, Rusa put Whiting under a general anesthetic so she wouldn't feel the removal of her skull and dura mater, or brain lining. Once Whiting was asleep, her head was secured with pins.

Doctors have been doing awake craniotomies for some time, often for epilepsy patients. But historically, the patient was given a local anesthetic for pain and kept wide awake for the entire surgery, said Dr. Robert Shangraw, an OHSU anesthesiology professor.

The development of better anesthetic drugs allows anesthesiologists to put patients under, then wake them up during surgery. A new generation of drugs take effect quickly and wear off quickly, and don't leave patients with a hangover or overly excited, Shangraw said.

Whiting remembers "semi waking up" during her surgery last Oct. 4 at OHSU. She remembers Rusa calling her name and patting her arm, and doctors asking her to move her feet and toes, and she remembers talking to them a little bit. And she remembered a distinctive sound.

"I remember hearing them suck the tumor out," she said. It sounded like a dentist vacuuming saliva out of a patient's mouth.

"The next thing I knew I was in my room," she said, adding that she felt no pain during the surgery.

The surgeon was able to remove about 50 percent of her tumor. She's still taking seizure medication, and has completed five of six rounds of chemotherapy to keep the tumor in check.

In the year since surgery, she's suffered just two seizures, and feels as if the surgery improved her life.

"Even if I have only two years left to live," she said, "they'll be better than my life was before the surgery."

Tim Christie covers health and medical issues. Call 338-2572 or e-mail [e-mail].