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Neurosurgery Advancements: Awake Surgery

Awake surgery for neurosurgery procedures offers fewer complications and also allows physicians to run cognitive tests during surgery.

Listen as Ichiro Nakano, MD., Neurosurgeon at UAB Medicine, discusses the latest Neurosurgery Advancements in Awake Surgery where the special comprehensive team at UAB is the only one in the state.

Neurosurgery Advancements: Awake Surgery
Featured Speaker:
Ichiro Nakano, MD
Ichiro Nakano, MD is a Professor who specializes in Neurosurgery.

Learn more about Ichiro Nakano, MD 

Dr. Nakano has no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant financial relationships to disclose.

There is no commercial support for this activity.

Melanie Cole (Host): During the past decade, numerous reports have supported the contribution of awake mapping and surgical removal of brain lesions in eloquent areas with a significant increase of the extent of resection while minimizing the risk of permanent deficit and even improving quality of life. My guest today is Dr. Ichiro Nakano, he’s a neurosurgeon at UAB Medicine. Welcome to the show Dr. Nakano, tell us a little bit about the evolution of the awake surgery.

Dr. Ichiro Nakano (Guest): So, this surgical treatment started about 10 or 15 years ago. Specifically called the sleep awake sleep procedure for malignant brain cancer. Just to let you know the current difficulty to treat brain cancer. The immediate survival of a patient with a primary brain tumor is somewhere around 15 months to 20 months. Even though we treat the patient with the surgery, with chemo therapy and radiation. Sleep awake sleep procedure we use that specifically for the tumors that are located in a functional brain area that controls verbal and also body movement. The reason why we need the sleep awake sleep procedure is because when tumor grows rapidly then the area that controls the body movement and the verbal function moves away as well. Functional MRI cannot detect the specifically the change of the location specific enough to avoid a complication during surgery. So, by having a patient awake during the procedure to take out the tumor that is either on top of the functional area, or adjacent to the functional area, we can communicate with the patient to make sure that the surgical removal of the tumor that’s not caused any symptomatic complication to cause the patient to become unable to speak or unable to move their body. This procedure can only be done by a comprehensive team, including a neurosurgeon, and neurooncologist, and neuroanesthesiologist and a speech therapist and a physical therapist that get together during the procedure to communicate with the patient, so that we can monitor the patient function during the time the surgeon is taking out the tumor. There is strong evidence that once we can take out the tumor as much as possible, then the patient outcome, including the life on or after surgery has a benefit. By doing this procedure we can even communicate with the pathologist to take out the piece to make a diagnosis and we can even directly communicate with the patient whether or not it is causing any complication, and then making a diagnosis during the procedure. As far as we know, the UAB Neurosurgery team is the only team in this area that provided sleep awake sleep procedure for brain cancer.

Melanie: Dr. Nakano tell us about the criteria for patient selection for this type of procedure.

Dr. Nakano: This procedure is for primary brain tumor. And the most frequent primary brain tumor is glioblastoma. Sometimes we apply this procedure for low grade glioma as well. So, patient with glioma including low grade, high grade it could be a glioblastoma, those are the patients that can be considered for this procedure.

Melanie: And can this technique which optimizes the surgical approach reduce post-operative morbidity?

Dr. Nakano: Because we monitor the patient during the procedure, which is sometimes called travel for the brain function, then obviously post-operative, we do not expect anything beyond what we had seen during the procedure.

Melanie: Speak about some of the anesthesiology protocols that are involved and can they at some point during or after the procedure place the patient back under general.

Dr. Nakano: You can imagine surgical treatment for brain cancer incurred an incision in the scalp and large born opening that can be painful for patients. That’s why we put the patients to sleep and the skilled neuroanesthesiologist can induce look and use a certain drug that causes asleep of the patient without causing a breathing problem. And then by finishing the painful procedure including the skinny incision, then we start to expulse the brain, which doesn’t cause any pain to the patient. That’s the time we put the patient back from the sleep to the awake stage. And this process is closely monitored by neuroanesthesiologist which control that consciousness level of the patient and also the pain of the patient. In case the patient has the pain than we use either increase or decrease the level of the sleepiness and also, we use local to reduce that pain of the patient.

Melanie: Dr. Nakano, speak of mapping of non-language functions and visual spatial and cognitive deficits.

Dr. Nakano: So, there’s accumulated studies to identify the location of the brain area that control the speech. But as you can imagine speech is a complicated process by comprehending what people are saying to you. And then to understand followed by motor speech that express what you want to speech. So, there are multiple areas that control individual steps. And when the tumor is located either on top of those areas or nearby, then that will cause so called plasticity. Plasticity means that the brain has shifted to a certain area, because of the presence of a rapidly growing tumor. And this process is unpredictable and there’s a big difference between patients. That’s why we need to use awake mapping individually during the procedure so that we can identify the change of the location individually during the procedure to take the brain cancer.

Melanie: And it’s not only for speech and language is that true?

Dr. Nakano: That is true. This is for motor function, sensory function, sometimes we monitor for example and other high brain function.

Melanie: So, in just the last few minute, Dr. Nakano, tell other physicians what you would like them to know about awake surgery and neurosurgical advancements in awake surgery.

Dr. Nakano: One thing I want people to know is that there is accumulative evidence that we need to take out as much tumor as possible. But at the same time the prognosis with a patient with a primary brain cancer including glioblastoma is unfortunately very poor, less than 2 years. So, we don’t want to cause any functional deficit with the time that is left for the patient. It is critically important to keep the function of the patient and take out the tumor that is called safely maximum resection of the tumor. So, this can be done, by again, comprehensive team including people, physicians with a different expertise. UAB in Neurosurgery Team is one of them.

Melanie: And how can a community physician refer a patient to UAB Medicine?

Dr. Nakano: You can make a phone call to 1-800-UABMIST and tell the person with my name, Dr. Nakano and I can navigate the patient to the appropriate person who can be in charge of the treatment.

Melanie: And tell us about your team. Why is UAB so great to work with?

Dr. Nakano: That is because we have a comprehensive team, including anesthesiologist, neurosurgeon, ICU, pathologist who will treat the patient as a single team.

Melanie: Thank you so much for being with us today. You’re listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to, that’s This is Melanie Cole, thanks so much for listening.