Overview

Craniotomy is a surgery to cut a bony opened in the skull. A ar of the skull, referred to as a bone flap, is eliminated to access the brain underneath. A craniotomy might be small or big depending on the problem. It might be performed to treat mind tumors, hematomas (blood clots), aneurysms or AVMs, traumatic head injury, foreign objects (bullets), swelling of the brain, or infection. The bone flap is usually changed at the finish of the procedure through tiny plates and also screws.

What is a craniotomy?

Craniotomies are named according to the area the skull (cranium) come be eliminated (Fig. 1). ~ the surgeon repairs the problem, the bone flap is then changed or covered with plates and also screws. If the bone flap is not replaced, the procedure is referred to as a craniectomy.


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number 1. Craniotomies are regularly named because that the bone gift removed. Some typical craniotomies include frontotemporal, parietal, temporal, and suboccipital.

Craniotomies vary in size and complexity. Tiny dime-sized craniotomies are called burr holes; "keyhole" craniotomies room quarter-sized or larger. Stereotactic frames, image-guided computer system systems, or endoscopes might be offered to exactly place tools through these little holes. Burr holes and keyholes are used for minimally invasive actions to:

insert a shunt right into the ventricle to drainpipe cerebrospinal fluid (to act hydrocephalus) insert one intracranial push (ICP) monitor remove a sample of organization cells (needle biopsy) drain a blood gerean (hematoma aspiration) insert one endoscope to eliminate tumors

Complex skull base craniotomies show off the removed of bone the supports the bottom of the mind where delicate cranial nerves, arteries, and veins leave the skull. Restoration of the skull base may require the added expertise of head-and-neck, otologic, or plastic surgeons. Surgeons frequently use image-guidance equipment to arrangement the accessibility for difficult-to-reach lesions to:

remove deep mind tumors or AVMs; clip aneurysms remove tumors that invade the bony skull

While most skull openings are made as tiny as possible, large decompressive craniectomies are made to enable the mind to swell after a head trauma or stroke. The bone flap is frozen and also replaced months later after recovery (cranioplasty).

You are watching: The surgical incision into the skull is

Awake craniotomies space performed when a lesion is near to an important speech areas. The patience is asleep for the bone opening and also then awakened to help the operated doctor map areas at risk. A probe is placed on the brain surface when you review or talk. Called brain mapping, this procedure identifies your unique brain areas for speech and also helps the operated doctor avoid and also protect this functions.

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

who performs the procedure?

A craniotomy is performed by a neurosurgeon; part have added training in skull basic surgery. A neurosurgeon might work with a team of head-and-neck, otologic, oculoplastic and reconstructive surgeons. Ask your neurosurgeon around their training, especially if your situation is complex.

What happens prior to surgery?

The operated doctor will define the procedure, that risks and also benefits, and also you will have time come ask questions. Consent forms are signed and also paperwork perfect to educate the surgeon around your medical background (e.g., allergies, medicines, anesthesia reactions, ahead surgeries). Presurgical test (e.g., blood test, electrocardiogram, chest X-ray) might need to it is in done several days prior to surgery. Consult your primary care physician about stopping certain medications and ensure you room cleared for surgery.

Stop acquisition all non-steroidal anti-inflammatory medicines (ibuprofen, naproxen, etc.) and blood thinners (Coumadin, aspirin, Plavix, etc.) 7 days prior to surgery. Avoid using nicotine and drinking alcohol 1 mainly before and 2 mainly after surgical treatment to avoid bleeding and healing problems.

If image-guided surgical procedure is planned, one MRI will be scheduled prior to surgery. Fiducials (small markers) may be put on your forehead and behind the ears. The markers help align the preoperative MRI to the picture guidance system. The fiducials must stay in place and also cannot be relocated or removed prior to surgery to ensure the accuracy of the scan.

You may be asked to wash your skin and also hair v Hibiclens (CHG) or Dial soap before surgery. It kills bacteria and reduces surgical website infections. (Avoid getting CHG in eyes, ears, nose or genital areas.)

Morning the surgery

No food, drink, gum or candy. Shower using antibacterial soap. Dress in freshly washed, loose-fitting clothing. Undertake flat-heeled shoes with closed backs. If you have instructions come take continuous medication the morning of surgery, do so with little sips of water. Remove make-up, hairpins, hair extensions / weaves, contacts, human body piercings, nail polish, etc. Leaving all valuables and also jewelry at home. Lug a perform of medications with dosages and the time of day normally taken. Carry a list of allergy to medicine or foods.

Patients are admitted to the hospital the morning that surgery. The nurse will define the preoperative procedure and discuss any type of questions you might have. One anesthesiologist will certainly talk v you to define the effects of anesthesia and its risks.

What happens throughout surgery?

relying on the underlying trouble being treated, the surgery have the right to take 3 to 5 hours or longer.

Step 1: prepare the patience You will certainly lie top top the operating table and also be given basic anesthesia. Once you room asleep, her head is put in a 3-pin skull fixation maker that attaches come the table and holds her head absolutely still throughout surgery (Fig. 2). A brain-relaxing drug called mannitol might be given.


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number 2. The patient’s head is put in a three-pin Mayfield skull clamp i m sorry holds the head absolutely still during delicate brain surgery. The hair is shaved follow me the skin incision heat (dashed line).

If image-guidance is used, her head will be registered with the infrared cameras to correlate the “real patient” come the 3D computer system model created from your MRI scans. The system functions as a general practitioners to aid plan the craniotomy and locate the lesion. Instruments are detect by the cameras and also displayed ~ above the computer system model.

Step 2: make a skin incision The scratch area that the scalp is prepped through an antiseptic. Skin incisions space usually made behind the hairline. A hair sparing method is used, where only a 1/4-inch broad area along the proposed scratch is shaved. Occasionally the entire incision area may be shaved.

Step 3: do a craniotomy, open the skull The skin and also muscles room lifted off the bone and also folded back. Next, tiny burr holes room made in the skull v a drill. The burr holes permit entrance the a unique saw referred to as a craniotome. Similar to making use of a jigsaw, the surgeon cut an overview of a bone window (Fig. 3). The reduced bone flap is lifted and removed to disclose the protective extending of the brain called the dura. The bone flap is safely set aside and will be replaced at the end of the surgery.


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figure 3. A craniotomy is reduced with a distinct saw referred to as a craniotome. The bone flap is removed to expose he protective spanning of the brain called the dura.

Step 4: expose the brain The dura is opened up to disclose the mind (Fig. 4). Retractors might be offered to gently open up a corridor in between the brain and skull. Surgeons usage magnification glasses (loupes) or an operating microscopic lense to view the vulnerable nerves and also vessels.


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number 4. The dura is opened and folded back to reveal the brain.

Step 5: exactly the problem Enclosed inside the bony skull, the mind cannot be easily moved next to access and repair problems. Neurosurgeons use a selection of very tiny instruments to job-related deep within the brain. These encompass long-handled scissors, dissectors and also drills, lasers, and ultrasonic aspirators (uses a good jet of water to rest up tumors and suction up the pieces). In part cases, evoked potential surveillance is supplied to stimulate particular cranial nerves if the response is monitored in the brain. This is done to preserve function of the nerve during surgery.

Step 6: near the craniotomy after the problem has been gotten rid of or repaired, any type of retractors space removed, and the dura is closed v sutures. The bone flap is put back in its initial position and secured to the skull through titanium plates and screws (Fig. 5). The plates and screws remain permanently to support the area, and they sometimes have the right to be felt under her skin. A drainpipe may be put under the skin for a couple of days to eliminate blood or fluid from the area. The muscles and skin are sutured earlier together. A soft adhesive dressing is placed over the incision.


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figure 5. The bone flap is replaced and secured to the skull with tiny plates and screws.

What wake up after surgery?

You space taken to the restore room where vital signs are monitored as you awake from anesthesia. You may have actually a sore throat from the tube supplied to help your breathing. After you awaken, you’ll be moved to the intensive treatment unit (ICU) because that close monitoring. Friend are frequently asked to relocate your arms, fingers, toes, and also legs. A nurse will examine your pupils with a flashlight and ask questions, such as "What is her name?" You might experience nausea and headache after ~ surgery. Medication can regulate these symptoms. Relying on the form of brain surgery, steroid medicine (to control brain swelling) and anticonvulsant medication (to avoid seizures) may be given. Once your condition stabilizes, you’ll be moved to a continual room where you’ll begin to increase your task level.

The size of the hospital stay varies, from just 2–3 job or 2 weeks depending on the surgery and also any complications. When released from the hospital, you’ll be offered discharge instructions.

Follow the surgeon’s home care instructions for 2 weeks after ~ surgery or until your follow-up appointment. In general, you deserve to expect:

Restrictions

don’t lift noþeles heavier than 5 pounds. No strenuous task including garden work, housework, and also sex. Don’t drink alcohol. The thins the blood and also increases the hazard of bleeding. Also, nothing mix alcohol v pain medicines. Nothing smoke or use nicotine products: vape, dip, or chew. The may delay healing. Don’t drive, go back to work, or fly air take trip until her surgeon says it’s OK.

Incision Care

You may shower the day after surgery and wash your hair v mild infant shampoo. Gently to wash the incision area through soap and water every day. Nothing scrub or allow the water beat tough on your incision. Beat dry. If Dermabond skin adhesive covers her incision, don’t rub or choose at the glue. nothing submerge or soak the incision in a bath, swimming pool or tub. Don’t use lotion/ointment on the incision, including hair styling products. You might hear strange noises (popping, crackling, ringing) inside her head. This is typical healing as air and also fluid reabsorb. Don’t shade your hair for 6 weeks. If you reduced your hair, usage caution near the incision.

Medications

Headaches are common after surgery. You may take paracetamol (Tylenol). Take it pain medications as command by her surgeon. Alleviate the amount and also frequency together your pains subsides. If girlfriend don’t need the pains medicine, don’t take it it. Narcotics can reason constipation. Drink lots of water and eat high-fiber foods. Stool softeners and laxatives can aid move the bowels. Colace, Senokot, Dulcolax and Miralax are over-the-counter options. Anti-seizure medicine might be prescribed. Some patients develop side results such together drowsiness, balance problems, or rashes. Contact the office if any type of of this occur. Don’t take anti-inflammatory pains relievers (Advil, Aleve), blood thinners, or supplements without surgeon’s approval.

Activity

obtain up and walk 5-10 minutes every 3-4 hours. Slowly increase walking together you room able. Swelling and also bruising the the eye or challenge may occur. It will take several weeks to walk away. Sleep through your head elevated and also apply ice 3-4 times every day because that 15-20 minute to help reduce pain and also swelling.

When to speak to Your Doctor

fever over 101.5º (unrelieved through Tylenol). signs of scratch infection, together as spreading redness, separation, or fancy drainage. increased drowsiness, weak of arms / legs, enhanced headaches, vomiting, or serious neck pain that avoids lowering your chin to chest. new or worsening vision, speech or confusion. ede at the incision with leaking the clear fluid from your ear or nose. Swelling and also tenderness in the calf that one leg. Seizure

Recovery

A follow-up appointment is make 10 come 14 work after surgery. The recovery time different from 1 come 4 weeks depending upon the underlying disease being treated and also your basic health. Full recovery may take up to 8 weeks. Walking is a good way to begin increasing your activity level. Do not overextend yourself, especially if you are proceeding treatment v radiation or chemotherapy. Ask your surgeon when you can expect to go back to work.

What room the risks?

No surgery is without risks. Basic complications of any surgery include bleeding, infection, blood clots, and also reactions come anesthesia. Details complications related to a craniotomy may include stroke, seizures, swelling of the brain, nerve damage, cerebrospinal liquid leak, and also loss of some psychological functions.

What space the results?

The outcomes of your craniotomy rely on the underlying problem being treated.

Sources & links

If friend have much more questions, please contact Mayfield mind & Spine at 800-325-7787 or 513-221-1100.

Glossary

biopsy: a sample of organization cells because that examination under a microscope to identify the presence or cause of a disease.

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

cerebrospinal liquid (CSF): a clear fluid developed by the choroid plexus in the ventricles that the brain that bathes the mind and spinal cord providing them support and buoyancy to safeguard from injury.

craniectomy: surgical removal that a section of the skull.

craniotome: a one-of-a-kind saw v a footplate that permits cutting the the skull there is no cutting the dura mater.

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

dura mater: the external protective extending of the brain.

endoscopic-assisted surgery: a procedure making use of a probe (endoscope) fitted with a small camera and also light, i m sorry is placed through a small keyhole craniotomy to eliminate a tumor.

laser: a machine that emits a small intense beam of energy to shrink and also cut tissue.

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

minimally invasive surgery: use of technology (e.g., endoscopes, cameras, image-guidance systems, robotics) to operate through small, keyhole incisions in the body.

image-guided surgery: usage of preoperative CT or MRI scans and also a computer system workstation to overview surgery.

seizure: uncontrollable convulsion, spasm, or series of jerking activities of the face, trunk, arms, or legs.

shunt: a drainage tube to relocate cerebrospinal liquid from inside the ventricles that the mind into one more body cavity (e.g., abdomen).

stroke: a problem caused by interruption of the blood it is provided to the brain; may cause loss of ability to speak or to move parts that the body.

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stereotactic: a precise an approach for locating deep mind structures through the usage of 3-dimensional coordinates.

ultrasonic aspirator: a surgical tool that offers a fine jet the water, ultrasonic vibration, and suction to rest up and also remove lesions.

updated > 1.2021 reviewed by > Vince DiNapoli, MD, PhD, Yair Gozal, MD, PhD, Mayfield Clinic, Cincinnati, Ohio