CRANIOTOMY
Surgical procedure in which a bone flap is temporarily
removed from the skull to access the brain.
Dr. Varun Kalia
• A craniotomy may be small or large depending on
the problem.
• It may be performed to treat brain tumors,
hematomas(blood clots), aneurysms, traumatic head
injury, foreign objects (bullets), swelling of the
brain, or infection. The bone flap is usually replaced
at the end of the procedure with tiny plates and
screws.
An aneurysm is a balloon-like bulge or
weakening of an artery wall.
Dr. Varun Kalia
CRANIECTOMY
If the bone flap is
not replaced, the
procedure is called a
craniectomy.
Dr. Varun Kalia
• Craniotomies vary in size and complexity.
• Small dime-sized craniotomies are called burr holes.
• "keyhole" craniotomies are quarter-sized or larger.
Dime size= 17.91
mm
Quarter size=
24.26 mm
Dr. Varun Kalia
Burr holes and keyholes are used for minimally
invasive procedures to:
• Insert a shunt into the ventricle to drain
cerebrospinal fluid (to treat hydrocephalus)
Dr. Varun Kalia
Burr holes and keyholes are used for minimally
invasive procedures to:
• Insert a deep brain stimulator (DBS)
Dr. Varun Kalia
Burr holes and keyholes are used for minimally
invasive procedures to:
• Insert an intracranial pressure (ICP) monitor
Dr. Varun Kalia
Burr holes and keyholes are used for minimally
invasive procedures to:
• Remove a sample of tissue cells (needle biopsy)
Dr. Varun Kalia
Burr holes and keyholes are used for minimally
invasive procedures to:
• Drain a blood clot (hematoma aspiration)
Dr. Varun Kalia
Burr holes and keyholes are used for minimally
invasive procedures to:
• Insert an endoscope to remove tumors
Dr. Varun Kalia
• Complex skull base craniotomies involve the
removal of bone that supports the bottom of the
brain where delicate cranial nerves, arteries, and
veins exit the skull.
• It can be use to remove deep brain tumors.
Dr. Varun Kalia
• While most skull openings are made as small as
possible, large decompressive craniectomies are
made to allow the brain to swell after a head trauma
or stroke. The bone flap is frozen and replaced
months later after recovery (cranioplasty).
Dr. Varun Kalia
• Awake craniotomies are performed when a lesion is
close to critical speech areas. The patient is asleep
for the bone opening and then awakened to help the
surgeon map areas at risk. A probe is placed on the
brain surface while you read or talk called brain
mapping, this process identifies your unique brain
areas for speech and helps the surgeon avoid and
protect these functions.
Dr. Varun Kalia
Preparations before surgery
• Several days before surgery, your primary care
physician will conduct tests (e.g.,
electrocardiogram, chest x-ray, and blood work) to
make sure that you are cleared for surgery.
• Discontinue all non-steroidal
anti-inflammatory medicines
and blood thinners typically
at least 1 week before surgery.
Dr. Varun Kalia
• Additionally, stop smoking, chewing tobacco, and
drinking alcohol 1 week before and 2 weeks after
surgery because these activities can cause bleeding
problems.
Dr. Varun Kalia
• Do not eat or drink after midnight the night before
surgery.
• MRI before surgery.
• In morning, Shower using antibacterial soap. Dress
in freshly washed, loose-fitting clothing.
• If you have instructions to take regular medication
in the morning of surgery, do so with small sips of
water.
• Remove make-up, hairpins, contact lens, body
piercings, etc.
Dr. Varun Kalia
Surgical Procedure
• Depending on the underlying problem being treated,
the surgery can take 3 to 5 hours or longer.
Dr. Varun Kalia
Patient Position
• You will lie on the
operating table and be
given general anesthesia.
Once you are asleep, your
head is placed in a 3-pin
skull fixation device that
attaches to the table and
holds your head absolutely
still during surgery.
• A brain-relaxing drug
called mannitol may be
given. Dr. Varun Kalia
Make a Skin Incision
• Make sure the incision area of the scalp is cleaned
with an antiseptic. A hair sparing technique is used,
where only a 1/4-inch wide area along the proposed
incision is shaved. Sometimes the entire incision
area may be shaved.
Dr. Varun Kalia
Open the Skull
• The skin and muscles are lifted off the bone and
folded back. Next, small burr holes are made in the
skull with a drill. The burr holes allow entrance of a
special saw called a craniotome.
Dr. Varun Kalia
• The surgeon cuts an outline of a bone window. The
cut bone flap is lifted and removed to expose the
protective covering of the brain called the dura. The
bone flap is safely set aside and will be replaced at
the end of the surgery.
Dr. Varun Kalia
Expose the Brain
• The dura is opened to expose the brain. Retractors
may be used to gently open a corridor between the
brain and skull. Neurosurgeons use magnification
glasses, called loupes, or an operating microscope to
see the delicate nerves and vessels.
Dr. Varun Kalia
Correct the Problem
• Enclosed inside the bony skull, the brain cannot be easily
moved aside to access and repair problems. Neurosurgeons
use a variety of very small instruments to work deep inside
the brain. These include long-handled scissors, dissectors
and drills, lasers, and ultrasonic aspirators (uses a fine jet of
water to break up tumors and suction up the pieces). In
some cases, evoked potential monitoring is used to
stimulate specific cranial nerves while the response is
monitored in the brain. This is done to preserve function of
the nerve during surgery. Dr. Varun Kalia
Close the Craniotomy
• After the problem has been removed or repaired, any
retractors are removed, and the dura is closed with sutures.
The bone flap is put back in its original position and secured
to the skull with titanium plates and screws. The plates and
screws remain permanently to support the area, and they
sometimes can be felt under your skin. Dr. Varun Kalia
• A drain may be placed under PT
the skin for a couple of days
to remove blood or fluid from
the area. The muscles and
skin are sutured back
together. A soft adhesive
dressing is placed over the
incision.
What happens after surgery?
• After surgery, you are taken to the recovery room where vital signs
are monitored as you awake from anesthesia.
• The breathing tube (ventilator) usually remains in place until you
fully recover from the anesthesia.
• You are frequently asked to move your arms, fingers, toes, and legs.
• A nurse will check your pupils with a flashlight and ask questions,
such as "What is your name?"
• You may experience nausea and headache after surgery. Medication
can control these symptoms.
• Depending on the type of brain surgery, steroid medication (to control
brain swelling) and anticonvulsant medication (to prevent seizures)
may be given.
• When your condition stabilizes, you’ll be transferred to a regular
room where you’ll begin to increase your activity level.
Dr. Varun Kalia
Discharge instructions
• After surgery, pain may be managed with narcotic medication.
Because narcotics are addictive, they are used for a limited period
of 2 to 4 weeks. Their regular use may also cause constipation, so
drink lots of water and eat high-fiber foods. Stool softeners (e.g.,
Colace, Docusate) and laxatives (e.g., Dulcolax, Senokot, Milk of
Magnesia) can be bought without a prescription. Thereafter, pain is
managed with acetaminophen (e.g., Tylenol).
• Ask your surgeon before taking nonsteroidal anti-inflammatory
drugs (NSAIDs). NSAIDs may cause bleeding and interfere with
bone healing.
• Anticonvulsant medicine may be prescribed to prevent seizures.
Some patients develop side effects like drowsiness, balance
problems, rashes from the anticonvulsants.
Dr. Varun Kalia
• Do not drive after surgery until discussed with your
surgeon and avoid sitting for long periods of time.
• Do not lift anything heavier than 5 pounds (e.g., 2-
liter bottle of soda), including children.
• Housework are not permitted until the first follow-
up. This includes gardening, vacuuming, ironing,
and loading/unloading the dishwasher, washer, or
dryer.
• Do not drink alcoholic beverages.
Dr. Varun Kalia
• You may shower and get your incision or sutures
wet. Use mild baby shampoo with no harsh
fragrances. Be careful not to let the water directly
hit your incision. Gently clean any old dried blood
from the incision area.
• Do not submerge your head in a bath.
• Inspect your incision daily and check for signs of
infection, such as swelling, redness, yellow or green
discharge, warm to the touch. Minimal swelling
around your incision is expected.
Dr. Varun Kalia
Risks
• No surgery is without risks. General complications
of any surgery include bleeding, infection, blood
clots, and reactions to anesthesia.
• Specific complications related to a craniotomy may
include stroke, seizures, swelling of the brain, nerve
damage, CSF leak, and loss of some mental
functions.
Dr. Varun Kalia
Mobility and Positioning Recommendations
• When lying down, keep head elevated using at least
two pillows.
• Move slowly when changing positions (e.g. going
from lying to sitting and from sitting to standing) to
avoid dizziness.
• Take frequent walks starting within your home and
progress to longer walks outdoors. Increase your
walking time based on your comfort and tolerance.
Dr. Varun Kalia
What to Avoid (for 2-4 weeks following your
surgery)
• Avoid bending over and putting your head in a lowered
position e.g., bending over toward the ground to tie your
shoes or picking up objects from the floor.
• For the first 2 weeks, do not lift anything greater than 10 lbs.
Then gradually increase the amount you lift as tolerated.
• Avoid straining or holding your breath.
• Do not participate in strenuous activity or pounding exercise
e.g., jogging. You are allowed to exercise for conditioning
but avoid exercises that will raise your blood pressure e.g.,
weight lifting or vigorous aerobic exercise.
• Avoid driving until cleared by your doctor.
Dr. Varun Kalia
