Craniotomy is a surgical procedure to chop a bony opening within the cranium. A piece of the cranium, known as a bone flap, is eliminated to entry the mind beneath. A craniotomy could also be small or giant relying on the issue. It might be carried out to deal with mind tumors, hematomas (blood clots), aneurysms or AVMs, traumatic head damage, overseas objects (bullets), swelling of the mind, or an infection. The bone flap is often changed on the finish of the process with tiny plates and screws.
What’s a craniotomy?
Craniotomies are named based on the world of cranium (skull) to be eliminated (Fig. 1). After the surgeon repairs the issue, the bone flap is then changed or coated with plates and screws. If the bone flap isn’t changed, the process known as a craniectomy.
Determine 1. Craniotomies are sometimes named for the bone being eliminated. Some widespread craniotomies embrace frontotemporal, parietal, temporal, and suboccipital.
Craniotomies range in dimension and complexity. Small dime-sized craniotomies are known as burr holes; “keyhole” craniotomies are quarter-sized or bigger. Stereotactic frames, image-guided pc techniques, or endoscopes could also be used to exactly place devices by way of these small holes. Burr holes and keyholes are used for minimally invasive procedures to:
- insert a shunt into the ventricle to empty cerebrospinal fluid (to deal with hydrocephalus)
- insert a deep mind stimulator (DBS)
- insert an intracranial strain (ICP) monitor
- take away a pattern of tissue cells (needle biopsy)
- drain a blood clot (hematoma aspiration)
- insert an endoscope to take away tumors
Complicated cranium base craniotomies contain the removing of bone that helps the underside of the mind the place delicate cranial nerves, arteries, and veins exit the cranium. Reconstruction of the cranium base might require the extra experience of head-and-neck, otologic, or plastic surgeons. Surgeons typically use image-guidance techniques to plan the entry for difficult-to-reach lesions to:
- take away deep mind tumors or AVMs; clip aneurysms
- take away tumors that invade the bony cranium
Whereas most cranium openings are made as small as doable, giant decompressive craniectomies are made to permit the mind to swell after a head trauma or stroke. The bone flap is frozen and changed months later after restoration (cranioplasty).
Awake craniotomies are carried out when a lesion is near vital speech areas. The affected person is asleep for the bone opening after which woke up to assist the surgeon map areas in danger. A probe is positioned on the mind floor when you learn or discuss. Known as mind mapping, this course of identifies your distinctive mind areas for speech and helps the surgeon keep away from and defend these features.
There are various sorts of craniotomies. Ask your neurosurgeon to explain the place the pores and skin incision can be made and the quantity of bone removing.
Who performs the process?
A craniotomy is carried out by a neurosurgeon; some have further coaching in cranium base surgical procedure. A neurosurgeon may match with a crew of head-and-neck, otologic, oculoplastic and reconstructive surgeons. Ask your neurosurgeon about their coaching, particularly in case your case is complicated.
What occurs earlier than surgical procedure?
The surgeon will clarify the process, its dangers and advantages, and you’ll have time to ask questions. Consent kinds are signed and paperwork accomplished to tell the surgeon about your medical historical past (e.g., allergic reactions, medicines, anesthesia reactions, earlier surgical procedures). Presurgical assessments (e.g., blood take a look at, electrocardiogram, chest X-ray) might have to be carried out a number of days earlier than surgical procedure. Seek the advice of your major care doctor about stopping sure drugs and guarantee you’re cleared for surgical procedure.
Cease taking all non-steroidal anti-inflammatory medicines (ibuprofen, naproxen, and many others.) and blood thinners (Coumadin, aspirin, Plavix, and many others.) 7 days earlier than surgical procedure. Cease utilizing nicotine and consuming alcohol 1 week earlier than and a couple of weeks after surgical procedure to keep away from bleeding and therapeutic issues.
If image-guided surgical procedure is deliberate, an MRI can be scheduled earlier than surgical procedure. Fiducials (small markers) could also be positioned in your brow and behind the ears. The markers assist align the preoperative MRI to the picture steering system. The fiducials should keep in place and can’t be moved or eliminated previous to surgical procedure to make sure the accuracy of the scan.
Chances are you’ll be requested to scrub your pores and skin and hair with Hibiclens (CHG) or Dial cleaning soap earlier than surgical procedure. It kills micro organism and reduces surgical website infections. (Keep away from getting CHG in eyes, ears, nostril or genital areas.)
Morning of surgical procedure
- No meals, drink, gum or sweet.
- Bathe utilizing antibacterial cleaning soap. Gown in freshly washed, loose-fitting clothes.
- Put on flat-heeled sneakers with closed backs.
- When you have directions to take common remedy the morning of surgical procedure, achieve this with small sips of water.
- Take away make-up, hairpins, hair extensions / weaves, contacts, physique piercings, nail polish, and many others.
- Depart all valuables and jewellery at house.
- Convey an inventory of medicines with dosages and the instances of day often taken.
- Convey an inventory of allergic reactions to remedy or meals.
Sufferers are admitted to the hospital the morning of surgical procedure. The nurse will clarify the preoperative course of and talk about any questions you’ll have. An anesthesiologist will discuss with you to clarify the results of anesthesia and its dangers.
What occurs throughout surgical procedure?
Relying on the underlying drawback being handled, the surgical procedure can take 3 to five hours or longer.
Step 1: put together the affected person You’ll lie on the working desk and be given basic anesthesia. As soon as you’re asleep, your head is positioned in a 3-pin cranium fixation machine that attaches to the desk and holds your head completely nonetheless throughout surgical procedure (Fig. 2). A brain-relaxing drug known as mannitol could also be given.
Determine 2. The affected person’s head is positioned in a three-pin Mayfield cranium clamp which holds the top completely nonetheless throughout delicate mind surgical procedure. The hair is shaved alongside the pores and skin incision line (dashed line).
If image-guidance is used, your head can be registered with the infrared cameras to correlate the “actual affected person” to the 3D pc mannequin created out of your MRI scans. The system features as a GPS to assist plan the craniotomy and find the lesion. Devices are detected by the cameras and displayed on the pc mannequin.
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Step 2: make a pores and skin incision The incision space of the scalp is prepped with an antiseptic. Pores and skin incisions are often made behind the hairline. A hair sparing method is used, the place solely a 1/4-inch large space alongside the proposed incision is shaved. Generally your complete incision space could also be shaved.
Step 3: carry out a craniotomy, open the cranium The pores and skin and muscle mass are lifted off the bone and folded again. Subsequent, small burr holes are made within the cranium with a drill. The burr holes enable entrance of a particular noticed known as a craniotome. Just like utilizing a jigsaw, the surgeon cuts a top level view of a bone window (Fig. 3). The lower bone flap is lifted and eliminated to show the protecting masking of the mind known as the dura. The bone flap is safely put aside and can be changed on the finish of the surgical procedure.
Determine 3. A craniotomy is lower with a particular noticed known as a craniotome. The bone flap is eliminated to disclose he protecting masking of the mind known as the dura.
Step 4: expose the mind The dura is opened to show the mind (Fig. 4). Retractors could also be used to softly open a hall between the mind and cranium. Surgeons use magnification glasses (loupes) or an working microscope to see the fragile nerves and vessels.
Determine 4. The dura is opened and folded again to show the mind.
Step 5: right the issue Enclosed contained in the bony cranium, the mind can’t be simply moved apart to entry and restore issues. Neurosurgeons use a wide range of very small devices to work deep contained in the mind. These embrace long-handled scissors, dissectors and drills, lasers, and ultrasonic aspirators (makes use of a superb jet of water to interrupt up tumors and suction up the items). In some circumstances, evoked potential monitoring is used to stimulate particular cranial nerves whereas the response is monitored within the mind. That is carried out to protect operate of the nerve throughout surgical procedure.
Step 6: shut the craniotomy After the issue has been eliminated or repaired, any retractors are eliminated, and the dura is closed with sutures. The bone flap is put again in its authentic place and secured to the cranium with titanium plates and screws (Fig. 5). The plates and screws stay completely to assist the world, they usually typically could be felt below your pores and skin. A drain could also be positioned below the pores and skin for a few days to take away blood or fluid from the world. The muscle mass and pores and skin are sutured again collectively. A comfortable adhesive dressing is positioned over the incision.
Determine 5. The bone flap is changed and secured to the cranium with tiny plates and screws.
What occurs after surgical procedure?
You might be taken to the restoration room the place important indicators are monitored as you awake from anesthesia. You could have a sore throat from the tube used to help your respiration. After you awaken, you’ll be moved to the intensive care unit (ICU) for shut monitoring. You might be ceaselessly requested to maneuver your arms, fingers, toes, and legs. A nurse will examine your pupils with a flashlight and ask questions, reminiscent of “What’s your title?” Chances are you’ll expertise nausea and headache after surgical procedure. Medicine can management these signs. Relying on the kind of mind surgical procedure, steroid remedy (to regulate mind swelling) and anticonvulsant remedy (to forestall seizures) could also be given. When your situation stabilizes, you’ll be transferred to an everyday room the place you’ll start to extend your exercise stage.
The size of the hospital keep varies, from solely 2-3 days or 2 weeks relying on the surgical procedure and any issues. When launched from the hospital, you’ll be given discharge directions.
Observe the surgeon’s house care directions for 2 weeks after surgical procedure or till your follow-up appointment. Generally, you’ll be able to anticipate:
- Don’t carry something heavier than 5 kilos.
- No strenuous exercise together with yard work, home tasks, and intercourse.
- Don’t drink alcohol. It thins the blood and will increase the chance of bleeding. Additionally, don’t combine alcohol with ache medicines.
- Don’t smoke or use nicotine merchandise: vape, dip, or chew. It might delay therapeutic.
- Don’t drive, return to work, or fly air journey till your surgeon says it’s OK.
- Chances are you’ll bathe the day after surgical procedure and wash your hair with gentle child shampoo. Gently wash the incision space with cleaning soap and water day-after-day. Don’t scrub or let the water beat arduous in your incision. Pat dry.
- If Dermabond pores and skin glue covers your incision, don’t rub or decide on the glue.
- Don’t submerge or soak the incision in a shower, pool or tub. Don’t apply lotion/ointment on the incision, together with hair styling merchandise.
- Chances are you’ll hear unusual noises (popping, crackling, ringing) inside your head. That is regular therapeutic as air and fluid reabsorb.
- Don’t shade your hair for six weeks. If you happen to lower your hair, use warning close to the incision.
- Complications are widespread after surgical procedure. Chances are you’ll take acetaminophen (Tylenol).
- Take ache medicines as directed by your surgeon. Cut back the quantity and frequency as your ache subsides. If you happen to don’t want the ache medication, don’t take it.
- Narcotics could cause constipation. Drink a number of water and eat high-fiber meals. Stool softeners and laxatives may also help transfer the bowels. Colace, Senokot, Dulcolax and Miralax are over-the-counter choices.
- Anti-seizure medication could also be prescribed. Some sufferers develop unwanted effects reminiscent of drowsiness, steadiness issues, or rashes. Name the workplace if any of those happen.
- Don’t take anti-inflammatory ache relievers (Advil, Aleve), blood thinners, or dietary supplements with out surgeon’s approval.
- Rise up and stroll 5-10 minutes each 3-4 hours. Steadily improve strolling as you’re able.
- Swelling and bruising of the attention or face might happen. It would take a number of weeks to go away.
- Sleep along with your head elevated and apply ice 3-4 instances per day for 15-20 minutes to assist cut back ache and swelling.
When to Name Your Physician
- Fever over 101.5º (unrelieved by Tylenol).
- Indicators of incision an infection, reminiscent of spreading redness, separation, or coloured drainage.
- Elevated drowsiness, weak point of arms / legs, elevated complications, vomiting, or extreme neck ache that forestalls decreasing your chin to chest.
- New or worsening imaginative and prescient, speech or confusion.
- Swelling on the incision with leaking of clear fluid out of your ear or nostril.
- Swelling and tenderness within the calf of 1 leg.
A follow-up appointment is made 10 to 14 days after surgical procedure. The restoration time varies from 1 to 4 weeks relying on the underlying illness being handled and your basic well being. Full restoration might take as much as 8 weeks. Strolling is an efficient method to start rising your exercise stage. Don’t overextend your self, particularly if you’re persevering with therapy with radiation or chemotherapy. Ask your surgeon when you’ll be able to anticipate to return to work.
What are the dangers?
No surgical procedure is with out dangers. Normal issues of any surgical procedure embrace bleeding, an infection, blood clots, and reactions to anesthesia. Particular issues associated to a craniotomy might embrace stroke, seizures, swelling of the mind, nerve harm, cerebrospinal fluid leak, and lack of some psychological features.
What are the outcomes?
The outcomes of your craniotomy depend upon the underlying situation being handled.
Sources & hyperlinks
When you have extra questions, please contact Mayfield Mind & Backbone at 800-325-7787 or 513-221-1100.
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biopsy: a pattern of tissue cells for examination below a microscope to find out the existence or reason behind a illness.
burr gap: a small dime-sized gap made within the cranium.
cerebrospinal fluid (CSF): a transparent fluid produced by the choroid plexus within the ventricles of the mind that bathes the mind and spinal twine giving them assist and buoyancy to guard from damage.
craniectomy: surgical removing of a portion of the cranium.
craniotome: a particular noticed with a footplate that permits reducing of the cranium with out reducing the dura mater.
craniotomy: surgical opening of a portion of the cranium to realize entry to the intracranial constructions and substitute of the bone flap.
dura mater: the outer protecting masking of the mind.
endoscopic-assisted surgical procedure: a process utilizing a probe (endoscope) fitted with a tiny digital camera and lightweight, which is inserted by way of a small keyhole craniotomy to take away a tumor.
laser: a tool that emits a slim intense beam of vitality to shrink and lower tissue.
lesion: a basic time period that refers to any change in tissue, reminiscent of tumor, blood, malformation, an infection or scar tissue.
minimally invasive surgical procedure: use of know-how (e.g., endoscopes, cameras, image-guidance techniques, robotics) to function by way of small, keyhole incisions within the physique.
image-guided surgical procedure: use of preoperative CT or MRI scans and a pc workstation to information surgical procedure.
seizure: uncontrollable convulsion, spasm, or sequence of jerking actions of the face, trunk, arms, or legs.
shunt: a drainage tube to maneuver cerebrospinal fluid from contained in the ventricles of the mind into one other physique cavity (e.g., stomach).
stroke: a situation attributable to interruption of the blood provide to the mind; might trigger lack of capability to talk or to maneuver elements of the physique.
stereotactic: a exact methodology for finding deep mind constructions by way of third-dimensional coordinates.
ultrasonic aspirator: a surgical instrument that makes use of a superb jet of water, ultrasonic vibration, and suction to interrupt up and take away lesions.
up to date > 1.2021 reviewed by > Vince DiNapoli, MD, PhD, Yair Gozal, MD, PhD, Mayfield Clinic, Cincinnati, Ohio