Awake Craniotomies: A Dance Between Consciousness and Surgery

By Dr Menaka Sharma

In neurosurgery, few procedures feel as rebellious against intuition as an awake craniotomy. A patient is not only alive and alert while a part of their skull is removed, they are talking, counting, sometimes even singing or playing an instrument. It is a moment where the brain, the master organ, becomes an active conversational partner in its own salvation.

My fascination began back in 2020, the day I first saw a video of a patient playing the violin while a tumour was meticulously dissected away from eloquent cortex by Professor Keyoumars Ashkan and his team, a procedure called intraoperative tumour monitoring. Until then, the brain had always seemed like a black box, untouchable during consciousness. Yet here was proof that the surgical world could bend that rule in service of preservation.

Historically, the roots trace back to pioneers like Wilder Penfield, who used cortical stimulation in awake patients to map epileptic foci and functions. It was a radical idea at the time: instead of rendering a patient silent under deep anaesthesia, let them speak to guide the surgeon’s hand. That simple reversal changed the trajectory of neurosurgery. Suddenly, removing a tumour didn’t have to mean sacrificing speech. Resections didn’t have to steal movement. Surgeons could listen to the brain while they operated on it.

Modern awake craniotomies are even more elegant. A calm patient lies under conscious sedation during scalp incision and craniotomy. Then, when the brain is ready to speak, anaesthesia lightens and the world re-enters the room. The surgeon resects, the patient responds, and the anaesthetistorchestrates the balance like a quiet conductor. Every word, nod, hesitation, or joke becomes clinical data.

There is something profoundly human in those exchanges. A patient counting to ten while a surgeon navigates Broca’s area. A musician playing to preserve hand function. A teacher naming animals to protect language fluency. Long before MRI tractography and neuronavigation, this was precision surgery guided by cortical truth.

From a medical student’s perspective, awake craniotomy feels like a perfect contradiction: the most invasive procedure performed in the most conscious state. Yet it works because the brain itself feels no pain. What surgeons unleash during those hours is not just technique, but trust, between patient, anaesthesiologist, and neurosurgeon. The operating room becomes part theatre, part science, part intense collaboration.

And it changes people. Surgeons describe the strange intimacy of watching a patient speak memories, sing songs, or joke while you hold the organ that generates every part of their identity. Patients describe a surreal pride: fear dissolving into participation, knowing they protected their own speech by using it.

We tend to think of surgery as a cold, silent battlefield. Awake craniotomy proves the opposite. It is dynamic, emotional, unpredictable, and profoundly shared.

The evolution continues. Better sedation protocols. Real-time stimulation mapping. Functional MRI guidance. Smaller craniotomies. Greater patient comfort. Each advancement pushes the boundary of how much of the person we can preserve while removing disease. Someday, I hope to witness that impossible combination of scalpel, dialogue, laughter, and neuroscience first-hand.  Until then, the thought of it is a reminder that neurosurgery is not just about operating on a brain, but preserving an identity.

By Author

Dr. Menaka Sharma

MBBS, IGGMC Nagpur

Co-Author

Dr. Danish Kaif

MBBS, MS General Surgery

FIAGES, FMAS