Craniotomy


By Dr Anand Dank
MBBS,MS Gen Surgery, M.Ch.(Neurosurgery), WFNS Fellow(Germany)
Sr. Consultant Neurosurgeon

Article Context

  1. Overview
  2. Benefits and risks
  3. Procedure
  4. Burr holes vs Craniotomy
  5. Care at Medicover
  6. Frequently Asked Questions

Craniotomy

A craniotomy is the temporary removal of a small portion of the skull bone. A neurosurgeon may perform a craniotomy to obtain access to the brain to treat a number of nervous system conditions.

According to the area of the skull that is involved, craniotomies are given different names. Different portions of the skull include frontal, parietal, occipital and suboccipital.The name of the craniotomy surgery is based on the portion of the skull.

Craniotomies can vary in location and size depending on the target that the surgeon must reach and the amount of working space needed to carry out a safe and successful operation.

craniotomy-overview

Indications:

A craniotomy may be done in cases of

  • Brain tumours (and when there is a need for biopsy)
  • Head trauma
  • Aneurysms
  • Blood clots/Brain Haemorrhage
  • Brain swelling
  • Infection
  • Hydrocephalus
  • Epilepsy
  • Arteriovenous malformations
  • Parkinson's disease
  • Severe nerve or facial pain (Trigeminal neuralgia)

Types:

There are many types of craniotomy including:

  • Craniotomy for assisted endoscopic surgery: Through a small incision, an instrument with a camera and a light is put into the skull for this surgery.
  • Stereotactic biospy through burrhole: To locate the part of the brain that requires treatment, a CT scan or an MRI is used.
  • Extended bifrontal craniotomy: An incision is made behind the hairline. The bone that forms the orbital and forehead shape is removed.
  • Minimally invasive supra-orbital eyebrow craniotomy: A small cut is made within the eyebrow. The benefits include lesser pain, fast recovery and minimal scarring.
  • Retro-sigmoid keyhole craniotomy: A small incision is made behind the ear. The benefits include minimal pain & scarring as well as fast recovery.
  • Orbitozygomatic craniotomy: The bone that contours the cheek and the eye socket is temporarily removed. This is done to minimise brain damage and get better access to the brain.
  • Translabyrinthine craniotomy: A cut is made behind the ear by removing bones including mastoid and inner ear bones. This often results in permanent hearing loss.

Benefits of craniotomy

  • Helps repair brain tissue
  • Helps diagnose neurological diseases
  • Helps drain abscess in the brain
  • Helps treat epilepsy (fits)
  • Relieves pressure in the brain caused by severe brain injury(DeCompression Craniectomy)

Risks associated with craniotomy

  • Common risks include bleeding, infections, and blood clots. Risks related to anaesthesia are lightheadedness and low blood pressure.
  • Retention of fluid and swelling of the brain.
  • Depending on the type of brain surgery, complications may include unintentional damage to the brain and nerves that impair memory, thinking, speech, or behaviour. They may also result in disabilities like deafness, blindness, double vision, numbness, paralysis, problems with balance, Loss of consciousness and coma, epilepsy, or issues with your bowels and bladder. As per Different Positions related Complications may happen.

Procedure

Protecting the integrity of the central nervous system is paramount for the patient undergoing craniotomy

Before the surgery

  • Detailed history and documentation of the patient’s preoperative neurological status is recorded.
  • Routine preoperative screening is performed (Complete blood count, BUN, serum creatinine, fasting blood glucose, chest x ray, ECG, blood grouping)
  • A week before the surgery, the patient must refrain from using any blood thinners. In order to reduce anxiety and to avoid postoperative swelling, infection, or seizures, the doctor may recommend taking medications.
  • Patients must avoid smoking, chewing tobacco, and consuming alcohol because these activities are known to result in difficulties during and after surgery. They may also slow down the healing process.
  • At least 8 to 12 hours prior to the surgery, the patient should not eat or drink anything.
  • Just prior to the procedure, the patient's skin is cleansed and the head is shaved, above the area where the craniotomy is to be performed.
  • XyloCocaine Sensitivity test & Inj.Tetanus to be taken.

During surgery

  • To sleep comfortably through the procedure, the patient is administered general anaesthesia through an IV placed in the arm/Neck.
  • Depending on where the problem is in the brain, the doctor then performs a surgical cut across the scalp that reveals the bone.
  • After the incision has been made, the skin, the muscles, and the tissues of the scalp are folded back, revealing the skull.
  • During surgery the affected area of the brain is inspected and the action is taken or the tumour is removed or a sample of the brain tissue is taken out. This helps with the diagnosis of the concerned nervous system diseases.
  • The bone flap is replaced using titanium plates and screws. They usually do not require further attention.
  • Based on the size of the incision, the scalp is closed with stitches and staples.
  • A dressing is applied which usually remains in place for the first 24- 48 hours after the surgery.
  • Once stable, the patient is moved to the ICU/Ward.

After the procedure

  • The patient is brought to the recovery area where a close eye can be kept on them.
  • The patients’ vital signs are monitored. A drip may be placed into a vein to administer fluids, and the breathing tubes and catheters are typically left in place.
  • Once the patient is awake, he/she is moved to the ICU for additional neurological monitoring. To check for any possible surgical complications, the patient is given basic instructions to move their hands, legs, fingers, and toes.
  • Nausea, headaches and swelling are common after the procedure. Medicines can be given to control these effects.
  • If everything goes well, the patient is moved to a regular hospital room. Depending on the situation and any possible complications, they may stay for 3 to 14 days(approximately).
  • The patient is given certain instructions and sent home. In the next 7 to 10 days he/she is advised to schedule a visit with the doctor for the removal of their staples/ sutures in the next 7 to 10 days or if any increased Headache /Drowsiness/Fever/Convulsions/any disability

Burr holes vs Craniotomy:

Based on the complexity of the disease, neurosurgeons suggest one of the two procedures to approach the nervous system.

CraniotomyBurr holes
In this procedure, the bone flap or large portion of the skull is removed and put back in place once the surgery is complete.In this, only a small hole is made in the skull instead of removing a portion of the skull.
The surgeon will have direct visualisation of the structures in the area being treated.Sometimes, the surgeon may insert a tube with a light and camera on the end. The surgery is performed with different tools placed through the endoscope. An MRI or CT scan can help to guide the doctor to the specific location.
Craniotomy is used for wide variety of diseases such as brain tumour, nerve disorders, aneurysms and infections of the brain.A surgeon may use a burr hole procedure to treat a subdural hematoma, or bleeding around the brain/ Stereotactic Biopsy.

Care at Medicover

At Medicover, we have the best team of neurosurgeons offering comprehensive diagnosis and treatment to get to the root of the problem and offer services with advanced technology tailored to suit the individual needs of the patients.



Frequently Asked Questions:

A craniotomy is a brain surgery that involves the temporary removal of bone from the skull to make repairs in the brain. It is highly intensive and comes with certain risks.

Yes, just like any other broken bone over time, the skull also heals itself.

Yes, after the operation, your hair will grow back where it had been shaved. Once the wound on your head is healed and any sutures or clips have been taken out, you can even wash your hair and use hair products as usual.

The side effects of craniotomy include head scarring, damage to sinuses, facial nerve damage, infection of the bone or flap and brain swelling.

After surgery, refrain from strenuous activities for 4 weeks. You can use walking as a workout. You may start to gradually resume your regular exercise 4 weeks after surgery. But do take advice from your doctor.

A regular craniotomy could take upto 3-5 hours.

In cases where the surgeon needs to operate close to the regions of your brain that regulate vision, movement or speech, you might need to be awake during surgery. It is done in Sleep -> Awake-> Sleep Cycles .

To fully heal from a brain surgery, it usually takes between 4 to 8 weeks. Your initial head incisions could hurt for up to a week following the procedure.

You have to wait four weeks following surgery before getting your hair coloured or trimmed. For four weeks after the surgery, avoid lifting, pushing, or pulling anything heavier than 4 to 5 kgs. If you feel unsteady, have someone help you to walk.

Headaches may develop within seven days of the craniotomy and persist for at least three whole months.

Citations:

  • https://www.beaumont.org/treatments/craniotomy-about
  • https://intermountainhealthcare.org/services/neurosciences/treatments/craniotomies/