On an otherwise unremarkable Monday afternoon last May, Luis Pagan was wrapping up work in a client’s attic when the unthinkable happened. He fell unconscious — while standing on top of a ladder.

Pagan, 37, an HVAC installer and father of two from Centereach, crashed to the ground. His client found him on the floor and called an ambulance. At South Shore University Hospital (SSUH), emergency physicians made a grim discovery.

An awake craniotomy enlists the patient’s participation in the process of removing lesions located in certain parts of the brain. By rousing them, delicately stimulating the area around their tumor, and then asking them to perform certain actions (moving a limb, say), a neurosurgeon can figure out where to cut — and, crucially, where not to cut. “When you have a tumor in locations in the brain that affect essential functions of the nervous system, like speech, vision or movement, it is important we operate very precisely and avoid critical tissue,” explains Dr. Klironomos.  

A sophisticated procedure, awake surgery remains relatively rare. Only specially trained surgeons and anesthesiologists with access to specific brain mapping technology can perform it. SSUH was able to add the procedure to its toolkit thanks to the recruitment of world-class clinicians and the adoption of cutting-edge surgical equipment.

Pagan didn’t know what to make of the idea. “It sounded like something out of a science fiction movie,” he says. “I had never heard of anything like it.” If he chose to move forward, Pagan would be the first patient in SSUH history to undergo an awake craniotomy.

History of awake craniotomy

The history of awake surgery is long and fascinating. In ancient times, well before the advent of modern anesthesia, trephining, the practice of drilling holes in the skull, was thought to release “evil air.” Later, awake surgery was used for the study and treatment of epilepsy. 

Though nervous, Pagan was encouraged to hear what Dr. Klironomos had to say. “The possibility of losing my ability to walk or use my hands was too big a risk,” he says. Awake surgery would minimize that danger. 

In the end, after talking through his options with Dr. Klironomos and Michael Greenberg, MD, the attending neuro-anesthesiologist at SSUH who would team with Dr. Klironomos in the operating room, Pagan decided to go for it. 

After hugging his wife — who he had married one week prior to his surgery in SSUH’s chapel — Pagan was wheeled to the operating theater, where Dr. Greenberg put him under light anesthesia. Dr. Klironomos and his team carefully opened Pagan’s skull, then placed electrodes on his motor cortex. 

About 30 minutes in, they embarked on the awake phase. During this portion, surgeons use the electrodes to determine where and where not to cut. With his skull open and surgeons exploring his brain, Pagan would be awake for about 30 minutes on the operating table and asked a series of questions. To test a patient’s ability to speak, for example, a physician stimulates the area of the brain associated with speech, then asks the patient if they can name a specific color or say a certain word. If the patient can’t, the surgeon knows not to remove tissue in that area.

Because Pagan’s tumor was in an area associated with motor skills, Dr. Klironomos and his team focused on testing his ability to move his fingers, arms and other parts of his body. Pagan has little memory of this part of his surgery. “I get flashes every now and then of being in the operating room,” he says, “but I don’t remember any conversations or what they asked me to do.” 

He also has no recollection of pain. Surprisingly, the brain itself doesn’t contain the kind of neurons that register tissue-threatening stimuli and send messages of discomfort. But skin, muscle and bones do, which is why Dr. Greenberg kept Pagan partially sedated and on pain medication while Dr. Klironomos opened and closed the skull.  Pagan needed nothing for pain relief while he was awake on the operating table — just medication to help quell anxiety.

Waking up to second chance after awake craniotomy

The three-hour procedure was a resounding success. When Pagan woke up, he was relieved to find he could wiggle his toes and squeeze his wife’s hand. He was up and walking in two days and discharged in five.  And “he was himself,” D’Ambrosio adds. “I was so scared. I didn’t know if he’d be able to take care of himself,” she says. “But he was fine.”

Following his surgery, Pagan started a six-week course of radiation and chemotherapy. He’ll continue chemotherapy for another year. 

Pagan says having his wife and children by his side is making the ordeal easier to bear.

Going through it “has been a rollercoaster of emotions,” he says. “But it’s given me a new appreciation of life.”