CRANIOTOMY

Overview

Craniotomy is a cut that opens the cranium. During this surgical procedure, a section of the skull, called
a bone flap, is removed to access the brain underneath. The bone flap is usually replaced after the
procedure with tiny plates and screws.

A craniotomy may be small or large depending on the problem. It may be performed during surgery for
various neurological diseases, injuries, or conditions such as brain tumors, hematomas (blood clots),
aneurysms or AVMs, and skull fractures. Other reasons for a craniotomy may include foreign objects
(bullets), swelling of the brain, or infection. Depending on the reason for the craniotomy, this surgery
requires a hospital stay that ranges from a few days to a few weeks.

What is a craniotomy?

Craniotomy is any bony opening that is cut into the skull. A section of skull, called a blone flap, is
removed to access the brain underneath. There are many types of craniotomies, which are named
according to the area of skull to be removed. Typically the bone flap is replaced. If the bone flap is not
replaced, the procedure is called a craniectomy.

Craniotomies are also named according to their size and complexity. Small dime-sized craniotomies are
called burr holes or keyhole craniotomies. Sometimes stereotactic frames, image-guided computer
systems, or endoscopes are used to precisely direct instruments through these small holes. Burr holes
or keyhole craniotomies are used for minimally invasive procedures to:

insert a shunt into the ventricles to drain cerebrospinal fluid (hydrocephalus)

insert a deep brain stimulator to treat Parkinson Disease
insert an intracranial pressure (ICP) monitor
remove a small sample of abnormal tissue (needle biopsy)
drain a blood clot (stereotactic hematoma aspiration)
insert an endoscope to remove small tumors and clip aneurysms

Large or complex craniotomies are often called skull base surgery. These craniotomies involve the
removal of a portion of the skull that supports the bottom of the brain where delicate cranial nerves,
arteries, and veins exit the skull. Reconstruction of the skull base is often necessary and may require the
additional expertise of head-and-neck, otologic, or plastic surgeons. Surgeons often use sophisticated
computers to plan these craniotomies and locate the lesion. Skull base craniotomies can be used to:

remove or treat large brain tumors, aneurysms, or AVMs

treat the brain following a skull fracture or injury (e.g., gunshot wound)
remove tumors that invade the bony skull

What happens before surgery?

The patient will typically undergo tests (e.g., blood test, electrocardiogram, chest X-ray) several days
before surgery. In the doctors office he will sign consent forms and complete paperwork to inform the
surgeon about his medical history (i.e., allergies, medicines, anesthesia reactions, previous surgeries).
He may wish to donate blood several weeks before surgery. Discontinue all non-steroidal anti-
inflammatory medicines (Naproxin, Advil, etc.) and blood thinners (coumadin, aspirin, etc.) 1 week before
surgery. Additionally, stop smoking, chewing tobacco, and drinking alcohol 1 week before and 2 weeks
after surgery because these activities can cause bleeding problems.
What happens during surgery?

There are 6 main steps during a craniotomy. Depending on the underlying problem being treated and
complexity, the procedure can take 3 to 5 hours or longer.

Step 1: prepare the patient

No food or drink is permitted past midnight the night before surgery. Patients are admitted to the
hospital the morning of the craniotomy. With an intravenous (IV) line placed in your arm, general
anesthesia is administered while you lie on the operating table. Once asleep, your head is placed
in a 3-pin skull fixation device, which attaches to the table and holds your head in position during
the procedure (Fig. 2).

Insertion of a lumbar drain in your lower back helps remove cerebrospinal fluid (CSF), thus allowing the
brain to relax during surgery. A brain-relaxing drug called mannitol may be given.

Step 2: make a skin incision

After the scalp is prepped with an antiseptic, a skin incision is made, usually behind the hairline. The
surgeon attempts to ensure a good cosmetic result after surgery. Sometimes a hair sparing technique can
be used that requires shaving only a 1/4-inch wide area along the proposed incision. Sometimes the
entire incision area may be shaved.

Step 3: perform a craniotomy, open the skull

The skin and muscles are lifted off the bone and folded back. Next, one or more small burr holes are
made in the skull with a drill. Inserting a special saw through the burr holes, the surgeon uses this
craniotome to cut the outline of a bone flap (Fig. 3). The cut bone flap is lifted and removed to expose
the protective covering of the brain called the dura. The bone flap is safely stored until it is replaced at
the end of the procedure.

Step 4: exposure the brain

After opening the dura with surgical scissors, the surgeon folds it back to expose the brain (Fig. 4).
Retractors placed on the brain gently open a corridor to the area needing repair or removal.
Neurosurgeons use special magnification glasses, called loupes, or an operating microscope to see the
delicate nerves and vessels.

Step 5: correct the problem

Because the brain is tightly enclosed inside the bony skull, tissues cannot be easily moved aside to
access and repair problems. Neurosurgeons use a variety of very small tools and instruments to work
deep inside the brain. These include long-handled scissors, dissectors and drills, lasers, ultrasonic
aspirators (uses a fine jet of water to break up tumors and suction up the pieces), and computer image-
guidance systems. In some cases, evoked potential monitoring is used to stimulate specific cranial
nerves while the response is monitored in the brain. This is done to preserve function of the nerve and
make sure it is not further damaged during surgery.

Step 6: close the craniotomy

With the problem removed or repaired, the retractors holding the brain are removed and the dura is
closed with sutures. The bone flap is replaced back in its original position and secured to the skull with
titanium plates and screws (Fig. 5). The plates and screws remain permanently to support the area;
these can sometimes be felt under your skin. In some cases, a drain may be placed under the skin for a
couple of days to remove blood or fluid from the surgical area. The muscles and skin are sutured back
together. A turban-like or soft adhesive dressing is placed over the incision.
What happens after surgery?

After surgery, you are taken to the recovery room where vital signs are monitored as you awake from
anesthesia. The breathing tube (ventilator) usually remains in place until you fully recover from the
anesthesia. Next, you are transferred to the neuroscience intensive care unit (NSICU) for close
observation and monitoring. You are frequently asked to move your arms, fingers, toes, and legs.

A nurse will check your pupils with a flashlight and ask questions, such as "What is your name?" You
may experience nausea and headache after surgery; medication can control these symptoms.
Depending on the type of brain surgery, steroid medication (to control brain swelling) and anticonvulsant
medication (to prevent seizures) may be given. When your condition stabilizes, you’ll be transferred to a
regular room where you’ll continue to be monitored and begin to increase your activity level.

The length of the hospital stay varies, from only 2–3 days or 2 weeks depending on the surgery and
development of any complications. When released from the hospital, you’ll be given discharge
instructions. Stitches or staples are removed 7–10 days after surgery in the doctor’s office.

What are the risks?

No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots,
and reactions to anesthesia. Specific complications related to a craniotomy may include:

stroke
seizures
swelling of the brain, which may require a second craniotomy
nerve damage, which may cause muscle paralysis or weakness
CSF leak, which may require repair
loss of mental functions
permanent brain damage with associated disabilities

What are the results?

The results of your craniotomy depend on the underlying condition being treated.

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SUMMARY:

Craniotomy is a cut that opens the cranium. During this surgical procedure, a section of the skull, called a
bone flap, is removed to access the brain underneath.

There are many types of craniotomies, which are named according to the area of skull to be removed.
Typically the bone flap is replaced. If the bone flap is not replaced, the procedure is called a craniectomy.

Craniotomies are also named according to their size and complexity. Small dime-sized craniotomies are
called burr holes or keyhole craniotomies. Burr holes or keyhole craniotomies are used for minimally
invasive procedures.Large or complex craniotomies are often called skull base surgery. These
craniotomies involve the removal of a portion of the skull that supports the bottom of the brain where
delicate cranial nerves, arteries, and veins exit the skull.

Craniotomies are often a critical operation performed on patients suffering from brain lesions or traumatic
brain injury (TBI), and can also allow doctors to surgically implant deep brain stimulators for the treatment
of Parkinson's disease, epilepsy and cerebellar tremor. The procedure is also widely used in
neuroscience for extracellular recording, brain imaging, and for neurological manipulations such as
electrical stimulation and chemical titration.

REACTION:

A craniotomy is a surgical operation in which a bone flap is (temporarily) removed from the skull, to
access the brain. Craniotomies are often a critical operation performed on patients suffering from brain
lesions or traumatic brain injury (TBI), and can also allow doctors to surgically implant deep brain
stimulators for the treatment of Parkinson's disease, epilepsy and cerebellar tremor. The procedure is
also widely used in neuroscience for extracellular recording, brain imaging, and for neurological
manipulations such as electrical stimulation and chemical titration.

Since the surgery would be affecting the brain, safety, coordination, and level of consciousness should be
carefully assessed to know the effectiveness of the operation. After surgery, patients should be well
educated before discharge.Discomfort is common after surgery so medications should be prescribed by
the doctor, and nurses should intstruct client’s to follow the medication regimen. Also client’s should be
instructed on what activities to do after surgery.
CRANIOTOMY

SUBMITTED TO:
MRS. KAYE ACHUMBRE
CLINICAL INSTRUCTOR

SUBMITTED BY:
MA.CARLA B. MARTINEZ
BSN-4E