A craniotomy is a procedure done by a neurosurgeon to remove a part (bone flap) of the cranium (skull) temporarily to get access to the brain. This procedure is not done by itself but rather as a part of another surgery done either to the brain or surrounding tissues. The bone flap is put back in place once the surgery is complete.
Types of Craniotomy
A craniotomy is done in different ways depending on the type of surgery that follows it. The types of craniotomies are:
A traditional craniotomy where the bone flap or part of the skull is removed and put back in place once the surgery is complete.
A burr hole where only a small hole is made in the skull instead of removing a portion of the skull.
In stereotaxy the inside of the brain is viewed using a computer.
Craniotomy is done under general anesthesia. However, an awake craniotomy, is done while the patient is awake—that is using only local anesthesia.
Reasons for Craniotomy
A craniotomy can be done for following:
- Inspection the brain for visible problems.
- Serious brain injury or head trauma.
- Removal of blood clot or hematoma from the brain.
- Biopsy – to take tissue samples from the brain to test for cancer.
- To draining an abscess of the brain.
- Relieving pressure against the skull from swelling of the brain.
- Controlling hemorrhage from a leaking blood vessel — cerebral aneurysm.
- Repairing of blood vessel problems.
- Brain tumor or cancer.
- Nerve disorders.
- Infections in the brain.
To prepare for the surgery, tests are ordered by the doctor several days before the procedure. These tests include blood tests, chest x-ray, electrocardiogram as well as a brain scan b y MRI, CT, or PET.
The patient should not take anti-inflammatory medicines or blood thinners, for at least one week before the procedure. The doctor may prescribe medications to take prior to surgery to remove anxiety and/or prevent procedure swelling, infection or seizures after surgery.
The patient should stop smoking, chewing tobacco, and drinking alcohol for 1-2 weeks before the surgery since these are known to cause complications during and after surgery and thereby slowing down the healing process.
The patient should not eat or drink anything for at least 8 – 12 hours before the procedure.
Just before the procedure, the patient’s head is shaved over the area where the craniotomy will be done. The scalp is usually shaved in the shape of a small horse-shoe.
As a preparation for the procedure, general anesthesia is administered through an IV placed in the arm, before the surgery to put the patient to sleep completely. However, if the patient is undergoing an awake craniotomy, general anesthesia is given, but the patient will be awake for a part of the procedure. In case of stereotaxy, local anesthesia is administered only in the area of operation.
Once anesthesia takes effect and the patient is asleep, the head is help in a fixed position using a 3-pin skull fixation device. Next, a drain is placed in the lower back to drain off the cerebrospinal fluid secreted in the brain and passed through the spinal column. Removing the spinal fluid helps relieve pressure from the brain during surgery. The scalp is then prepped with an antiseptic and an incision made on the skin. The incision may be made either around the occipital bone at the nape of the neck or a curved incision above the ear and eye. Care is taken to avoid the hairline; however, if the surgeon thinks it is needed he may shave a part of the head and cut there.
Once the incision is made, the skin, muscles and tissues of the scalp are then folded back and the skull is exposed. Next, small holes are drilled in the skull using a high speed drill and a bone saw to cut out a flap through the holes. This bone flap is then removed to expose the brain tissues at the area the surgeon will do surgery or examination.
After surgery, the bone flap is put back in place and held with soft wires, plates and screws. The surgeon may choose to place a drain under the skin to remove blood and fluid from the site of the surgery. The drain may stay in place for 1-2 days. The skin and muscles are then sewn together. Finally, a bandage or dressing is put over the incision.
The complete procedure, from anesthesia to the wearing off of the anesthesia post-surgery, takes about 4-6 hours.
After the surgery, the patient is taken to the recovery room and watched closely. The vital signs (that is, temperature, blood pressure, heart rate, and breathing) are monitored. The breathing tubes and catheters are usually left in place and a drip may be put into a vein to give fluids. AFter the patient wakes up, the patient is then transferred to the ICU (intensive care unit) for further neurological observation. The patient is asked to do simple commands like move their hands, legs, fingers, toes to check for complications from surgery.
Nausea and headaches are common after a craniotomy. Medicines can be given to control these along with seizures and swelling in the brain following surgery.
If everything is going as expected, the patient is transferred to a regular hospital room, where the patient may stay for 3-14 days depending on the type of brain surgery and if there are any complications.
The patient is discharged with instructions to follow at home and to make an appointment to see the doctor in 7-10 days to have stitches or staple removed.
Risks and Complications
Complications from a craniotomy are usually of 3 types:
- those normally associated with any kind of surgery
- those related to the craniotomy procedure
- those related to the surgery done on brain and nerves after the craniotomy
The common risks associated with any type of surgery include bleeding; infections; blood clots; risks related to anesthesia like light-headedness, low blood pressure, etc.
Complications associated with the craniotomy include retention of fluid and later swelling of the brain.
Depending on the type of surgery done on the brain, complications can be unintentional damage to the brain tissues and nerves causing loss of brain functions (that is, problem with memory, thinking, speech or behavior) or even causing disabilities like deafness, blindness, double vision, loss of sense of smell, numbness, paralysis, problems with balance, seizures, or bowel and bladder problems. The risk of specific complications depends on which area of the brain is affected by the surgery.
Post-surgery Home Care
In order to speed up your recovery, the patient should get plenty of rest and eat a healthy diet. In addition, take all medications exactly as prescribed by the doctor for pain, swelling and/or seizures. Some pain medicines can cause constipation, which can be controlled by drinking plenty of water and eating food high in fiber.
Care should be taken of incision site. You can take a shower 3-4 days after surgery but don’t get the incision wet—wear a shower cap. The incision should be kept dry until the sutures are taken out and the skin heals. The sutures or staples are usually removed 7-10 days after surgery.
Depending on the type of the surgery, physical therapy, occupational therapy and/or speech therapy may be ordered. Therapy can help improve speech and strength and the ability to do activities of daily living. However, it is very common for the patient to fell tired. It is recommended that the patient build up activity levels only as tolerated.
Certain activities should be avoided, such as drinking alcoholic beverages; sitting for long periods of time; driving; lifting anything (including children) heavier than 5 pounds; housework or yard work like loading/unloading the washing machine or dishwasher, vacuuming, ironing, mowing the lawn or gardening.
Always follow your doctor’s instructions and call your doctor’s office if you have questions about your recovery or what you should be doing.
Call your doctor if:
- You have a temperature above 101°F
- Redness, swelling, drainage along with pain at the incision site
- Increased pain or seizure, which are not controlled with pain medicine
- Nausea, vomiting, drowsiness, weakness, neck pain or stiffness
- Any change in your mental status (like alertness, memory, thought process and/or consciousness)