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Awake brain surgery

When patient Peter Chaisit-Charles was able to answer a question during neurosurgery viewer reaction was extraordinary. As surgeon Paul Grundy removed a tumour from Peter's awake brain, thousands of questions flooded in wanting to know more.

Questions ranged from whether Peter would remember the operation afterwards to what kind of things could go wrong during the procedure. During the programme, #slive became the second most popular trending topic on Twitter.

Here is a selection of questions that were answered on the night. Surgeon Paul Grundy also kindly answered more of your questions especially for this website.

Why does the patient have to be awake for this? (via Twitter)

'Er, yeah, it's a very good question. The answer to the question is that it is our preference here, if we're ever operating on a tumour which lies anywhere near to a vital region in the brain, and by which I mean those that might control speech, movement, or feelings, then we would elect to do that operation awake, and we do that for two reasons, principally. The first is that before we start operating and removing sections of the brain, we can test them with a small electrical probe, which we'll be doing in due course, and what we need to ensure is that those areas are silent - they're electrically silent, before we remove them. And the other thing we can do whilst we're working on the brain, is to test the patient continuously. It so happens with this patient, who's left-handed, there's actually a moderate chance that when we look to test his speech function, we find that the speech function is not located in this hemisphere. Now obviously that will be very reassuring for us, we'll know we can go on and remove this part of the brain without risking him. So that's what we hope to find really.'

Paul Grundy, neurosurgeon, Southampton General Hospital (while operating)

Is it true that there are no nerve endings in the brain so the patient can't feel pain? (via Twitter)

'Yeah, exactly right. I mean, in the brain itself there are no pain-sensitive cells, but it is not reasonable to assume patients can't experience any pain because there are parts of the inside of the skull that are pain-sensitive. We hope we won't elicit that response later on, but if we do, often this area on the lower part of the skull is pain-sensitive.'

Paul Grundy, neurosurgeon, Southampton General Hospital (while operating)

At what point is it decided that surgery is the best option rather than less invasive techniques? (by the audience)

'This patient has already had a least invasive set of images and biopsy, and unfortunately, due to the nature of this tumour being very diffuse, just infiltrating throughout the brain, like fingers through the brain, that biopsy didn't give us the answer that we wanted. In fact it didn't give us anything very useful, it just showed some abnormal cells in the brain. The samples of the tissue were not large enough for the pathologist to be sure that it's a tumour, and the primary importance of this operation is to establish the diagnosis, by removing part of this lesion, so in due course, he can go and have some more treatment, which is likely to be radiotherapy.'

Paul Grundy, neurosurgeon, Southampton General Hospital (while operating)

How do you know that part of the brain isn't going to be used for anything else - you've tested it for speech, but nothing else. (by the audience)

'Because I know from my knowledge of anatomy, my rudimentary knowledge of anatomy, that, the temporal lobe on the left-hand side, doesn't have any roles in movement, or anything else - feeling. What it does do on the inner surface, which we're going to see later on, is it does have a very important role in memory, and Peter's memory, as we heard earlier on, has already been affected by this. I'm not going to make that any better I'm afraid, by this operation. I hope not to make it any worse.'

Paul Grundy, neurosurgeon, Southampton General Hospital (while operating)

Can you ask Peter if he can feel any pressure or movement, inside his head as a result of what the surgeon is doing? (via Twitter)

'No, I can't feel a thing at the moment. Just, well, I can hear what's going on, I can sort of hear a slight sort of cracking noise, but there's no feeling to go with it.'

Peter Chaisit-Charles, patient (while being operated on)

'It's pretty close to the ear, there's no doubt that that can be a little distressing to some patients.'

Crispin Weidmann, anaesthetist, Southampton General Hospital

Hello, I was just wondering with the patient being kept awake, would they remember anything about the operation afterwards, and would it be traumatic for them? (Jamie Masterman, by phone)

'I can probably answer that question. It varies very much. We've had people that have remembered absolutely nothing, and you see them the following day after the operation and they can't believe they've gone through the procedure, and other people who remember virtually everything. I should say, in a positive way. So it is variable. It depends on, to some extent, on the presenting of their condition.'

Crispin Weidmann, anaesthetist, Southampton General Hospital

How do you tell what is tumour and what is brain tissue? (via Twitter)

'It's exceptionally difficult in this situation. I rely very heavily on having looked at the scans and interpreted them, and working out which parts of the brain that we need to remove, and also I rely very heavily on this navigation system that we use.'

Paul Grundy, neurosurgeon, Southampton General Hospital (while operating)

If you'd've found that that area had actually been the vocal area, what would you have then done? (by the audience)

'I'd almost certainly have been able to identify some of the brain that was quiet, electrically silent, and I would've just had to remove a lesser piece of the brain than I was wanting to.'

Paul Grundy, neurosurgeon, Southampton General Hospital (while operating)

Does the patient want to watch his operation back when it's over? (via Twitter)

'I would be quite keen to watch the programme and I want to see what's going on, and so, see what it looks like when it all gets put back together again. That would be rather good to watch.'

Peter Chaisit-Charles, patient (while being operated on)

I've heard that the brain can repair itself to some extent, is that true and how will it do so after this operation? (Tara Marron, by phone)

'Well, the brain is not terribly good at repairing itself. Certainly if you kill some of the nerve cells they don't usually regenerate, but there is a degree of plasticity in the brain, so other parts can take over to a certain extent. You don't regrow parts of your brain like you do livers and things like that, unfortunately.'

Paul Grundy, neurosurgeon, Southampton General Hospital (while operating)

If something goes wrong, how do you hide it from the patient? Do you speak in code? In other words, 'is the cat on the mat?' (via Twitter)

'No, there's no code, it's usually very obvious to the patient if there's a problem. The reason we're doing the operations awake is usually to test the patient's function so movement in the arms or legs, and if they become weak, it's very obvious to the patient. The patients are warned about this, of course, beforehand and they're fully aware of why we're doing surgery in this way, and they're warned to expect that actually, with this type of high-risk surgery, a moderately high chance they will develop at least a temporary worsening of function. So you can't hide it from them, but patients are reassured by the fact that detecting these problems means we can identify them early and they're very very likely to make a full recovery.'

Paul Grundy, neurosurgeon, Southampton General Hospital (while operating)

What if the patient coughs or sneezes? (via Twitter)

'Patients often do move a little bit, and we don't fix the heads rigidly as they used to do. We kind of get used to working with the patient, in fact they often nod their head and shake their head in answer to questions, and have to be reminded not to do so. What we do as a surgical technique is we rest our hands on the patient's head, so our hands move with the patient and you have to get to operating on a somewhat moving target on occasions.'

Paul Grundy, neurosurgeon, Southampton General Hospital (while operating)

Is it possible that this type of operation could effect the patient's personality trait after the operation?

'That's very unusual. Usually to affect someone's personality you need to remove large sections of the frontal lobes, and often actually on both sides, before you start to affect the personality. So it's not impossible but it is very unlikely that it would do so.'

Paul Grundy, neurosurgeon, Southampton General Hospital (while operating)

Why is the brain moving? Does it pump like the heart? (via Twitter)

'No, but the brain does move. It moves with respiration, with breathing, as the patient breathes in and out, that brain pulsates, and also it beats very slightly with the heart beat. So yes, these are transmitted pulses if you like through the brain.'

Paul Grundy, neurosurgeon, Southampton General Hospital (while operating)

If the patient decides to have the surgery halted, and not to proceed halfway through would that be possible? (via Twitter)

'It would be possible, but we do an awful lot of these operations and we have never been in that position. I think the patients are very carefully counselled beforehand and on top of that, as you may have seen they're given some pretty powerful drugs that keep them nice and calm and relaxed and comfortable during the procedure so it's not a situation that we've encountered but I have actually been in the position where we've had conversations with patients, during an operation, about whether we should or shouldn't proceed, we have weighed up the risks and benefits of surgery, as the operation's changed.'

Paul Grundy, neurosurgeon, Southampton General Hospital (while operating)