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Awake Craniotomy & Brain Tumour Surgery In Mumbai
Expert Brain Tumour Resection with Awake Brain Mapping, Neuronavigation, and Intraoperative Cortical Stimulation at Shree Hospitals
Brain tumour surgery demands the highest level of neurosurgical expertise, because the brain's critical areas for speech, movement, vision, and cognition lie immediately adjacent to where tumours grow. Awake craniotomy - performing brain tumour surgery while the patient is conscious and responsive - is the most advanced technique available for removing tumours from or near eloquent cortex (the brain regions controlling language, motor function, and sensory processing), allowing the neurosurgeon to continuously test these functions during tumour removal and immediately stop at any sign of neurological change. At Shree Hospitals, our specialist neurosurgeons combine awake brain mapping, intraoperative neuronavigation (StealthStation), intraoperative ultrasound, and fluorescence-guided resection to achieve the maximum safe tumour removal while preserving every neurological function the patient needs for a full quality of life.
Brain Tumour Diagnosis? Consult Our Specialist Neurosurgeons at Shree Hospitals
Quick facts
Conditions Treated : High-Grade Glioma (GBM), Low-Grade Glioma, Meningioma, Brain Metastases, Recurrent Tumour
Techniques : Awake Craniotomy, Neuronavigation, Intraoperative Ultrasound, 5-ALA Fluorescence
Anaesthesia : Asleep-Awake-Asleep Protocol (Awake Craniotomy) / General Anaesthesia
Duration : 4 to 8 hours
Hospital Stay : 3 to 5 days
Key Technology : Neuronavigation, Intraoperative Ultrasound, 5-ALA Fluorescence, Brain Mapping
MDT : Neuro-oncology, Radiation Oncology, Neuropathology, Neuropsychology
What is Awake Craniotomy and When Is It Used for Brain Tumour Surgery?
A craniotomy is the surgical procedure in which a portion of the skull (a bone flap) is temporarily removed to access the brain beneath. Brain tumour surgery via craniotomy aims to remove as much of the tumour as safely possible - a concept called maximum safe resection. The extent of tumour removal is the most important surgical factor influencing survival and quality of life for patients with high-grade glioma (GBM, Grade IV glioblastoma), low-grade glioma (Grade II and III), anaplastic astrocytoma, meningioma, and brain metastases. However, the brain's critical functional areas - the eloquent cortex - surround many tumour locations, and removal of healthy eloquent brain tissue causes permanent hemiplegia (paralysis), aphasia (loss of speech), or other devastating neurological deficits. Awake craniotomy enables the neurosurgeon to test brain function in real-time during tumour removal to guide the safe extent of resection.
Awake craniotomy uses a carefully titrated asleep-awake-asleep (AAA) anaesthetic protocol: the patient is under general anaesthesia for the scalp incision, skull opening, and dural opening; they are then awakened (with anxiolysis and light sedation to keep them comfortable but alert and communicative) for the critical phase of tumour mapping and resection; and they are returned to general anaesthesia for wound closure. During the awake phase, an experienced neuropsychologist and speech and language therapist continuously test the patient's speech (naming objects, counting, reading), motor function (asking the patient to move specific limbs), and cognitive tasks while the neurosurgeon uses a cortical and subcortical stimulation probe to map the functional areas adjacent to the tumour. When stimulation of a brain area disrupts the patient's speech or motor function, the neurosurgeon marks that area as "eloquent" and avoids resecting it. This allows tumour removal to proceed right up to the functional boundary without crossing it.
At Shree Hospitals, brain tumour surgery is planned at a dedicated Neuro-Oncology MDT attended by neurosurgeons, neuro-oncologists, radiation oncologists, neuroradiologists, and neuropathologists. The optimal surgical approach, extent of resection, and need for awake craniotomy vs standard craniotomy under general anaesthesia is determined for each patient based on tumour location, functional anatomy, molecular tumour characteristics (IDH mutation, MGMT methylation status, 1p/19q codeletion - determined from pre-operative biopsy or from resection specimen histology), and patient fitness. MRI spectroscopy, perfusion MRI, and functional MRI (fMRI) with diffusion tensor imaging (DTI) tractography (to visualise the white matter tracts such as the arcuate fasciculus for language and the corticospinal tract for motor function) are used to plan the surgical approach to eloquent region tumours.
Who Needs Awake Brain Tumour Surgery?
Awake craniotomy is indicated for:
- Tumours in or adjacent to eloquent cortex: motor strip (precentral gyrus), speech areas (Broca's area - inferior frontal gyrus; Wernicke's area - posterior superior temporal gyrus), sensory cortex, visual cortex
- Low-grade gliomas in eloquent areas: these slow-growing tumours can often be maximally resected during awake craniotomy to delay malignant transformation and extend survival
- High-grade gliomas (GBM) adjacent to eloquent cortex: awake mapping maximises extent of resection while protecting function
- Dominant hemisphere tumours (left hemisphere in right-handed patients - controls speech and language in 95% of right-handers)
- Recurrent tumour re-surgery in eloquent regions where standard resection was too conservative
- Patients who can cooperate with the awake mapping procedure (assessed pre-operatively by the neuropsychologist and anaesthetist)
Is Awake Craniotomy Right for You?
Awake craniotomy is appropriate when:
- Your tumour is in or adjacent to a functional brain area and maximum safe resection is the surgical goal
- You are psychologically prepared and willing to be awake during part of the operation (fully discussed and rehearsed in pre-operative sessions)
- You do not have severe claustrophobia, anxiety disorder, or inability to cooperate with testing
- Your language and motor function is intact enough to be tested intraoperatively (patients with pre-existing severe aphasia cannot be adequately mapped)
- Your neuropsychologist has completed pre-operative cognitive and language baseline testing and rehearsed the intraoperative tasks with you
- The MDT has agreed that awake craniotomy offers a better functional outcome than standard surgery under general anaesthesia for your specific tumour
Why Extent of Resection Directly Affects Survival?
The amount of tumour removed at surgery is one of the most important determinants of outcome:
- For GBM (Grade IV glioblastoma): patients achieving gross total resection (GTR) - complete removal of the enhancing tumour on MRI - survive significantly longer than those with subtotal resection. Median survival increases from approximately 10 months (biopsy only) to over 15 to 18 months (GTR + Stupp protocol chemoradiotherapy)
- For low-grade glioma (Grade II): extent of resection directly correlates with time to malignant transformation and overall survival. Maximally safe resection is the primary goal
- Awake brain mapping enables tumour removal closer to functional boundaries than is safely possible under general anaesthesia, where function cannot be monitored in real-time
- The combination of awake mapping, neuronavigation, and 5-ALA fluorescence provides the neurosurgeon with three independent methods to maximise resection while protecting function
Awake craniotomy with real-time brain mapping at Shree Hospitals enables maximum safe tumour resection while protecting speech, motor, and cognitive function.
Our specialist neurosurgery team at Shree Hospitals uses the combination of awake cortical and subcortical mapping, neuronavigation, intraoperative ultrasound, and 5-ALA fluorescence-guided resection to deliver the highest achievable extent of safe tumour removal for each brain tumour patient, with post-operative function preserved and adjuvant therapy planned from day one by our neuro-oncology MDT.
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Our Approach to Awake Craniotomy and Brain Tumour Surgery
At Shree Hospitals, every brain tumour patient receives a personalised surgical plan developed at the Neuro-Oncology MDT, combining the most advanced intraoperative technologies with meticulous pre-operative functional mapping to achieve the best possible oncological and neurological outcome.
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Pre-Operative Functional Brain Mapping
Before any surgery, the neurosurgical team performs comprehensive pre-operative mapping to understand exactly which brain areas are functional and which are tumour. Functional MRI (fMRI) maps cortical activation during language, motor, and sensory tasks (the patient performs word-generation, hand-clenching, and sensory tasks during the MRI scan). Diffusion Tensor Imaging (DTI) tractography visualises critical white matter tracts including the corticospinal tract (motor), arcuate fasciculus (language), optic radiations (vision), and uncinate fasciculus (memory). These data are loaded into the neuronavigation system to create a 3D pre-operative map of tumour and functional anatomy that guides surgery. A neuropsychologist establishes baseline cognitive and language function and rehearses the intraoperative tasks with the patient in the weeks before surgery.
Awake Brain Mapping Protocol
The asleep-awake-asleep (AAA) protocol is executed by an experienced neuroanaesthetist expert in awake craniotomy. After scalp block and monitored sedation (propofol and dexmedetomidine), the patient is maintained deeply sedated for bone flap removal and dural opening. The patient is then gently awakened and positioned comfortably with the neuropsychologist and speech therapist conducting continuous real-time testing. The neurosurgeon uses a bipolar cortical stimulation probe (5mm diameter, 50-60Hz, 1-20mA) to stimulate the cortical surface systematically, creating a functional map. Positive sites (areas where stimulation disrupts speech or movement) are marked with sterile numbered tickets. Tumour resection then proceeds with continuous monitoring, stopping immediately if any new deficit appears during subcortical stimulation (which maps the deep white matter tracts along the resection cavity margin).
Intraoperative Technology Stack
The neurosurgery theatre at Shree Hospitals is equipped with the complete technology platform for brain tumour surgery: Neuronavigation (StealthStation) provides real-time 3D localisation of the surgical instruments within the brain, overlaid on the pre-operative MRI, fMRI, and DTI tractography. Intraoperative ultrasound allows real-time assessment of tumour margins and residual tumour during resection, compensating for brain shift (the displacement of brain tissue that occurs during surgery and makes pre-operative neuronavigation less accurate as the case progresses). 5-ALA (5-aminolevulinic acid) fluorescence (discussed in detail on the Fluorescence-Guided Tumour Excision page) delineates tumour tissue in real-time under violet-blue light. Intraoperative neurophysiological monitoring (IONM) with continuous EEG monitoring for seizure detection during awake mapping and motor-evoked potential (MEP) monitoring provides an additional safety layer.
Post-Operative Management and Adjuvant Therapy Planning
After surgery, the patient is managed in the neurosurgical high-dependency unit (HDU) with close neurological observation. Post-operative MRI (ideally within 48 to 72 hours) assesses the extent of resection - the key surgical outcome measure. The resection specimen is sent for comprehensive neuropathological analysis including WHO Grade, IDH1/2 mutation, MGMT promoter methylation, 1p/19q codeletion (for oligodendroglioma), TERT promoter mutation, and EGFR amplification/EGFRvIII - all of which determine the tumour's molecular subtype and guide adjuvant therapy decisions. The post-operative results are discussed at the Neuro-Oncology MDT within 2 weeks of surgery to plan adjuvant temozolomide chemotherapy and radiotherapy (for GBM: Stupp protocol - 6 weeks concurrent chemoradiotherapy + 6 cycles adjuvant temozolomide). Rehabilitation (physiotherapy, speech therapy, neuropsychological support) begins from day 1 post-operatively.
Top Neurosurgeons in Mumbai
Every specialist at Shree Hospitals is MCh Neurosurgery board-certified with over 15 years of clinical experience in awake craniotomy, brain tumour surgery, neuronavigation, fluorescence-guided resection, functional brain mapping, and neuro-oncology.
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Dr. Yashwant Shelke
DNB Neurosurgery
Dr. Survendra Rai
Micro-Neurosurgery, Minimally Invasive Spine Surgery
Dr. Medha Vyas
Consultant Neurosurgeon & NeuroSpine Surgeon
Dr. Viswanathan Iyer
Consultant Neurosurgeon & Endovascular
Step by Step Process of Awake Craniotomy
Step 1 - Neuro-Oncology MDT and Pre-Operative Planning
The patient's case is presented at the Neuro-Oncology MDT with clinical presentation, MRI brain (with and without gadolinium, plus perfusion MRI and MRS), and any prior histology. The MDT agrees: surgical plan, extent of resection target, need for awake craniotomy, pre-operative biopsy need, and provisional adjuvant therapy plan based on expected molecular profile. Functional MRI and DTI tractography are arranged. A pre-operative neuropsychological assessment is conducted and the awake mapping tasks are rehearsed with the patient over 1 to 2 sessions.
Step 2 - Scalp Nerve Block and Positioning
On the day of surgery, the neuroanaesthetist places a scalp nerve block (blocking the supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, greater occipital, and lesser occipital nerves with long-acting local anaesthetic) to allow the scalp to be manipulated with minimal discomfort during the awake phase. The patient is positioned in a Mayfield three-pin head clamp for rigid head fixation (essential for neuronavigation accuracy). Patient position is optimised to place the tumour at the highest point of the surgical field and to allow the patient to be comfortable enough to cooperate during the awake phase.
Step 3 - Craniotomy Under Sedation
The patient is sedated with propofol and dexmedetomidine for the scalp incision and craniotomy. A bone flap sized to give adequate access to the tumour and to the surrounding functional cortex that needs to be mapped is removed. The dura is opened and reflected. Neuronavigation registration and intraoperative ultrasound imaging of the tumour are performed. The patient is then gently lightened from sedation.
Step 4 - Awake Brain Mapping
As the patient awakens, the neuropsychologist begins continuous functional testing. The neurosurgeon applies the cortical stimulation probe systematically across the exposed cortex in a grid pattern, with each stimulation site tested while the patient performs the language or motor task. Positive sites are marked. The subcortical white matter tracts adjacent to the tumour are also stimulated as resection proceeds deeper - a positive subcortical response (arm movement, leg movement, or speech arrest) indicates proximity to a critical tract and the resection margin is adjusted.
Step 5 - Tumour Resection with Real-Time Monitoring
Tumour resection proceeds under the operating microscope using ultrasonic surgical aspirator (CUSA), with 5-ALA fluorescence guiding identification of tumour margins. Intraoperative ultrasound is used repeatedly during resection to assess residual tumour and compensate for brain shift. The resection continues until: the tumour is completely removed, the 5-ALA fluorescence signal is gone, ultrasound shows no residual tumour mass, or the cortical/subcortical mapping signals indicate the functional boundary has been reached. At that point resection stops.
Step 6 - Closure, Recovery, and Post-Operative MRI
The patient is returned to general anaesthesia for dural closure, bone flap replacement (fixed with titanium plates and screws), and scalp closure. The patient recovers in the neurosurgical HDU with hourly neurological observations. A post-operative MRI within 48 hours quantifies extent of resection. The resection specimen undergoes comprehensive neuropathological and molecular analysis. Results are reviewed at the next Neuro-Oncology MDT to finalise the adjuvant treatment plan. Dexamethasone (to reduce brain oedema) is given post-operatively and weaned over 1 to 2 weeks. Antiepileptic medication (levetiracetam) is continued for the immediate post-operative period.
Patient Questions About Awake Craniotomy and Brain Tumour Surgery
Is awake craniotomy as frightening as it sounds?
Most patients who undergo awake craniotomy describe the experience as much less frightening than they anticipated. The key is the intensive pre-operative preparation the neuropsychologist meets with the patient multiple times before surgery, explains exactly what will happen at each stage, rehearses the tasks that will be performed during the awake phase (naming pictures, counting, moving hands), and answers every question. Patients understand that the awake phase - while they are conscious and talking during surgery - is precisely what protects their brain function. During the operation, sedation and anxiolytic medications keep the patient comfortable and relaxed. The scalp nerve block means the scalp is numb and the brain itself has no pain receptors, so the awake phase is not painful. The patient is in continuous communication with the neuropsychologist and can be re-sedated immediately if they feel distressed. The great majority of patients report that knowing their function was continuously protected throughout surgery gives them significant reassurance.
What types of brain tumours are treated with craniotomy?
Craniotomy for brain tumour removal is used for a wide range of primary and secondary brain tumours. Primary brain tumours include: glioblastoma (GBM, Grade IV) - the most common and aggressive primary brain tumour in adults, anaplastic astrocytoma (Grade III), low-grade glioma (Grade II astrocytoma, oligodendroglioma), meningioma (benign tumour arising from the meninges - the brain coverings), acoustic neuroma (vestibular schwannoma), pituitary adenoma (usually treated endoscopically - see the Endoscopic Skull Base and Pituitary Surgery page), primary CNS lymphoma (usually treated without surgery), and ependymoma. Secondary brain tumours (brain metastases) from breast, lung, melanoma, renal, and colorectal primaries are common and may require surgical resection when they are large (over 3cm), causing significant mass effect, or when histological confirmation is required. The MDT determines whether surgery, Gamma Knife radiosurgery, whole brain radiotherapy, or a combination is the optimal approach for each patient.
What are the risks of brain tumour surgery?
Brain tumour surgery carries risks that vary with tumour location, size, and the patient's pre-operative condition. The most significant risks are: neurological deficit - new or worsened weakness, speech difficulty, visual field loss, or cognitive change (minimised by awake mapping and neuronavigation but not completely eliminated, particularly for tumours deeply infiltrating eloquent structures), seizure (occurs in approximately 10 to 20% post-operatively, managed with antiepileptic medication), infection - wound infection or meningitis (under 2% with modern antibiotic prophylaxis), bleeding (haematoma) - post-operative haematoma within the resection cavity requiring return to theatre (approximately 2 to 3%), brain swelling (cerebral oedema) - managed with dexamethasone, and DVT and pulmonary embolism - risk increased by prolonged surgery and immobility. The risk of each complication is discussed in detail at the pre-operative consultation in the context of the specific tumour anatomy and the expected benefit of surgery.
What happens after brain tumour surgery?
After brain tumour surgery, the immediate post-operative period (3 to 5 days in hospital) involves close neurological monitoring, management of brain swelling with dexamethasone, seizure prophylaxis, and early rehabilitation. The resection specimen is analysed by the neuropathologist for WHO Grade and molecular markers - results typically take 5 to 10 working days for comprehensive molecular testing. These results determine the adjuvant treatment plan. For GBM, the Stupp protocol (6 weeks of concurrent daily temozolomide chemotherapy and fractionated radiotherapy, followed by 6 months of adjuvant temozolomide cycles) is the standard treatment. For low-grade glioma, the decision between watchful waiting, radiotherapy, and PCV or temozolomide chemotherapy depends on molecular subtype and extent of resection. Rehabilitation after craniotomy - physiotherapy for motor weakness, speech therapy for language deficits, neuropsychological support for cognitive changes - is integral to recovery and is coordinated from the neurosurgical ward from day 1 post-operatively.
Evidence-Based Case Studies by Our Specialists
Would Recommend Us
"When I was told I needed brain surgery near my speech area, I was terrified. The neurosurgery team at Shree Hospitals took weeks to prepare me - rehearsing the tasks, explaining every step. During the operation I named pictures and counted while they removed the tumour. I woke up able to speak perfectly. The pre-operative preparation made all the difference."
Mr. Aditya K
"The tumour was right next to the area controlling my left arm. The neurosurgeon at Shree Hospitals explained they could map which areas to avoid during the operation while I was awake. After surgery, my arm function actually improved compared to before. I am now on the chemotherapy and radiotherapy plan."
Mrs. Rekha M
"The meningioma had been growing for years and was finally causing headaches and affecting my balance. The neurosurgery team at Shree Hospitals removed it completely. I was walking the next day and home on day four. The six-month MRI scan confirmed it had not come back."
Mr. Suresh B
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