Craniotomy

Definition
Craniotomy is a surgical procedure where an opening is made
in the skull to enable to access and expose the brain.
Types of Craniotomy
Craniotomy can be classified into several types depending on
the location. The skull consists of the frontal bone located at
the forehead, the temporal bones at the temples, the parietal
bones on both sides, and the occipital bone at the back of the
head.
 Frontal craniotomy is performed through the frontal bone
 Temporal craniotomy is performed through the temporal
bone
 Parietal craniotomy is performed through the parietal
bone
 Occipital craniotomy is performed through the occipital
bone
 Pterional craniotomy is performed at the junction of the
frontal, temporal, greater wing of sphenoid and parietal
bones. The sphenoid is a bone at the base of the skull.
Craniotomy can involve more than one skull bones, for
example, frontotemporal craniotomy, frontotemporoparietal
craniotomy 

Other types of craniotomies include:

 Keyhole Craniotomy, where the surgery is carried out
through a small hole. It is done for lesions that are not
immediately just below the brain.
 Stereotactic Craniotomy, where a 3-dimensional
coordinates system is used to precisely locate the problem
area that needs surgery.
 Awake Craniotomy, where the patient can be woken up
during the surgery. It is commonly done for epilepsy
surgeries, or when the lesion is close to a critical area of the
brain. The patient’s responses are checked during the
surgery to make sure that the vital parts of the brain are not
being affected.

Indications for Craniotomy

 Surgical removal of a tumor or blood clot, or draining of

an abscess within the skull. Brain injury following trauma
is one of the commonest indications for craniotomy.
 Clipping of an aneurysm: Clipping of the aneurysm
reduces blood flow through it and therefore decreases its
size and its potential to burst.
 Removal of an arteriovenous malformation: An
arteriovenous malformation is an abnormal communication
between an artery and a vein. It can bleed and result in
grave consequences.
 Surgery for epilepsy: Certain cases of epilepsy do not
respond to medication and require surgery
 Ventricular shunting. Ventricular shunting is a procedure
performed to reduce pressure in the skull due to excess
fluid accumulation.

 Other procedures like inserting deep brain stimulators for

the treatment of conditions like brain tumours, Parkinson’s
disease, essential tremor and dystonia.
Investigations Done Prior to Craniotomy
Tests done prior to craniotomy include the tests required to
diagnose the pathology and locate it precisely within the skull,
as well as routine tests done before any surgery. These
include:
 Imaging Tests like CT scan (most common), MRI and
functional MRI are performed to identify and locate the
lesion. An angiography may also be done in selected cases
to identify the blood supply to the lesion.
 Routine Tests which are done before any surgery
include:
 Blood tests like hemoglobin levels, blood group, and
liver and kidney function tests; tests to ensure that the
blood coagulation system is intact
 Urine tests
 ECG to study the electrical activity of the heart
 Chest x-ray
In older patients, a detailed assessment of the heart may be
required to make sure that they are fit for surgery.

Medications that are administered prior to the surgery

depending on the type of lesion include:
 Anti-seizure medications to prevent the development of
seizures
 Corticosteroids to reduce swelling
 An antibiotic to prevent infection due to the surgery
Blood thinners should be stopped a few days before the
surgery to prevent excess bleeding

How is Craniotomy Preformed?

Type of Anesthesia - A combination of general
anesthesia and local anesthesia is often used for the
craniotomy procedure. If patient is under general anesthesia,
he/she will be asleep during the procedure and will not be
aware of what is going on. If patient is undergoing a sleep-
awake-sleep craniotomy, he/she may be given general
anesthesia but will be woken up during the surgery. The local
anesthetic is mixed with epinephrine to reduce bleeding from
the incision.

Pre-operative Check-up - Routine tests as indicated above

are ordered a few days before the surgery. Admission is
usually required a day before the surgery.

Fasting Before Surgery - Overnight fasting is required and

occasionally intravenous fluid maybe required to keep patient
well hydrated. Sedation is sometimes required for good
overnight sleep before the surgery. 

Incision for Craniotomy - The location of the incision for the

craniotomy procedure depends on which part of the brain has
to be operated. The inner part of the skull is divided by tissue
called tentorium cerebelli into an upper supratentorial part and
a lower and posterior infratentorial part.
 For a surgery in the supratentorial part, the incision is
made through the frontal, temporal, parietal or occipital
bones, or through more than one bone
 For a surgery in the infratentorial part, the incision is
made through the back of the skull just above the neck

The desired location of the incision is marked on the skin. The

hair in the area may be shaved off and a scalp flap is made.
The incision should preferably be behind the hairline for
cosmetic effect. A local anesthetic with epinephrine is usually
injected just before the incision is made to reduce bleeding.
The muscles below the scalp are separated to reach the bone
of the skull.
Craniotomy - Four to five holes are bored into the skull. The
holes are connected with a saw and a bone flap is cut out after
carefully separating it from the dura below. The dura is then
cut and retracted, exposing the brain.

Once the surgery on the brain is done, the bone is usually

replaced and kept in position with soft wire, or plates and
screws. The overlying tissues are replaced and the scalp is
then sutured into position.

Post-operative Recovery – patient will remain in the hospital

for a few days following the procedure.

 Light foods may be allowed following the surgery. 

 Chest physiotherapy is started after 24 hours to prevent
chest infection. Manual mobilisation techniques like
hacking clapping vibration followed by suctioning.
 DVT Prophylaxis - Early movement of the legs and some
mobilization prevents DVT or deep vein thrombosis.
Other measures like small dose of heparin and special
stockings may also be used.
 Regular turning every 2 hourly
 Regular movement of limbs are required – active, active
assisted or passive movements as per ability of patient is
given.

After discharged from the hospital, patient will have to

revisit doctor after 5 to 10 days for removal of the
sutures.
 Risks Associated with Craniotomy
Craniotomy is a highly complex surgery. Complications of
craniotomy can be life threatening and include:

 Headache
 Leakage of cerebrospinal fluid (CSF), the fluid
surrounding the brain, through the cut area if it is not closed
properly
 Bleeding resulting in the formation of a hematoma. The
hematoma may be required to be removed with repeat
surgery
 Spasm of blood vessel resulting in reduced blood supply
to a particular part of the brain, thereby resulting in damage
to that part
 Infection
 Air embolism, where air enters a blood vessel and
interferes with blood supply to a particular part. Insertion of
a CVP line (central venous pressure line) just before the
surgery helps to remove any possible air embolisms
 Diabetes insipidus due to damage to the pituitary gland,
an important endocrine gland in the brain
 Seizures
 Damage to cranial nerves, the nerves supplying the head
and neck region
 Respiratory problems

Burr hole surgery

Burr holes are small holes that a neurosurgeon makes in

the skull. Burr holes are used to help relieve pressure on
the brain when fluid, such as blood, builds up and starts
to compress brain tissue. It is most commonly used for
subdural haematoma.
Procedure: The patient will be taken to the operating
room and put to sleep under general anaesthesia. The
head will be partially shaved, to expose the area of
operation. The head may simply rest on towels, or it
may be placed in three fixation points (Mayfield head
pins). The area where surgery is to be performed is then
"prepped and draped" using an antibiotic solution. Next,
the surgeon will make an incision, and reflect the scalp
over the area of the hematoma. Then, an air powered
drill is used to make a hole in the skull. The dura mater
(tough covering of the brain) is then opened. The
hematoma (blood clot) is now seen, and the surgeon will
irrigate some of it out, and may pass a drain around the
brain to provide post-operative drainage. The surgeon
will then close the scalp.