To expose the brain, a craniotomy is the surgical removal of part of the bone from the skull. To extract the part of bone called the bone flap, specialized tools are used. After the brain procedure has been completed, the bone flap is briefly removed and replaced.
The guidance of computers and imaging (magnetic resonance imaging [MRI] or computerized tomography [CT] scans) can be used in certain craniotomy procedures to reach the exact position inside the brain to be treated. This technique involves the use of a frame mounted on the skull or a frameless device using markers or landmarks superficially placed on the scalp. It is called stereotactic craniotomy when one of these imaging techniques is used along with the craniotomy process.
In combination with these machines and localizing frames, brain scans offer a three-dimensional view of a tumor inside the brain, for example.
It is helpful in separating the tumor tissue from the healthy tissue and in reaching the exact position of the abnormal tissue.
Stereotactic biopsy of the brain (a needle is directed into an irregular region so that a fragment of tissue can be removed under a microscope for examination), stereotactic aspiration (fluid removal from abscesses, hematomas, or cysts), and stereotactic radiosurgery are other uses (such as gamma knife radiosurgery).
An endoscopic craniotomy is another form of craniotomy that involves inserting a lighted scope through a small incision in the skull with a camera into the brain.
Another surgical procedure which may involve a craniotomy is aneurysm clipping. A cerebral aneurysm (also referred to as an intracranial aneurysm or brain aneurysm) is a bulging region in the wall of the brain’s artery that is compromised, resulting in excessive enlargement or ballooning. There is a chance of rupture (bursting) of the aneurysm because of the damaged region in the artery wall. The placing of a metal clip around the “neck” of the aneurysm isolates the aneurysm by restricting the flow of blood from the rest of the circulatory system, thereby preventing rupture.
Craniectomy is a similar procedure during which, after swelling has reduced, a part of the skull is permanently removed or replaced later during a second operation.
Other related procedures that may be used to diagnose brain disorders include cerebral arteriogram , computed tomography (CT) scan of the brain , electroencephalogram (EEG) , magnetic resonance imaging (MRI) of the brain , positron emission tomography (PET) scan , and X-rays of the skull . Please see these procedures for additional information.
Extended Bifrontal Craniotomy
A conventional skull base technique used to target challenging tumors at the front of the brain is prolonged bifrontal craniotomy. It is based on the idea that the removal of extra bone is better than excessively manipulating the brain.
The prolonged bifrontal craniotomy involves making an incision behind the hairline in the scalp and extracting the bone that forms the orbit and forehead contour. At the end of surgery, this bone is replaced. The temporary removal of this bone enables surgeons to operate in the space between and right behind the eyes without having to manipulate the brain excessively.
For certain tumors that are not a candidate for removal by minimally invasive methods, extended bifrontal craniotomy is usually used regardless of either the tumor structure, the potential pathology of the tumor, or the objectives of surgery.
Types of tumors treated with the extended bifrontal craniotomy include meningiomas , esthesioneuroblastomas and malignant skull base tumors .
Minimally Invasive Supra-Orbital “Eyebrow” Craniotomy
Supra-orbital craniotomy (often called “eyebrow” craniotomy) is a procedure used to remove brain tumors. In this procedure, neurosurgeons make a small incision within the eyebrow to access tumors in the front of the brain or pituitary tumors . This approach is used instead of endonasal endoscopic surgery when a tumor is very large or close to the optic nerves or vital arteries.
Because it is a minimally invasive procedure, supra-orbital “eyebrow” craniotomy may offer
The supra-orbital craniotomy may be part of the treatment for Rathke’s cleft cysts, skull base tumors and some pituitary tumors.
Retro-Sigmoid “Keyhole” Craniotomy
Retro-sigmoid craniotomy (often called “keyhole” craniotomy) is a minimally-invasive surgical procedure performed to remove brain tumors. This procedure allows for the removal of skull base tumors through a small incision behind the ear, providing access to the cerebellum and brainstem. Neurosurgeons may use this approach to reach certain tumors, such as meningiomas and acoustic neuromas (vestibular schwannomas).
Benefits of “keyhole” craniotomy includes less pain after the procedure than after an open craniotomy, less scarring and a more rapid recovery.
The retro-sigmoid craniotomy may be performed for the following types of brain tumors:
Orbitozygomatic Craniotomy
A typical skull base technique used to target challenging tumors and aneurysms is the orbitozygomatic craniotomy. It is based on the idea that the removal of extra bone is better than excessively manipulating the brain.
Orbitozygomatic craniotomy, usually used for those lesions that are too complex for removal by more minimally invasive techniques, includes making an incision in the scalp below the hairline and extracting the bone that forms the orbit and cheek contour. At the end of surgery, this bone is replaced. Removing this bone temporarily enables surgeons to access deeper and more demanding areas of the brain while preventing permanent brain damage.
Craniopharyngiomas, pituitary tumors, and meningiomas include brain tumors that can be treated with orbitozygomatic craniotomy.
Translabyrinthine Craniotomy
A translabyrinthine craniotomy is a procedure involving the removal of the mastoid bone and some of the inner ear bone through an incision in the scalp behind the ear (specifically, the semicircular canals which contain receptors for balance). The surgeon will then identify and remove the tumor, or as much of the tumor as possible, without any chance of permanent brain injury.
Acoustic neuroma (vestibular schwannoma) is treated with one of three approaches: suboccipital, translabyrinthine, and middle fossa for translabyrinthine craniotomy.
The translabyrinthine solution is also considered when there is no beneficial hearing or hearing is to be sacrificed. The semicircular canals of the ear are cut during the translabyrinthine craniotomy in order to reach the tumor. As a result of the elimination of the semicircular canals, complete hearing loss occurs.
The risk of facial nerve damage can be minimized, while hearing is lost with translabyrinthine craniotomy.
A craniotomy may be done for a variety of reasons, including, but not limited to, the following:
There may be other reasons for your doctor to recommend a craniotomy.
Risks of the procedure
Complications can occur, as in any surgical procedure. The risk of brain surgery is related to the particular position in the brain that will be affected by the procedure. For example, if there is surgery on the part of the brain that regulates speech, then speech will be impaired. The following include but are not limited to several more general complications:
The following complications are uncommon and typically refer to particular locations within the brain, so for those individuals they may or may not be legitimate risks:
Depending upon your unique medical condition, there might be other dangers. Prior to the operation, make sure to address any questions with your doctor.
Before the procedure
During the procedure
A craniotomy generally requires a hospital stay of 3 to 7 days. You may also go to a rehabilitation unit for several days after your hospital stay. Procedures may vary depending on your condition and your doctor’s practices.
Generally, a craniotomy follows this process:
After the procedure
In the hospital
You will be taken to a recovery room for observation directly after the operation, before being taken to the intensive care unit (ICU) to be closely monitored. Or you may be brought from the operating room directly to the ICU.
You may be given medication to alleviate brain swelling in the ICU.
Depending on the type of operation performed and the type of anesthesia provided, the healing process can differ. You can be brought to the ICU or your hospital room until your blood pressure, pulse, and breathing are steady and you are alert.
You can move to a room in a neurosurgical nursing unit in the hospital after you remain in the ICU. You will stay for some more days in the hospital.
After surgery, you can need oxygen for a period of time. Oxygen is usually discontinued before you go home.
To help re-expand the lungs and avoid pneumonia, you will be taught deep-breathing exercises.
The nursing and medical staff will perform regular neurological examinations to assess your brain function and to ensure that your body systems function properly after your surgery. In order to test your brain capacity, you will be asked to obey a series of simple instructions, such as shifting your arms and legs. Your students will be tested with a flash light, and questions will be asked to determine your orientation (such as your name, the date, and where you are). There will also be checks on the strength of the arms and legs.
To avoid swelling of the face and ears, the head of your bed may be elevated. It is common to have some swelling.
When your strength increases, you will be able to move around as tolerated when in bed and to get out of bed and walk around with assistance at first.
You will be asked to assess your strength, balance, and mobility by a physical therapist (PT) and give you recommendations for exercises to do both in the hospital and at home.
To avoid blood clot formation, you would possibly have sequential compression devices (SCDs) put on your legs when you are in bed. SCDs have an air compressor that pumps air slowly into and out of tailored sleeves that are located on the thighs. By passively compressing the leg veins to keep blood flowing, they help prevent blood clots from developing.
A few hours after surgery, you might be given beverages to drink, depending on your condition. When you can tolerate them, your diet can be progressively adjusted to include more solid foods.
For a day or two, or before you can get out of bed and walk about, you can have a catheter in your bladder to remove your urine. As these may be signs of an infection that can be treated, be sure to report any painful urination or other urinary symptoms which occur after the catheter is removed.
You could be moved to a rehabilitation center for a period of time to recover your power, depending on your status.
Before you are released from the hospital, plans are made with your doctor for a follow-up appointment. You will also be given directions from your doctor for home treatment.
At home
It is crucial to keep the incision clean and dry until you are home. Relevant bathing instructions are given to you by your doctor. On a follow-up office visit, if stitches or surgical staples are used, they will be removed. Keep them dry if adhesive strips are used, and they may fall off within a few days.
A loose turban or hat over the incision may be worn. You should not wear a wig until the incision has healed completely (about 3 to 4 weeks after surgery).
There may be pain in the incision and head, especially with deep breathing, coughing, and exertion. As advised by your physician, take a pain reliever for soreness. The risk of bleeding can be increased by aspirin or other blood thinning medicines. Make sure only the recommended medications are taken and ask if you are uncertain.
To stop lung infection, continue the breathing exercises used in the hospital. To prevent exposure to upper respiratory illnesses (colds and flu) and irritants such as cigarette smoke, fumes, and pollutants to the atmosphere, you will be told.
When you can control them, you can progressively increase your physical activity. Returning to your previous energy and strength level can take several weeks.
To prevent pressure on your surgical incision, you might be advised to avoid lifting heavy objects for several weeks.
Do not drive until permission is given to you by your doctor.
Call your doctor to report any of the following:
Following a craniotomy, your doctor can give you other directions, depending on your particular circumstance.