CRANIOTOMY or CRANIOTOMY or CRANIECTOMYCRANIECTOMY

What is a craniotomy?What is a craniotomy? Craniotomy is any bony opening that is cut into the skull. A Craniotomy is any bony opening that is cut into the skull. A

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

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

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

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

aneurysms. aneurysms.

Skull base craniotomies can be used to: Skull base craniotomies can be used to: remove or treat large brain tumors, aneurysms, or AVMs remove or treat large brain tumors, aneurysms, or AVMs treat the brain following a skull fracture or injury (e.g., treat the brain following a skull fracture or injury (e.g.,

gunshot wound) gunshot wound) remove tumors that invade the bony skull remove tumors that invade the bony skull

There are many kinds of craniotomies. Ask your neurosurgeon There are many kinds of craniotomies. Ask your neurosurgeon to describe where the skin incision will be made and the to describe where the skin incision will be made and the amount of bone removal.amount of bone removal.

Who performs the procedure?Who performs the procedure? A craniotomy is performed by a neurosurgeon; some have additional A craniotomy is performed by a neurosurgeon; some have additional

training in skull base surgery. A neurosurgeon may work with a team of training in skull base surgery. A neurosurgeon may work with a team of head-and-neck, otologic, oculoplastic and reconstructive surgeons. head-and-neck, otologic, oculoplastic and reconstructive surgeons. Ask your neurosurgeon about their training, especially if your case is Ask your neurosurgeon about their training, especially if your case is complex.complex.

What happens before surgery?What happens before surgery? You will typically undergo tests (e.g., blood test, electrocardiogram, You will typically undergo tests (e.g., blood test, electrocardiogram,

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

What happens during surgery?What happens during surgery?

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

Step 1. Patient preparation Step 1. Patient preparation Step 2. Skin incisionStep 2. Skin incisionStep 3. Craniotomy, opening the skull Step 3. Craniotomy, opening the skull Step 4. Exposure of the brainStep 4. Exposure of the brainStep 5. Correct the problemStep 5. Correct the problem Step 6. ClosureStep 6. Closure

What happens after surgery?What happens after surgery? After surgery, you are taken to the recovery room where vital signs are After surgery, you are taken to the recovery room where vital signs are

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

Discharge instructions:Discharge instructions: Discomfort ;Discomfort ; After surgery, headache pain is managed with narcotic medication. After surgery, headache pain is managed with narcotic medication.

Because narcotic pain pills are addictive, they are used for a limited Because narcotic pain pills are addictive, they are used for a limited period (2 to 4 weeks). Their regular use may also cause constipation, period (2 to 4 weeks). Their regular use may also cause constipation, so drink lots of water and eat high fiber foods. Laxatives (e.g., Dulcolax, so drink lots of water and eat high fiber foods. Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) may be bought without a prescription. Senokot, Milk of Magnesia) may be bought without a prescription. Thereafter, pain is managed with acetaminophen (e.g., Tylenol) and Thereafter, pain is managed with acetaminophen (e.g., Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen, nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve). Advil, Motrin, Nuprin; naproxen sodium, Aleve).

A medicine (anticonvulsant) may be prescribed temporarily to prevent A medicine (anticonvulsant) may be prescribed temporarily to prevent seizures. Common anticonvulsants include Dilantin (phenytoin), seizures. Common anticonvulsants include Dilantin (phenytoin), Tegretol (carbamazepine), and Neurontin (gabapentin). Some patients Tegretol (carbamazepine), and Neurontin (gabapentin). Some patients develop side effects (e.g., drowsiness, balance problems, rashes) develop side effects (e.g., drowsiness, balance problems, rashes) caused by these anticonvulsants; in these cases, blood samples are caused by these anticonvulsants; in these cases, blood samples are taken to monitor the drug levels and manage the side effects taken to monitor the drug levels and manage the side effects

RestrictionsRestrictions Do not drive after surgery until discussed with your surgeon and avoid sitting Do not drive after surgery until discussed with your surgeon and avoid sitting

for long periods of time. for long periods of time. Do not lift anything heavier than 5 pounds (e.g., 2-liter bottle of soda), Do not lift anything heavier than 5 pounds (e.g., 2-liter bottle of soda),

including children. including children. Housework and yardwork are not permitted until the first follow-up office visit. Housework and yardwork are not permitted until the first follow-up office visit.

This includes gardening, mowing, vacuuming, ironing, and loading/unloading This includes gardening, mowing, vacuuming, ironing, and loading/unloading the dishwasher, washer, or dryer. the dishwasher, washer, or dryer.

Do not drink alcoholic beverages. Do not drink alcoholic beverages.

ActivityActivity Gradually return to your normal activities. Fatigue is common.Gradually return to your normal activities. Fatigue is common. An early exercise program to gently stretch the neck and back may be advised.An early exercise program to gently stretch the neck and back may be advised. Walking is encouraged; start with short walks and gradually increase the Walking is encouraged; start with short walks and gradually increase the

distance. Wait to participate in other forms of exercise until discussed with distance. Wait to participate in other forms of exercise until discussed with your surgeon. your surgeon.

Bathing/Incision CareBathing/Incision Care You may shower and shampoo 3 to 4 days after surgery unless You may shower and shampoo 3 to 4 days after surgery unless

otherwise directed by your surgeon. otherwise directed by your surgeon. Sutures or staples, which remain in place when you go home, Sutures or staples, which remain in place when you go home,

will need to be removed 7 to 14 days after surgery. Ask your will need to be removed 7 to 14 days after surgery. Ask your surgeon or call the office to find out when. surgeon or call the office to find out when.

When to Call Your DoctorWhen to Call Your DoctorIf you experience any of the following: If you experience any of the following:

A temperature that exceeds 101º F A temperature that exceeds 101º F An incision that shows signs of infection, such as redness, An incision that shows signs of infection, such as redness,

swelling, pain, or drainage. swelling, pain, or drainage. If you are taking an anticonvulsant, and notice drowsiness, If you are taking an anticonvulsant, and notice drowsiness,

balance problems, or rashes. balance problems, or rashes. Decreased alertness, increased drowsiness, weakness of arms Decreased alertness, increased drowsiness, weakness of arms

or legs, increased headaches, vomiting, or severe neck pain or legs, increased headaches, vomiting, or severe neck pain that prevents lowering your chin toward the chest. that prevents lowering your chin toward the chest.

RecoveryRecovery The recovery time varies from 1 to 4 weeks depending on the The recovery time varies from 1 to 4 weeks depending on the

underlying disease being treated and your general health. underlying disease being treated and your general health. Full recovery may take up to 8 weeks. Walking is a good way Full recovery may take up to 8 weeks. Walking is a good way to begin increasing your activity level. Start with short, to begin increasing your activity level. Start with short, frequent walks within the house and gradually try walks frequent walks within the house and gradually try walks outside. It’s important not to overdo it, especially if you are outside. It’s important not to overdo it, especially if you are continuing treatment with radiation or chemotherapy. Ask continuing treatment with radiation or chemotherapy. Ask your surgeon when you can expect to return to work. your surgeon when you can expect to return to work.

What are the risks?What are the risks? No surgery is without risks. General complications of any No surgery is without risks. General complications of any

surgery include bleeding, infection, blood clots, and reactions surgery include bleeding, infection, blood clots, and reactions to anesthesia. Specific complications related to a craniotomy to anesthesia. Specific complications related to a craniotomy may include: may include:

stroke stroke seizures seizures swelling of the brain, which may require a second craniotomy swelling of the brain, which may require a second craniotomy nerve damage, which may cause muscle paralysis or nerve damage, which may cause muscle paralysis or

weakness weakness CSF leak, which may require repair CSF leak, which may require repair loss of mental functions loss of mental functions permanent brain damage with associated disabilitiespermanent brain damage with associated disabilities

Decompressive craniectomy –Decompressive craniectomy – is a is a neurosurgical procedure in which part of the procedure in which part of the skull is removed to is removed to allow a swelling allow a swelling brain room to expand without being room to expand without being squeezed. It is performed on victims of squeezed. It is performed on victims of traumatic brain injury and and stroke..

Reduction of intracranial pressureReduction of intracranial pressure Though the procedure is considered a last resort, Though the procedure is considered a last resort,

some evidence suggests that it does improve some evidence suggests that it does improve outcomes by lowering outcomes by lowering intracranial pressure (ICP), the (ICP), the pressure within the skullpressure within the skull..Raised intracranial pressure Raised intracranial pressure is very often debilitating or fatal because it causes is very often debilitating or fatal because it causes compression of the brain and restricts compression of the brain and restricts cerebral blood flow. The aim of decompressive . The aim of decompressive craniectomy is to reduce this pressure. The part of craniectomy is to reduce this pressure. The part of the skull that is removed is called a the skull that is removed is called a bone-flap. A . A study has shown that the larger the removed bone-study has shown that the larger the removed bone-flap is, the more ICP is reduced.flap is, the more ICP is reduced.

Other effectsOther effects In addition to reducing ICP, studies have found In addition to reducing ICP, studies have found

decompressive craniectomy to improve decompressive craniectomy to improve cerebral perfusion pressure and and cerebral blood flow in in head injured patients.head injured patients.

Decompressive craniectomy is also used to manage major Decompressive craniectomy is also used to manage major strokes, associated with "malignant" edema and strokes, associated with "malignant" edema and intracranial hypertension. The pooled evidence from three intracranial hypertension. The pooled evidence from three randomised controlled trials in Europe supports the randomised controlled trials in Europe supports the retrospective observations that early (within 48 hours) retrospective observations that early (within 48 hours) application of decompressive craniectomy after application of decompressive craniectomy after "malignant" stroke may result in improved survival and "malignant" stroke may result in improved survival and functional outcome in patients under the age of 55, functional outcome in patients under the age of 55, compared to conservative management alone.compared to conservative management alone.

The procedure is recommended especially for young The procedure is recommended especially for young patients in whom ICP is not controllable by other patients in whom ICP is not controllable by other methods.Age of greater than 50 years is associated with a methods.Age of greater than 50 years is associated with a poorer outcome after the surgerypoorer outcome after the surgery..

ComplicationsComplications Infections such as meningitis or brain abscess can Infections such as meningitis or brain abscess can

occur after decompressive craniectomy.occur after decompressive craniectomy.

Follow-up treatmentFollow-up treatment After a craniectomy, the risk of brain injury is After a craniectomy, the risk of brain injury is

increased, particularly after the patient heals and increased, particularly after the patient heals and becomes mobile again. Therefore, special measures becomes mobile again. Therefore, special measures must be taken to protect the brain, such as a helmet must be taken to protect the brain, such as a helmet or a temporary implant in the skull [10].or a temporary implant in the skull [10].

When the patient has healed sufficiently, the When the patient has healed sufficiently, the opening in the skull is usually closed with a opening in the skull is usually closed with a cranioplasty. If possible, the original skull fragment cranioplasty. If possible, the original skull fragment is preserved after the craniectomy in anticipation of is preserved after the craniectomy in anticipation of the cranioplastthe cranioplast..

GlossaryGlossary biopsy:biopsy: a sample of tissue cells a sample of tissue cells

for examination under a for examination under a microscope to determine the microscope to determine the existence or cause of a disease.existence or cause of a disease.

burr hole:burr hole: a small dime-sized a small dime-sized hole made in the skull.hole made in the skull.

craniectomy:craniectomy: surgical removal surgical removal of a portion of the skull.of a portion of the skull.

craniotome:craniotome: a special saw a special saw with a footplate that allows with a footplate that allows cutting of the skull without cutting of the skull without cutting the dura mater.cutting the dura mater.

craniotomy:craniotomy: surgical opening surgical opening of a portion of the skull to gain of a portion of the skull to gain access to the intracranial access to the intracranial structures and replacement of structures and replacement of the bone flap.the bone flap.

dura mater:dura mater: the outer the outer protective covering of the protective covering of the brain.brain.

laser:laser: a device that emits a a device that emits a narrow intense beam of energy narrow intense beam of energy to shrink and cut tissue.to shrink and cut tissue.

lesion:lesion: a general term that a general term that refers to any change in tissue, refers to any change in tissue, such as tumor, blood, such as tumor, blood, malformation, infection or scar malformation, infection or scar tissue. tissue.

stereotactic:stereotactic: a precise method a precise method for locating deep brain for locating deep brain structures by the use of 3-structures by the use of 3-dimensional coordinates.dimensional coordinates.

ultrasonic aspirator:ultrasonic aspirator: a a surgical tool that uses a fine jet surgical tool that uses a fine jet of water, ultrasonic vibration, of water, ultrasonic vibration, and suction to break up and and suction to break up and remove lesions. remove lesions.

skull base surgeon:skull base surgeon: a doctor a doctor with special training to perform with special training to perform complex craniotomies at the complex craniotomies at the base of the skull.base of the skull.