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He`s awake, alert with brain exposed (The Arizona Daily Star) ... sharp pain when the drill moved through the skull bone and hit the sensitive lining of his brain....... as the surgeon began the delicate and dangerous job of cutting out a cancerous tumor embedded deep in his brain.......~~~ the procedure is done only on the most dangerously located tumors, and on patients who can handle it.... - Nov 30 3:42 AM ET

Al Musella's Comments: (This is his personal views and are not necessarily the views of the Musella Foundation!)


Posted on: 12/01/2001

He's awake, alert with brain exposed


The man was calm, relaxing on the operating table at St. Mary's Hospital, his head pinned in a vise, as the sedatives took gentle hold of him.

He felt almost nothing when the surgeon sliced his scalp, then slowly peeled it back off his skull.

Remarkably steady under such a traumatic assault, the patient knew what was coming.

As the surgeon's drill buzzed into action, he trembled at the ominous sound. Seconds later, he jerked slightly, feeling a tiny, sharp pain when the drill moved through the skull bone and hit the sensitive lining of his brain.

"I can feel that," the patient quickly told the team of doctors and nurses hovering around him.

Immediately, the surgeon stopped his work and the anesthesiologist sent a dose of painkiller through the intravenous lines.

Very soon, the surgeon was drilling again, this time without interruption, until he had cut a sizable chunk out of the left side of the skull, exposing the man's precious, living, red-pink brain to the world.

Still calm, in a kind of twilight zone of consciousness, the man dozed off for a bit, as the surgeon began the delicate and dangerous job of cutting out a cancerous tumor embedded deep in his brain.

In the worst possible place, the tumor was stuck between the lobes of the brain that control the critical functions of speech and mobility. Cut into either of those areas while trying to get the tumor out, and the patient is permanently paralyzed or talking gibberish, or both.

That is why this patient was denied the comforting oblivion of general anesthesia during this extremely rare, five-hour brain surgery, performed in Tucson two weeks ago.

He had to stay awake and alert throughout the ordeal, so he could answer questions and move his body on command every five minutes as the operation progressed.

That way, if the patient did not respond as expected, the surgeon would know immediately that he was hitting a part of the brain that would permanently disable his patient, and stop.

Called "awake craniotomy," the procedure is done only on the most dangerously located tumors, and on patients who can handle it. Tucson neurosurgeons say no more than one or two are done in Tucson in a year, if that many, and few have had any experience with it.

It was the first for the young neurosurgeon Dr. Abhay Sanan, 34, who, after much thought, decided it was the only way to go after the one-inch tumor growing inside the brain of Javier Armenta, 41, father of two young children from Nogales, Ariz.

"It was in such a treacherous, critical area, and it was very large, so there was a real challenge to figure out how to do it safely," Sanan said.

"The risk was just too great in the area we had to operate, so I decided I wanted Javier awake and able to tell me exactly how he was doing. I wanted to be able to go after this tumor aggressively, and I wanted him fully functional when it was over.

"The goal was to prolong his life, by decades, and there was no way I would have been able to go as far and get as much tumor if he was asleep."

Although today's sophisticated brain-imaging and brainmapping technology makes brain surgery far more precise - and therefore safer - than ever before, "sometimes we just don't get as much information as we need," said Dr. Philip Carter, longtime Arizona brain surgeon, formerly at University Medical Center and Barrow Neurological Institute in Phoenix, now in private practice in Tucson.

"That's when you have to consider keeping the patient awake. But it's very stressful on both the patient and the surgeon. It's a matter of the surgeon's confidence, and having a surgical team that's really on top of things. That's one reason why it's very rare."

Although Sanan had never done this kind of surgery before, he had assisted in several during his residency at the Mayo Clinic in Minnesota. But to be absolutely certain, he asked Tucson neurosurgeon Dr. Thomas Norton, who has had experience in this specialty, to assist him.

Finding an anesthesiologist to do it, however, was another matter.

"I sent out 30 e-mails, and only one anesthesiologist responded. Only one felt comfortable enough to agree to do it," Sanan said.

"It's very tricky. The anesthesiologist has to juggle a cocktail of drugs to put the patient on the fine line between wakefulness and sleep, to be sure he can respond to questions but keep him calm enough to not disrupt the operation. He has to talk the patient through the whole surgery and monitor his function.

"And if he puts him too far under, he would have to intubate the patient immediately" - put him on a breathing machine - "and I would be shut down. I would not be able to go after much of the tumor."

Without hesitation, Tucson anesthesiologist Dr. Isaac Gomez-Avraham accepted the challenge. Trained in awake craniotomy at Mount Sinai Hospital in New York City, he knew the drill, although he had never done one in Tucson.

"I was definitely very busy the entire time," he said. "It's a fine balancing act, but Dr. Sanan and I communicated through the whole procedure - he tells me what he is doing so I know what drugs to use when."

After Sanan separated the vital brain lobes to begin work on Armenta's tumor, Gomez-Avraham began slowly reducing the sedation, then roused the dozing patient.

"What is this?" he said, holding up a pen.

"A pen," Armenta answered immediately, delighting his doctors with the simple but exhilaratingly correct answer.

And so it went, every five minutes, for hours.

"Squeeze my fingers," Gomez-Avraham commanded as Armenta did so.

"What is this?" the doctor asked, holding up his shoe.

"A shoe," the good patient said, as Sanan cut deeper and deeper into the cancer, extending life with every excision.

"Move your right foot," came the request. The right foot wiggled, reassuring everyone. Applause all around.

"My nose itches," Armenta volunteered at one point, eliciting some giggles. Problem resolved by the doctor.

Paper clips, a match, a chair, a piece of paper, a clenched fist, a waved hand, a pair of scissors - Armenta passed every test, telling Sanan he was always in safe brain territory.

At only one point, near the end of the surgery, did the stoic Armenta feel fear, he said.

"I moved my hands and my legs, and that was reassuring to me. But then I tried to move my head, and I couldn't. I thought, oh no, something is wrong," he said.

"By that time, I just had forgotten how tightly my head was pinned down. So really, everything was fine."

Armenta admitted he tried hard not to think much about his surgery before or during, to avoid feeling panic or fear - an all-too-common problem with awake craniotomy and another reason it is so uncommon.

"Some patients find their head in pins, they hear the noise of the drill and the cutting, and some just panic right there and say stop, and it's over. The patient's anxiety level is absolutely crucial," Sanan said.

Armenta - now back home, fully functional, enjoying his two young boys - well remembers the alarming skull drill, he said.

"Oh yes, the drill. But I really wanted to stay calm. These doctors spent a lot of time with me, months, so I knew exactly what was going to happen and why I had to be awake. I think I was able to do it because I had 100 percent confidence in them from the start."

Armenta will now undergo radiation, to zap whatever is left of the tumor tissue. After that, doctors predict an almost full lifespan for him - because he stayed awake while they took his brain apart.

"If he had been asleep, I'm sure I wouldn't have gotten enough to do that," Sanan said.

* Contact Carla McClain at 806-7754 or at

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