Craniotomy Procedure
Overview
A craniotomy is a type of brain surgery where a surgeon carefully removes a part of the skull bone to access the brain. This procedure is used for various reasons, such as diagnosing or treating brain tumors, blood clots, aneurysms, vascular malformations, seizures, or relieving pressure caused by swelling after an injury or stroke.
Surgeons perform different types of craniotomies depending on the area of the brain being treated. Each type is named based on the location of the skull bone removed or the condition being addressed. In some cases, surgeons use smaller openingsāknown as keyhole craniotomiesāto reduce risk and speed up recovery.
Types of Craniotomy
| Type | Area of Skull | Common Uses |
|---|---|---|
| Bifrontal | Front, behind the hairline | Aneurysms, tumors |
| Supraorbital | Front, above/below eyebrow | Tumors, aneurysms |
| Eyebrow | Over eyebrow | Tumors |
| Pterional (Frontotemporal) | Above/around ear, temple area | Tumors, aneurysms, clots, epilepsy, malformations |
| Middle Fossa | Above the ear | Tumors, access via several approaches |
| Retrosigmoid Keyhole | Behind the ear | Aneurysms, acoustic neuroma |
| Suboccipital | Lower back of skull | Chiari malformations, tumors, aneurysms |
| Far Lateral Approach | Behind the ear | Tumor removal with endoscope |
The neurosurgical team uses specialized tools to cut and lift the skull bone, plans the operation using advanced imaging, and selects the most appropriate craniotomy approach for each case.
Guidance technology, called neuronavigation, may also be used to increase precision and protect healthy brain tissue. In certain cases, surgeons perform related procedures along with or after a craniotomy:
- Cranioplasty: Repairing or replacing skull bone after surgery.
- Craniectomy: Temporarily leaving the bone off to allow the brain to swell safely.
- Neuronavigation: Using technology to help guide the operation more accurately.
Common Conditions and Craniotomy Goals
| Condition | Purpose of Craniotomy |
|---|---|
| Brain tumor/Brain tumour | Tumor removal |
| Bleeding/Brain bleed | Stop bleeding, remove blood |
| Stroke | Relieve swelling, prevent damage |
| Aneurysm | Repair or clip vessel |
| Hematoma | Remove blood accumulation |
| Arteriovenous malformation (AVM) | Remove or repair vessels |
| Meningioma | Tumor removal |
These conditions include:
- Brain Tumors: Surgeons remove or sample abnormal growths.
- Aneurysms: Surgeons repair weak, bulging blood vessels at risk of rupturing.
- Blood Clots and Bleeding: Surgeons stop or clear pooled blood that can harm brain tissue.
- Vascular Malformations: Surgeons fix tangled or abnormally formed blood vessels.
- Epilepsy and Seizures: Surgery sometimes helps control seizures when medicines do not work.
- Relieving Pressure: Surgeons may use a craniotomy to ease swelling after trauma or stroke.
Possible Complications
Craniotomy carries several risks that patients should know about. Infection, bleeding, and blood clots are common concerns. Other issues include seizures, neurological injuries, and swelling of the brain.
Changes in smell, vision, or sensation can occur, as well as trouble with balance or coordination. There is also a risk for heart or lung problems, and cerebrospinal fluid (CSF) leaks may develop. Rarely, coma or death can result.
Getting Ready for Surgery
Eating, Drinking, and Taking Medicine
Before a craniotomy, the healthcare team provides detailed steps about food and medicine. Patients should share a full list of every medicine, supplement, or vitamin they take, including both prescription and over-the-counter products. They should also report any allergies, especially to medications or anesthesia.
Some medicines may need to be stopped for a certain amount of time before the surgery. Blood thinners are an example. If there’s any uncertainty, the patient should contact the healthcare team or a pharmacist.
For people who take medicine for diabetes, such as metformin, changes may be neededāespecially if contrast dye will be used during brain scans. The provider may advise the patient to stop certain diabetes medicines temporarily, depending on bloodwork results.
Patients might also receive antibiotics to lower the chance of infection or medication to help with anesthesia. Always ask the healthcare provider if any pre-surgery medicines are needed.
Patients must carefully follow instructions about when to stop eating and drinking before anesthesia. Most people need to stop eating by a certain time the night before surgery. Sometimes only clear liquids are allowed for a short while. This reduces the risk of complications during anesthesia.
Sample Pre-surgery Checklist
| Task | When to Do It | Notes |
|---|---|---|
| Tell staff about all medicines and allergies. | Before surgery. | Include all supplements and vitamins. |
| Discuss blood thinners or diabetes medicine. | Before surgery. | May need to pause or change medicines. |
| Stop eating food. | As instructed (often midnight before). | No solid food after designated time. |
| Only clear liquids allowed. | Up to a certain time before surgery. | Follow doctor’s instructions exactly. |
| Take pre-surgery medicine (if prescribed). | As instructed. | Ask if antibiotics or other drugs are needed. |
Important: Not following these directions can delay or cancel the procedure.
Patients must use only small sips of water if theyāre allowed to take medicine on the morning of surgery. Makeup, nail polish, and hair products should be avoided, as they can affect monitoring devices or sterility.
What You Can Expect
What Happens During Surgery
Before the procedure, staff may shave the patientās head to help prevent infection. Most people lie on their back during the operation, but sometimes the position changes to the side, stomach, or even sittingādepending on where the surgeon needs to reach.
A head frame often keeps the head still, though very young children typically do not use this device. During the surgery, a neurosurgeon makes a cut in the scalp and folds back the skin. Using a medical drill, the doctor carefully removes a section of the skull called a bone flap, which allows access to the brain.
The sturdy covering under the skull, called the dura mater, is then opened. If the surgery is for a brain tumor, some patients may receive a contrast dye that makes the tumor glow under special lights. This helps the surgeon distinguish it from normal brain tissue. The type of anesthesia can vary. Some patients receive general anesthesia and stay asleep throughout.
Others undergo an awake craniotomy, where the patient may wake up for part of the surgery. In these cases, only the scalp and brain are numbed, and sedatives help keep the patient calm. This approach allows doctors to test critical functions, like speech and movement, by asking questions or having the person name objects or move a limb during the operation.
Common Techniques and Tools
- Imaging Technology: The surgical team may perform MRI scans or use other imaging during surgery. These help confirm tumor size and location or guide the treatment of issues like aneurysms.
- Cortical Stimulation: Surgeons may apply tiny electrical currents to the brainās surfaceāa technique called cortical mappingāto identify areas responsible for essential functions such as speech or movement. This helps avoid damage to critical regions.
- Biopsy and Treatment: If the goal is to collect a tissue sample, the surgeon removes a small piece of brain tissue. For tumors, vascular issues, or aneurysms, the surgeon works directly on the target area. In cases of bleeding or blood clots, removing the blood relieves pressure on the brain.
The goal may be to completely remove a tumor. However, if itās near important brain regions, only part of the tumor might be removed. Additional treatments like chemotherapy or radiation can be given during or after surgery as needed.
After the brain work is complete, the dura is stitched and sealed. The bone flap is placed back onto the skull and secured with titanium plates, screws, wires, or stitches. Titanium is strong and MRI-safe. Finally, the scalp is closed with stitches or staples.
Overview Table of Steps During the Procedure
| Step | Description |
|---|---|
| Head is prepped | Hair often shaved, head may be placed in a frame |
| Scalp incision | Cut made through skin and muscle |
| Skull opening (bone flap) | Bone carefully removed to expose dura |
| Dura opened | Tough covering over the brain is cut |
| Procedure on brain | Tumor removal, biopsy, blood clot cleaning, or aneurysm repair |
| Use of imaging/cortical mapping | MRI, fluorescent dyes, and electrical mapping may be used |
| Dura closed | Dura sealed with stitches |
| Bone flap replaced | Bone fixed using titanium plates or other materials |
| Scalp closed | Skin closed with stitches or staples |
What Happens After Surgery
Once the surgery is complete, most patients have a small plastic tube, called a drain, leading out of their scalp. This tube lets extra fluid or blood drain away, and doctors usually remove it a few days later.
Within the first few days, doctors may perform an imaging scan such as MRI or CT to check if they treated the tumor or problem correctly. These tests help doctors see if any tumor remains or if there are other issues. Most people need to stay in the hospital for about 4 to 6 days.
The exact length depends on the personās health, the type of surgery, and if other treatments are needed. Recovery speed can vary. It often takes several weeks at home before people start feeling like themselves again. Typical events right after surgery:
- Doctors may leave drain tubes in place for up to three days.
- The team performs follow-up scans 1ā3 days after the procedure.
- Hospital recovery lasts up to 6 days in many cases.
- Full recovery at home generally takes several weeks.
- Headaches, tiredness, and trouble focusing are common but tend to slowly improve.
For people who were taking blood thinners before surgery, the healthcare team should discuss when to restart these medicines. It is also important to talk with them about which drugs are safe for pain relief, as some regular pain medicines may not be safe right after brain surgery.
Common Symptoms After Surgery
| Symptom | How long it can last | Management tips |
|---|---|---|
| Tiredness | Several weeks | Rest, slow return to normal activity |
| Headaches | Several days to weeks | Use approved medication, hydration |
| Trouble focusing | Days to weeks | Patience, involve family support |
| Swelling | Usually short-term | Follow up with doctor if worsening |
| Drainage | First few days | Doctors monitor amount and type |
If surgeons had to leave some tumor tissue behind, they may recommend more treatments like radiation, chemotherapy, or special medication put into the brain. Regular checkups help doctors look for complications and track healing speed.
People who had an awake craniotomy usually recover just like those who were fully asleep, though they may remember parts of the procedure. Following doctorās orders and asking questions about any symptoms helps support the healing journey. The healthcare team supports each step of recovery.
Findings
Most people will visit their healthcare team several times after a craniotomy. These follow-up visits help the care team check for issues and see how recovery is going. Doctors often order regular tests, such as MRI or CT scans, to look for signs of tumor return or other brain changes.
Doctors may also order blood tests to monitor overall health. If a surgeon removes a tumor, the team usually sends a sample to the lab to find out what kind of tumor it is. This information helps the team decide if further treatments like radiation or chemotherapy are necessary. Some common problems after surgery include:
- Headaches
- Memory problems
- Trouble walking or with balance
Recovery time depends on the patient and the exact reason for the surgery. Some might need more treatment or even a second surgery depending on test results.
