What is a Craniotomy?
A craniotomy is a surgical procedure in which a section of the skull bone is removed to access the brain underneath in order to treat various conditions affecting the brain. The surgery is mostly performed under general anaesthesia and involves utilising specialised instruments to temporarily cut open a part of the skull bone called the bone flap, carry out the required repair of the brain, and replace the bone flap to its original position.
Indications for Craniotomy
A craniotomy may be indicated for several reasons, including, but not limited to, the following:
- Repairing or clipping of a cerebral aneurysm
- Removal of a brain abscess
- Treating, removing, or diagnosing brain tumours
- Removal of blood clots or blood from a leaking blood vessel in the brain
- Repairing of skull fractures
- Addressing an arteriovenous fistula or removal of an arteriovenous malformation
- Relieving intracranial pressure by removing swollen or damaged brain tissue
- Repairing a rupture or tear in the dura mater (membrane lining the brain)
- Placement of a stimulator device in the brain to treat conditions such as Parkinson’s disease
- Treatment of epilepsy
- Biopsy of abnormal brain tissue
Types of Craniotomy
Craniotomies are classified into different types based on the location of the surgical cut on the skull. Some of the common types of craniotomies include:
- Translabyrinthine craniotomy: In this type of procedure, your surgeon removes a section of the skull in a region behind the ear to access lesions or tumours in that region.
- Supraorbital craniotomy: This procedure is also known as eyebrow craniotomy and involves making a hole in the skull bone just on top of the eyebrows to access tumours or lesions close to the front of the head.
- Extended bifrontal craniotomy: During this type of procedure, your surgeon removes a portion of the skull just behind the hairline to access bleeds or tumours at the front of the brain.
- Orbitozygomatic craniotomy: This is an aggressive type of craniotomy procedure that involves removing a part of the skull just behind your scalp line (close to the cheeks) to access deep tumours like pituitary tumours.
- Retrosigmoid craniotomy: This is a minimally invasive type of surgery in which your surgeon makes a small “keyhole” incision in the skull bone just behind the ear to remove brain tumours.
Preparation for Craniotomy
Pre-procedure preparation for craniotomy will involve the following steps:
- A thorough examination by your doctor is performed to check for any medical issues that need to be addressed prior to surgery.
- Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure.
- You will be asked if you have allergies to medications, anaesthesia, or latex.
- You should inform your doctor of any medications, vitamins, or supplements that you are taking.
- You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for 1 to 2 weeks prior to surgery.
- You should refrain from alcohol or tobacco at least a week before and two weeks after surgery.
- You should not consume any solids or liquids at least 8 hours prior to surgery.
- You will be instructed to shower with an antibacterial soap the morning of surgery to help lower your risk of infection after surgery.
- Arrange for someone to drive you home as you will not be able to drive yourself after surgery.
- A written consent will be obtained from you after the surgical procedure has been explained in detail.
Procedure for Craniotomy
The craniotomy procedure is usually performed under general anaesthesia and takes about 3 to 5 hours or longer. In general, the procedure involves the following steps:
- You will be asked to take off any jewellery, clothing, or other objects that may obstruct the procedure and wear a hospital gown.
- An intravenous (IV) line will be inserted into your hand or arm to provide medicines and fluids.
- A urinary catheter will be inserted to drain your urine.
- You will be placed on the operating table in a way that gives your surgeon the best access to the side of the brain to be operated on.
- Your anesthesiologist will continuously monitor your vital signs throughout the surgery.
- Your head will be shaved and the surgical site will be cleaned with an antiseptic solution.
- Your head will be held in position by a Mayfield head holder or a similar device until the end of the surgery.
- Based on the location of the treatment area, an incision is made accordingly to remove the portion of the skull. Your surgeon may use special instruments such as a medical drill and a saw to make burr holes and cut the skull bone respectively. The removed bone flap will be saved and replaced after the procedure.
- The dura mater (outer covering of the brain) under the skull is cut open to expose the brain and the dura folds are secured with retractors.
- Your surgeon performs the required treatment such as removal of a blood clot, abscess, aneurysm, or tumour accordingly.
- Once the treatment is complete, the retractors are removed, the layers of tissue are stitched together, and the bone flap is reattached using wires, plates, or sutures.
- The skin incision is finally closed with surgical staples or stitches, and a sterile dressing or bandage is applied to complete the operation.
Postoperative Care and Recovery
In general, postoperative care instructions and recovery after a craniotomy will involve the following steps:
- You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anaesthetic reactions and monitor your vital signs as you recover. Frequent neurological checks will be performed by your medical staff to assess your brain function.
- The length of hospital stay varies from 2 to 3 days to a week or more depending on the type of craniotomy performed.
- You may experience pain, inflammation, and discomfort in the operated area. Pain and anti-inflammatory medications are provided as needed.
- Application of cold and heat therapy on the operated area is also recommended to reduce inflammation and pain.
- Antibiotics are prescribed as needed to address the risk of surgery-related infection.
- Keep the surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
- Refrain from smoking and alcohol for a specific period of time as it can negatively affect the healing process.
- Gentle neck stretches and regular walking is recommended to improve strength and endurance.
- Refrain from strenuous activities and lifting anything heavier than 5 pounds until the first follow-up visit. These activities include housework, yard work, gardening, mowing, etc.
- Gradual increase in activities over a period of time is recommended. You may take many weeks to return to your previous level of strength and energy.
- Refrain from driving until you are fully fit and receive your doctor’s consent.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications
Craniotomy is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as:
- Blood loss
- Blood clots or deep vein thrombosis
- Anaesthetic/allergic reactions
- Nerve damage
- Cerebrospinal fluid leakage
- Brain swelling
- Blood pressure fluctuation