Evolution of awake brain surgery: Awake brain procedures are not new to this country. Canadians with even a fleeting knowledge of medical history will recognize the story of Dr. Wilder Penfield, the path-breaking neurologist and neurosurgeon who in the 1930s helped perfect the “Montreal Procedure,” a method that allowed him to electronically stimulate the brains of hundreds of epileptic patients as they lay awake and, eventually, to create the first functional maps of the surface of the human brain. His work was cemented in the popular imagination with a Canadian Heritage Minute that featured a woman on an operating table exclaiming: “Dr. Penfield, I can smell burnt toast!”

After Penfield’s breakthroughs, however, operating on awake patients fell out of fashion.

“I think a lot of people thought that awake brain surgery was barbaric,” said Dr. Mark Bernstein, a neurosurgeon at Toronto Western Hospital who has performed more than 1,000 awake craniotomies since 1991, when he and an American colleague helped revive the practice for the purpose of safely extracting tumours.

The St. Michael’s medical team that would operate on Daniels has added its own small footnote to the legacy of surgeons like doctors Penfield and Bernstein. The team helped refine an anesthesia protocol, using a recently approved sedative called dexmedetomidine, that allows doctors to safely perform the longest awake craniotomies ever recorded in the medical literature – including on patients for whom the procedure would normally be considered too risky, such as the old, the obese, and those afflicted with tough-to-extract brain tumours.

“The advantage here is if you’ve got a brain tumour near an area of your brain that’s very important to your function – speech, movement or language – you want to maximize the resection of that tumour without impacting the normal functions for your life.”— Dr. Gregory Hare, anesthesiologist at St. Michael’s Hospital

The team’s first surgery on an awake patient lasted an astonishing nine hours and allowed them to wake the patient multiple times for testing.

So far, Das and anesthesiologists Dr. Marco Garavaglia and Dr. Andrea Rigamonti have used the protocol in more than 30 cases, the first 10 of which they recounted in a clinical report published in the Journal of Neurosurgical Anesthesiology in July. Now they use it on all their patients, even otherwise healthy ones like Daniels whose surgery is not expected to last longer than five hours.

A controversial approach: Lengthy awake craniotomies are somewhat contentious. Patients with their heads locked in a clamp can become uncomfortable and claustrophobic as the operation drags on.

“I’m very sensitive about time. Anything that I think will go longer than four hours I don’t book for an awake craniotomy,” said Bernstein, the veteran neurosurgeon at Toronto Western.

Still, he called it a “terrific operation,” and praised the dexmedetomidine protocol, which provides patients with sedation and anxiety relief without requiring a breathing tube or laryngeal mask, thereby allowing them to speak.

Toronto Western is in the midst of a clinical trial comparing the new sedative to a more traditional alternative, propofol, which – like dexmedetomidine – keeps the airway clear, but doesn’t appear to protect it quite as well. St. Michael’s, meanwhile, has just launched a different sort of study of the dexmedetomidine protocol, one that aims to measure the short- and long- term psychological effects of being awake during brain surgery.

The St. Michael’s team is also test-driving a tablet for neurological testing that is safe to use inside the giant magnet of an MRI machine and on the operating table while patients are awake, a tool developed by scientists at Toronto’s Sunnybrook Research Institute.

But before doctors could use the new tablet in Daniels’s case, they had to get into her head. After they turned her on her side, secured her skull in a brace and draped her body in sterile sheets, they sliced a reverse-question mark incision above her left ear and exposed her brain.

Testing the brain: It took more than 20 minutes to rouse Daniels. A microphone amplified her voice and a video streaming onto a screen let Das watch her face as he worked. More than a dozen times he asked Daniels to count to 10 – shifting his wand, prodding her brain as she spoke.

Sometimes she plowed through the kindergarten chant with ease; other times her voice dropped off halfway through and picked up again after Das removed the electric charge.

After the counting test, Das asked her to read words flashed on a screen and to write on the tablet designed by Simon Graham, a senior scientist and engineer at the Sunnybrook Research Institute. (Daniels had used the tablet to perform similar tasks inside an MRI machine before her surgery, allowing the doctors to make a rudimentary map of the area around her tumour.)

When the neurological tests ended, an emotionally raw Daniels apologized for “failing” – not realizing that for the tests to succeed, she would have to fail to determine which parts of her brain couldn’t be cut into without compromising speech, writing, language and other core functions.

Das reassured her she had done well. She turned on her iPhone and fell back to sleep. She had been awake for a little more than 25 minutes.

Rush to pathology: When Das reached the lesion in Daniels’s brain, he removed a tiny sample and sent it off for initial review at a small lab inside the hospital. Pathology staff slipped the specimen onto a glass slide and peered at it through a microscope, allowing them the first in-depth look at the tumour that had been causing Daniels’s seizures.

The growth was consistent with a low-grade ganglioglioma – a benign, slow-growing tumour that often affects children and young adults. Later, further pathology testing on Daniels’s tumour confirmed the finding. An MRI reading after the surgery yielded even better news: Her scan was clear.

Feeling strong: Three weeks to the day after the operation, the awake portion of the surgery felt like a hallucination Daniels could barely recall. A few dream-like snatches stayed with her, but she had no memory of the performance anxiety she expressed at the end of the neurological testing.

“I think I remember me doing well,” she said. “I think so. I can’t exactly remember. I feel like I did well on it, but I’m not exactly sure.”

Daniels had not seen the video of her surgery. Told she had apologized to the doctors for struggling with the tests, Daniels admitted to an inner insecurity that the drugs had apparently laid bare. But surviving her seizures and surgery has boosted her confidence.

“Now I actually want more of [my hair] shaved on the side to kind of show off my scar,” she said. “I’m just proud of what I went through and how strong I was.”