The Hannibal Lecter of modern times

 

That infamous dinner party scene from Hannibal—the one where Dr Lecter, the ever so refined host, performs a pseudo-awake craniotomy with the finesse of a Michelin-starred chef. While it’s horrifyingly fictional, I found a grim fascination in that… Ahemm, I know what you are thinking- this guy needs a psych assessment to rule out sociopathic tendencies. Well, of course, when you watch endless videos of people chopping away at others, that is quite so normal, isn’t it? (Huge Snort).

On a more serious note, Hannibal is quite the man- to chop your own hand instead of that damsel’s hand requires a ‘Macho-man’ courage, which, unfortunately most of our male homo sapiens think they possess. God gave the male counterpart two ‘heads’ and most probably, blood supply to one head is more. You can guess which one based on the number of theatricals the male earthling is involved in, for example, petting a wild lion or a croc. Well, at the end of that day, the world balance is restored- you will find no difference in the ‘head’ count when comparing that man to a woman.

Let’s set the record straight: no, I am an Anaesthesiologist in training, not a Neurosurgeon. No, I don’t serve brain tissue as a side dish, and yes, patients are far more responsive than Ray Liotta’s drugged-up character. Watching Hannibal lift the top of Krendler’s skull while his cheerful victim nonchalantly chats is every anaesthesiologist’s (most of us anyway) worry. Why? Well, you might be calm because I am, as the blog so well describes it, an educated drug dealer with an armada or weapons- Propofol, Remifentanil, Dexmedetomidine, Scalp Block and so on. But cheerful? That probably indicates you need an exorcist more than a Neurosurgeon. I wouldn’t be surprised if you jump on the ceiling at some point and creep us all out!

Let’s come to the real deal- Being awake when your skull is cracked open! The first awake craniotomy was performed in 1886 by Sir (D)r Victor Alexander Haden Horsley, a British neurosurgeon who was a pioneer neurosurgeon at a time when ether and chloroform were the height of anaesthesia ‘technology’. His patient, a young woman with severe epilepsy caused by a brain tumour, was kept awake during the procedure. Dr Horsley relied on her responses to ensure he didn’t inadvertently disrupt critical brain areas.

In a move ingeniously daring, he essentially invented the practice of functional mapping on the spot. He exposed her brain and stimulated different regions to observe their effects on movement and speech—a crude but effective way to navigate uncharted cerebral territory. The surgery was successful, with the patient reportedly free of seizures afterwards, though I suspect her Yelp review would have included something about "insufficient sedation and good service but definitely room for improvement".

This groundbreaking procedure set the stage for what we now know as awake craniotomy, where cutting-edge neuroimaging, functional mapping, and meticulously titrated anaesthesia combine to make the experience safe and, dare I say, cooperative. Dr. Horsley’s boldness was the start of a legacy that turned the brain from a quiet mysterious organ to one that ‘talks’ to us during surgery. Essentially, that’s awake craniotomy simplified- your brain notifies us when the neurosurgeon is being a pervert and touching the ‘wrong’ places on its surface!

Ah, the awake craniotomy—where we, as anaesthesiologists, earn our money with real hard work. No gassing down and having coffee. No no no! This is the ultimate balancing act: the neurosurgeons dig while we juggle sedation and consciousness like a circus act. It's the "brain's got talent" show, and the whole team is the host keeping everything running smoothly.

The brain is an organ we are barely beginning to understand. Your brain during an awake craniotomy is like the captain of two ships- your body and the ‘Neurosurgery theatre’. It steers us to where the surgery needs to happen and maintains the normal functioning of your own body.

From the anaesthesiologist's perspective, the challenge lies in reaching nirvana or the Goldilocks zone: not too awake to cause a panic attack in the middle of cortex mapping, and not too sedated to risk the surgeon missing critical feedback. Sedation is like salt seasoning, my boss often said- Too much and you ruin the dish, too little and it's tasteless.

Neurosurgeons love these moments where we work as hard as they need to—social media fodder, no doubt—but for us, it’s a reminder to keep the airway secure and the vitals steady. Nobody wants their patient belting out ‘I’m alive’ by Celine Dion before suddenly flatlining!

Dr. Henry Marsh, in his memoir, Do No Harm, noted- Brain surgery is like rocket science, but harder. A statement we appreciate when we are managing the other half of the equation: ensuring the patient is calm and cooperative while the surgeons gently prod the very essence of their existence.

Functional mapping during an awake craniotomy is a bit like playing a warped game of “Operation.” Touch the wrong spot, and suddenly the patient forgets how to move their pinky. Hit the right area, and it’s all smiles and thumbs-ups. It's gratifying to watch the neurosurgeon consult the patient in real-time: “Can you wiggle your toes?” “Yes.” Snip snip.

Anaesthesia ensures these moments aren’t interrupted by vomiting, hypertension, seizures (Yes! They are touching that brain, what do you expect- Cotton candy out of your ass?) or a surprise airway event.

And for me, that’s the beauty of it, isn’t it? Not the cotton candy part! Awake craniotomy is a testament to our ability as a team to problem-solve in the most awe-inspiring ways. It’s a privilege to help a patient find their words, their music, or their art—all while managing their haemodynamics like a maestro.

Well, awake craniotomy is definitely a work of art- It is brainstorming done right- The neurosurgeons storm your brain, and the anaesthesiologists troubleshoot(brainstorm) it!

NB. Huge smirk from me!