Yes, You’re Awake During Brain Surgery… and Other Brain Surgery Facts

A brain tumour diagnosis is scary, and the idea of surgery—even more so. But not all tumours are the same. Here’s what you need to know about different types and how surgery can help save lives.

WORDS LIM TECK CHOON

FEATURED EXPERT DR LEE FOO CHIANG Consultant Neurosurgeon Beacon Hospital

Our brain is the reason why we can feel and do the things we enjoy in life. Hence, the very notion of having a tumour in the brain terrifies many of us, as we immediately think of the loss of our senses and the ability to do the things we love, and even death.

SHOULD YOU BE WORRIED ABOUT A BRAIN TUMOUR?

• A tumour is not necessarily a cancer.
• It is just a mass of cells that has lost the ability to replicate or die like normal cells.
• Dr Lee Foo Chiang explains that, just like other tumours, brain tumours can be benign or malignant.

Malignant Tumours

• The malignant tumour is what we would call a cancer.
• Cancers that originate in the brain rarely spread to other parts of the body.
• However, the malignant brain tumour can still spread to other parts of the brain, and sometimes to the rest of the central nervous system.
• Dr Lee points out that it is also possible for cancers from other parts of the body to move to the brain.

Benign Tumours

• The benign tumour is not necessarily life-threatening.
• Dr Lee says that, if it is located in a spot that does not significantly affect the health and the normal functions of the person, the person may go about their daily lives in a fairly normal manner.
• However, a benign tumour may exert pressure on the tissue around it, causing damage and inflammation as well as affecting the body functions controlled by the affected area of the brain.

SHOULD A BENIGN BRAIN TUMOUR BE REMOVED, THEN?

Dr Lee explains that the neurosurgeon has to consider a few things when determining the best course of treatment.

Location of the Tumour

Our brain controls all our non-instinctive actions, so there is always a possibility that removing a tumour can affect the person’s life in significant manner.

“You may end up with facial palsy (paralysis), hearing loss, double vision, and such. So, even if the tumour is removed, the quality of life is not there,” Dr Lee says.

• If the tumour is located at a position that allows it to be completely removed with minimal consequences, of course it is often better to remove it.
• But when the location is less than ideal, things get complicated, regardless of whether the tumour is benign or malignant.
  • A tumour located in the skull base, for example, can be difficult to remove without causing damage to the cranial nerves.
  • In such a situation, Dr Lee says a partial or subtotal removal may be the better option.

“We have to weigh the benefits of removing the tumour against the possible consequences of its removal,” says Dr Lee, adding that the following needs to be considered:

• Is the patient suffering from symptoms that affect his or her daily functions?
• Will the tumour threaten the patient’s life in both medium- and long-term?

“The answers have to be weighed against the possibility of disability and impairment of other body functions,” says Dr Lee.

The Person’s Age

Dr Lee explains that it may be better to take a wait-and-see approach if:

• The tumour is not affecting the person’s health or daily functions in a significant manner.
• The person is already of an advanced age, such as 70 years old and above.

This means regular medical follow-ups with the neurosurgeon.

If the tumour is found to have progressed to a stage that will threaten the person’s life or affect the quality of life, necessary steps would then be taken to address the issue.

WHAT HAPPENS IF A BRAIN TUMOUR CANNOT BE COMPLETELY REMOVED?

Dr Lee points out that even in such a situation, the brain tumour may still be reduced in size.

This procedure is called debulking, which will see the neurosurgeon removing as much of the tumour as possible within safety limits.

For malignant tumours that cannot be removed completely, debulking allows the patient to live longer while still maintaining some degree of quality of life.

“We can debulk a chunk of the tumour, and then apply radiosurgery on the remaining tumour tissue,” Dr Lee says to illustrate this point.

He adds: “If the tumour stays the same size over the next decade or two, then this is as good as it gets to a cure!”

GOING FOR A BRAIN SURGERY

Dr Lee says that the patient will be ‘wide awake’ during brain surgery.

• He assures us that the procedure is not as terrifying as it may seem.
• “The brain cannot feel pain. The nerves that detect pain are actually in the skin, the skull and the outer layer of the skull membrane (dura).”
• “We inject anaesthesia into the dura, so the patient can remain awake without worrying that it will hurt,” he adds.

Why Does the Patient Need to Be Awake During Brain Surgery?

• This is sometimes necessary because the neurosurgeon needs to check periodically whether the patient’s brain functions are still working while the brain is being operated on.
• This is done by asking the patients simple questions, name common objects and number, recite the ABC or state what day it is.

Is the Surgery Messy and Bloody?

• With a laugh, Dr Lee explains that the actual surgery is far less messy.
• “We use ultrasound to fragment the tumour and then extract these fragments out,” he says.
• The device used, called the ultrasonic aspirator, can perform these functions as well as others to facilitate a clean, painless, and safe procedure.

ON A CASE-BY-CASE BASIS

• At the end of the day, there is no ‘one size fits all’ treatment for brain tumours. Two people may come to Dr Lee with a similar case, but there is a possibility that they will receive different treatments.
• However, he assures everyone that the neurosurgeon will make the time and effort to lay everything out on the table to the patient before implementing any treatment.
• “We will explain not only the benefits of a treatment, but also any potential consequences that can arise,” Dr Lee says. “We will also share alternative treatment options, if they are available, and do our best to help the patient make the best-informed decision for his or her needs and well-being.”