Awake Surgery

02 Aug 2023

By Dr. Barbara Buccilli

My initial exposure to neurosurgery was through awake surgery.  I began my internship in the department, and I immediately joined an ongoing research project on awake surgeries for arteriovenous malformations (AVMs). This may seem unusual, but when considering my fascination with this type of surgery and my overall obsession with the nervous system, it becomes less surprising. These factors drew me closer to the field and motivated me to pursue that internship.

The significance of awake procedures in neurosurgery extends beyond the remarkable experience of having our hands on a patient’s brain while they engage in activities like reciting Shakespeare, answering questions, or singing a tune. Brain tumors, AVMs, and other lesions can often be located within or near eloquent areas of the brain, necessitating a delicate balance between efficient removal of affected tissue and preservation of function. Asleep-awake-asleep procedures have transformed these operations from a blind pursuit, relying solely on anatomical knowledge and assistance with navigational technology, into ambitious strategic maneuvers aiming for a level of precision comparable to gamma knife procedures. We can now adapt the familiar anatomical map to each individual patient, accounting for the inherent variability we encounter in every surgical setting. This approach allows us to map brain activity in real-time, reducing the risk of damaging critical areas and connections, while maximizing lesion resection.

Achieving such remarkable results requires thorough study and preparation. Advanced imaging is necessary before bringing the patient into the operating room. Following the initial craniotomy, the neurosurgeon employs electrical probes to stimulate the brain, aiding in the identification of critical functions. The patient is then instructed to perform specific tasks based on the targeted area of interest. This meticulous mapping of functional boundaries enables precise monitoring throughout the entire removal process, empowering the neurosurgeon to adapt their approach as needed.

Awake neurosurgery also presents an incredible opportunity to study neuroplasticity and observe how the brain reorganizes and adjusts its functions in response to surgical intervention. Functional MRI (fMRI) can be utilized during surgery to obtain real-time images of brain activity, bringing us a step beyond the sole implementation of direct electrical stimulation to visualize functional areas.

It is crucial not to overlook the potential stress faced by patients undergoing awake neurosurgery. Providing psychological support, step-by-step explanations of the procedure, and relaxation techniques are essential components of their care.

While we cannot predict its ultimate development, I firmly believe that awake neurosurgery represents the future of the field, particularly when combined with other emerging technological approaches to medicine. Advancements in brain-computer interface technology, for example, hold the potential for direct communication between the surgical team and the patient’s brain during the procedure, facilitating even more precise mapping and monitoring. I consider today’s neurosurgeons, neurologists, and neuroscientists to be exceptionally fortunate as we are witnessing and actively participating in one of the most revolutionary eras in our collective field.


Barbara Buccilli, MD, is an Italian medical doctor, an incoming Cerebrovascular and Neurologic Critical Care Pre-residency Fellow at The Mount Sinai Hospital, and an applicant for US medical residency. She has always had a deep passion for the nervous system and has dedicated her career to this field. Dr. Buccilli obtained her medical degree from Sapienza University of Rome, where she graduated in the top 5% of her class. Throughout her academic journey, she consistently achieved scores higher than the national average on the annual progress test, which earned her the corresponding awards.


In 2021, Dr. Buccilli obtained her medical license from the OMCEO. Since then, she has been actively involved in medical practice while concurrently preparing for and successfully completing all three steps of the United States Medical Licensing Examination (USMLE). Dr. Buccilli is currently engaged in research activities and actively participating in the writing of a comprehensive neuroanatomy book.

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