Awake craniotomy: speech and language therapists at the cutting edge

Join us as we uncover the fascinating role of speech and language therapists working in awake craniotomy. We go to Birmingham to meet SLT Georgie Harrington and Mr Ismail Ughratdar, Consultant neurosurgeon to find out how they work as part of a team. Donald Innes, an expert by experience, who has had two awake craniotomies, shares his story and thoughts about the process. Kathleen Graham, SLT and now senior project manager for the RCSLT and lead on new awake craniotomies position paper (Oct 2025), gives us some of the history about the procedure.

With thanks to speakers:

• Donald Innes, expert by experience
• Kathleen Graham, Senior Project Manager, Royal College of Speech and Language Therapists
• Georgie Harrington, Clinical lead, Speech and Language Therapy Outpatients, University Hospitals Birmingham NHS Foundation Trust
• Mr Ismail Ughratdar, Consultant Neurosurgeon, Speech and Language Therapy Outpatients, University Hospitals Birmingham NHS Foundation Trust

Useful links:

• RCSLT awake craniotomy position paper (October 2025)
• Awake craniotomy | RCSLT (resources for the public)
• Awake craniotomy resources | RCSLT (resources for members of the RCSLT)
• What to expect during an awake craniotomy for brain tumour removal 

Please be aware that the views expressed are those of the guests and not the RCSLT.

Please do take a few moments to respond to our podcast survey: uk.surveymonkey.com/r/LG5HC3R

Transcript

Transcript Name: 

Awake Craniotomy: speech and language therapists at the cutting edges

Transcript Date: 

7 November 2025 

Speaker Key:

HOST:                         JACQUES STRAUSS 

ISMAIL:                       ISMAIL UGHRATDAR

GEORGIE:                  GEORGIE HARRINGTON

KATHLEEN:                KATHLEEN GRAHAM 

DONALD:                    DONALD INNES 

BACKGROUND 

AUDIO:                       0:00:03 Welcome on board this Avanti West Coast service to Birmingham New Street. 

HOST:                         0:00:12 Well, RCSLT is on the road again, this time on our way to Queen Elizabeth Hospital, Birmingham to meet Mr Ismail Ughratdar, Consultant Neurosurgeon and Georgie Harrington, highly specialist SLT to talk about awake craniotomies. 

                                    MUSIC PLAYS: 0:00:26-0:00:37

HOST:                         0:00:36 Welcome to the RCSLT podcast. My name is Jacques Strauss. At RCSLT, we do tend to be quite practical. Our podcasts are timed with the release of new guidance or research, and this is no exception. There is a new position paper about the role of SLTs in awake craniotomies, but we thought this is also a good opportunity to reveal the true breadth of the field. 

SLTs can be working in prisons, in schools, in care homes, in the community, or they could be scrubbing in for some of the most advanced surgery performed, which is why I found myself at Queen Elizabeth Hospital. 

ISMAIL:                       0:01:21 Hello. My name is Ismail. I’m a consultant neurosurgeon at Birmingham. I super-specialise in removing brain tumours, and I also undertake epilepsy surgery. 

GEORGIE:                  0:01:32 Hi, my name is Georgie. I’m a clinical lead speech and language therapist at the Queen Elizabeth Hospital in Birmingham, and my area of specialty is neurology, neurosurgery, and awake craniotomy. 

HOST:                         0:01:44 I guess the first question would be, why do we even perform awake craniotomies? 

ISMAIL:                       0:01:49 So, we all know that the brain controls very, very important functions in your body. That could be motor movement, it could be speech, it can be memory, it can be vision. 

Now, there are certain instances where there are brain tumours in specific parts of the brain that are next to areas that control these functions, or very closely linked in with them. So, when we’re trying to remove brain tumours, what we don’t want to do is leave the patient with a deficit, i.e. an inability to speak. And so, for those kind of patients with those kind of tumours in those locations, the best way to do an operation is to actually wake them up through the operation, once their skull is opened up, and then test the areas of the brain that we’re about to remove to see if they’ve got any of that function. 

If I walk you through the pathway, just to give you an idea. Once we’ve identified a patient that needs this particular type of surgery, we will very carefully counsel them as to what it involves. For the first part of the operation, they go off to sleep, so we put them to sleep under general anaesthetic. The anaesthetist will do something called a scalp block, where they numb all the areas of the scalp. And then we take them into theatre. We get them into a position. We don’t want any movement of the head while awake. And then we do all the painful bits, so opening up the scalp, taking the bone away, exposing the brain wirelessly, and then we wake them up. That’s the first stage done. 

And then we come to the second stage where we want to do what we call the mapping and the tumour removal and so we wake them up for that bit. That’s the kind of main crux of the awake craniotomy. At that point, what we start doing, once they’re fully awake, is we start something called mapping. And what we do is we send little bits of electrical stimulation through the parts of the brain that we’re interested in. While we’re doing that, we ask them to do the particular function that we’re interested in, whether it’s speech or movement. And every time we send a little bit of current down the brain and they’re doing that function, if it is interrupted in any way, so if there’s a speech problem or there’s a movement problem it stops. 

For example, if you’re moving your hand and if your hand suddenly stops, we know that bit of brain is responsible for that function because the brain actually looks very similar. It all looks very similar to the tumour, so you certainly can’t tell. 

HOST:                         0:04:23 Just to unpack what Ish was talking about, if you haven’t seen an awake craniotomy before, once the brain is exposed, the neurosurgeon applies a small electrical current to different areas of the brain. If the electrical current acts as an off switch for that part of the brain, this is a signal that the area is important for the task they’re being asked to do. 

ISMAIL:                       0:04:48 If that is positive, and it’s called a positive outcome, then we know that bit of brain is eloquent, i.e. important, and so we wouldn’t touch that and work away from there, and we find other areas where it would be negative, i.e. there is no function, and that’s our corridor into the tumour, or take this part of the tumour and we start taking that out.

HOST:                         0:05:12 Would it be fair to say that what still makes it quite difficult is that the brain is still something of a mystery to us? 

ISMAIL:                       0:05:18 Yeah, there are certain things, certain functions that are fairly well established and we know roughly where they are, we know what they do. With some of the more high-end function, we still really don’t understand the brain, I don’t think, as well as we should do. And then on top of that, when you’ve got distortion of the anatomy from a tumour that’s large, it’s pressing, there’s swelling around it, you really sometimes don’t know which way… not just what I call the outer surface where the function is, but the wiry, the circuitry, the wires that go down into the other parts of brain to the body, we don’t know where they’ve been shifted as well. 

GEORGIE:                  0:06:05 As Ish has said, we need to be continually mapping and testing various parts of the brain as the tumour is being removed, or even just to access the tumour in the first place. We will be designing… testing paradigms that correlate with the language function that we believe that area of the brain is responsible for. We will be looking at the individual language modalities in relation to neuroanatomical language models and selecting the tasks accordingly. 

HOST:                         0:06:40 Can I stop you then. You got very technical, very quickly! Would you mind just unpacking that a little bit?

GEORGIE:                  0:06:47 Okay. So, if we know that a specific area of the brain is responsible for object-naming, for example, we will be asking a patient to complete an object-naming task. 

BACKGROUND 

AUDIO (MALE 

VOICE):                      0:07:04 31 Here’s an igloo. There’s a pretzel. This is a rhino. Here is a screw. That is a… 

BACKGROUND 

AUDIO (FEMALE

VOICE):                      0:07:16 Errors…

BACKGROUND 

AUDIO (MALE

VOICE):                      … wheelchair. 

BACKGROUND 

AUDIO (FEMALE 

VOICE):                      0:07:18 There, we got it. 

GEORGIE:                  0:07:20 If that function is interrupted during the mapping process, so when the electrical stimulation is in place, then we know that area of brain is required for that person to name objects. And we use a whole host of different tasks depending on the neuroanatomy and the area of the brain that the surgeon is working on. 

As well as sort of that continuous assessment, we’ll also be having conversation with the patient. We will typically use more formal assessment tasks during the mapping session of the procedure, and then during the reception, we will be having conversation just to monitor a person’s language function in a more dynamic way, and evaluating whether they are deviating from their baseline. 

Beforehand, I will have met with them. I get to know them on an individual level – get to know their interests, their motivation, so that the conversation could be structured around things that motivate them. The patient should be speaking more than I’m speaking. 

HOST:                         0:08:30 Awake craniotomies go back a surprisingly long way. Kathleen Graham, a Speech and Language Therapist and Senior Project Manager at RCSLT, explains. 

KATHLEEN:                0:08:41 The history of awake craniotomies is quite fascinating and brings us back right to the 1800s. In 1874, we had Robert Bartholo, and he was the first person to do experiments on people to try and map functional areas of the brain in people that were awake. And then his work was followed a few years later in 1886 by Sir Victor Horsley, and he was the first person to perform an awake craniotomy and he used electrical stimulation. That was for people who were epileptic. 

And that continued, so Wilder Penfield in the 1920s continued to pioneer awake craniotomy in people with epilepsy and looking at brain function and correlation. But it wasn’t until the 1980s where we started using awake craniotomy in people with brain tumours. 

BACKGROUND 

AUDIO (FEMALE 

VOICE):                      0:09:34 … college and beginning the next chapter of his life when he began suffering debilitating headaches. Those headaches turned out to be a tumour, one that was very close to the area of the brain necessary for language. So, Daniel did something most of us cannot imagine. He was awake for his own brain surgery. 

KATHLEEN:                0:09:55 And the surgery that they might have to do a tumour resection. Roughly in the 1990s then speech and language therapists started to become involved. As the procedure became more refined, we needed the specialties of people with the specific skills in assessing speech and language function to be able to understand which areas needed to be left intact during brain resections and brain tumour surgery. 

Since then, it’s really grown, their involvement. So, speech and language therapists now play a critical part in that assessment and the retention of language and speech function for people with a brain tumour. 

DONALD:                    0:10:53 I wasn’t really aware of brain tumours, to be honest. I think it’s not until you’re actually faced with it that you don’t hear about them, unfortunately. My name’s Donald Innes. I’m 62. I’ve had a career in science, so I started when I was 17, actually, working in labs, and then worked in labs for 34 years, and then into scientific sales. 

So, yeah, I had no idea what it was. The first I knew of it is I had a massive seizure. I was otherwise fit and well, and it was just like a bolt out the blue. 

I’ve had two surgeons, because I’ve two awake craniotomies, and the first surgeon I had 20 years ago was so reassuring. I had no qualms at all. He laid it all out what it was. He suggested the best way to do it would be awake craniotomy and I just had to take him on his advice and his experience. 

Where my tumour is situated is near the speech and language centres, so having the awake craniotomy meant that they could take out as much of the tumour as possible without affecting function on speech and language. 

HOST:                         0:12:21 Presumably, it would have been around this time that you were introduced to a speech and language therapist? 

DONALD:                    0:12:27 Yeah, which was a great experience, actually. She went over the whole process and basically what would happen. Obviously, you have to try and get some rapport going, so that was really good. And she went through what she was wanting from me when I was coming up from the anaesthetic. Like, she asked me my favourite football team, so as we had something that I was aware of and that she could check on me and make sure I was all right. It was a lovely conversation, actually. She made me feel so relaxed and whatever, which I think is extremely important.

I was sort of aware of when the surgery was going on. They were obviously going to different regions, and when she was asking me questions, it’s quite a funny feeling. I knew I wanted to say, but I just couldn’t do it so they’re probing the area that they wanted to have a look at. You don’t see very much. All I could really see was the face of the speech and language therapist and for the first time, it was a good to have that because I’d met her, you know. I remembered the conversation, and I knew exactly what was happening. She was asking me questions and sort of reassuring me, so that was very, very helpful. 

HOST:                         0:13:55 What struck me when talking to Ish and Georgie was a great sense of camaraderie, which I imagine must develop in that sort of team. And both Donald and Ish were at pains to point out how vital the role of the SLT is in being able to perform these procedures at all. 

Yeah, so that’s a good question. I mean, how would you do the procedure before? 

ISMAIL:                       0:14:20 Yes, so we wouldn’t operate on because we knew that we’d cause a problem, or we’d operate on them and they’d be left with a speech problem. And we’ve got a mantra in neuro-oncology: remove as much tumour as possible, but preserve as much function as possible. 

My very first patient was a nurse, front-line nurse in A&E, with a tumour that was deemed inoperable. And then we operated, took the majority of it out, preserved her function, she was back at work with a little bit of speech rehab. The amount of quality of life that she’s got after that is phenomenal, you know, changing that life, or preserving that function, or increasing the survival rates from months to years and years that’s one of, I think, the ultimate rewards from this closed surgery. 

GEORGIE:                  0:15:04 And from, yeah, the perspective of a speech and language therapist specifically, the majority of referrals come to us once that deficit is in place. So, we are asked to see a patient who has had a change in their language function, who has lost some language function. This is a really rare opportunity to preserve that function. 

Whilst we know that a lot of the patients that we work with will inevitably go on to lose that function at some point, or have a deterioration in that function and we’ve been able to give them more time with communication style that makes them them. 

HOST:                         0:15:40 Do you have to have conversations with patients, I guess about the trade-off between longevity and retained function? 

ISMAIL:                       0:15:51 Yes. So, there are occasions where I’ve spoken to patients where, on the pre-operative imaging, I can see that there’s going to be a problem area. Occasionally, I have asked them what you want me to do at that point? Because obviously you can’t ask them in the theatre, and so I usually leave that to them. If we encounter this problem, i.e. there’s tumour left behind, but I can take it, but I would leave you a permanent problem, but that means you can live longer what you want me to do? If it’s intraoperatively, i.e. I wasn’t anticipating it, i.e. a speech problem, then I’ll always leave it. If we have to go back in, we can always go back in, but I will not make that decision for them. 

Because often, most patients, and I think this reflects kind of Western values, is that people prefer quality of life over quantity of life. Obviously, we love both. If you compare that with, for example, the Far East, some of my colleagues tell me that the patients will say, no, take the whole tumour out; I’m not fussed if I’m left paralysed, can’t speak, my family will look after me, but I want to live. 

GEORGIE:                  0:17:03 I think that’s why it’s important to really understand how a patient or how a person uses language. What type of person they are. Are they an avid reader? Do they care if their reading skills are intact or not? It depends. It’s what do they do for work? Are they multilingual in a professional context? Are they multilingual in the context they can order a sandwich on holiday? What are we trying to preserve and why are we trying to preserve it? 

Particularly if the context of a multilingual awake craniotomy, it’s going to make procedure longer, so we need to be sure that they… if there’s a lack of tolerance from the patient during the procedure, we need to know what their priorities are. 

DONALD:                    0:17:47 That’s the thing, I get scanned annually just to check the progress of the tumour. Although my tumour is low grade, the second surgery they got 70% of the tumour out, so there is a chance it will come back. And if it does come back, I’ll still be thinking the same as I have about the first two operations and would definitely go for an awake craniotomy again. In fact, I might even go one step forward because apparently now you can have it and without going in for general first and them waking you up. Which I think would be better because you’re not having to undergo general anaesthetic. 

HOST:                         0:18:31 In fact, Ish and Georgie did talk about how there are some centres in the UK that are able to discharge the patient on the same day, and the benefits of getting patients out of hospital as quickly but safely as possible are well established. 

There’s no specific certification for SLTs to become involved in this area. For those that are interested, I asked Kathleen to explain a little more about it.

KATHLEEN:                0:18:59 We do have regional centres of excellence. There’s 14 across the UK that the Tessa Jowell Academy has certified as a clinical centre for excellence. Most speech and language therapists almost fall into this area, so they could have a background in adult neural, particularly adult acute communication. And then they learn on the job, so they’ve got those expert skills in the assessment of speech and language function, and then they learn how those can be transferred into the area of awake craniotomy and brain and central nervous system tumours in more general. 

HOST:                         0:19:36 RCSLT has now come out with a position paper about awake craniotomies. But first off, could you just explain what a position paper is? 

KATHLEEN:                0:19:45 A position paper is a document that sets out the position that RCSLT want to take within a particular area, and it usually is either a very controversial area where there might be some conflicting evidence in terms of the evidence base, or it could be where our roles are new or developing within a particular area. 

What we really wanted to do with this was to say that best practice would state that speech and language therapists are a key part of the MDT for people who are undergoing an awake craniotomy. And I think to reinforce the specific skill-set that speech and language therapists can bring to this… there are other professionals who can assess in different areas of brain function, but to really set out that this is a crucial role for the speech and language therapist. 

HOST:                         0:20:38 Both Georgie and Donald were part of the working group. Who else was involved? 

KATHLEEN:                0:20:43 Our working group was mostly made up of speech and language therapists working in awake craniotomy. We also had representation from the Tessa Jowel Academy, and we had some expert reviewers of neurosurgeons, neurophysiologists, specialists, anaesthetists, to make sure that what we were saying within the document was accurate and of the best quality. 

What we really want to achieve with the paper as well is to support those organisations who maybe don’t have an established SLT role within awake craniotomies that we want to support them to do business cases to have a speech and language therapist there to ensure that the outcomes for the service user are the best that we can possibly do. 

HOST:                         0:21:31 It’s worth remembering that position papers are really useful if you need to put together a business case to get funding for a needed team member. 

I asked Georgie if she had thoughts on practical takeaways for SLTs involved in awake craniotomies. 

GEORGIE:                  0:21:47 I think adaptations are a big one, so making those reasonable adjustments wherever we can. We’ve done sort of a variety of things from increasing the size of the words and the pictures on the screen for people with variation in their in their sight, making sure people have their glasses, have their hearing aids with them if they use those, we’ve used amplification both ways, so if a patient has a hearing impairment we have amplified ourselves, if they have reduced vocal volume we amplify the patient. And we actually have tended to bring an amplifier into most procedures recently because we do find that throughout the procedure the patient’s volume can reduce. Particularly, it’s quite useful for the surgical team to hear a bit more what’s going on as well because, yeah, just not being able to see the patient’s face can impact that too. 

So yeah, adaptations from that point of view, but also adaptations linguistically. We need to know how a patient uses their language, how they use it on a day-to-day basis, socially, professionally. And if they are non-English speaking, if they’re multilingual, we need to be considering them when we prepare them for surgery. We will work closely with interpreting services, ideally the same interpreter before and during and after the procedure for the same reason, that familiarity.

HOST:                         0:23:26 Ish and Georgie had so many interesting stories to share, but I think we should end with a memorable case about keeping an open mind. 

ISMAIL:                       0:23:40 For me, particularly the one that I do remember is one patient who had learning difficulties. Very deep tumour, very large tumour. We didn’t know if he would actually get through the procedure because he needed a bit of comprehension. We didn’t know if he’d actually get through it. So, when we saw him in clinic, we floated the idea that we want to think about awake craniotomy. And he actually… he was quite… he changed our way of thinking. He went away and actually wrote a letter saying, no, I’m up for it, I understand what it’s all about. And so, we were quite shocked by this…surprised. So, we actually took him into theatre. It was a long procedure. It was such a deep tumour, but he tolerated it amazingly, and he was joking with us all the way through, and it’s probably one of the best tumours that I’ve ever done, and he’s been stable ever since. It was really… [Fades out 0:24:31]. 

HOST:                         0:24:47 A very big thank you to everyone who made the time to speak to us for this podcast. Not long after recording this interview, Ish travelled to Gaza to treat those affected by the war, as he has done before, and we are pleased to report that he has returned home safely. 

As always, please see show notes for links of interest, including ones to the position paper. 

Deepening the public’s understanding of speech and language therapy is very important if we are to advocate for the profession and its service users, and it also helps to recruit more broadly, which leads to better patient outcomes. So, we ask that you share this episode, perhaps with someone who you think may be interested in speech and language therapy as a profession, but doesn’t yet know it. 

Until next time, keep well. 

MUSIC PLAYS: 0:25:34

END OF TRANSCRIPT: 0:25:39