A craniotomy is a surgical procedure opening the skull to treat conditions inside the skull cavity such as lesions of the brain.
A craniotomy is used when tumors inside the brain are pushing on the brain, hemorrhage (bleeding) in the brain from stroke, aneurysm, vascular malformation or trauma. In addition, craniotomy is used to treat intractable epilepsy, brain infections (abscess), hemifacial spasm and trigeminal neuralgia.
General anesthesia is used with a special technique called neuroanesthesia. This includes an arterial line for monitoring blood pressure accurately, central venous catheter line in a major central vein and a Foley urinary catheter. Sometimes stereotactic image guidance is used to navigate an accurate approach to the lesion inside the brain. This involves using computer guidance of the MRI or CT scanner. The head immobilized with sterile pins for accurate cranial fixation to prevent any intraoperative movement during microdissection. Special operating room tables are used for head and body positioning in the ideal orientation. Intraoperative MRI (BrainSUITE) is sometimes used for intraoperative imaging to identify the lesion and confirm the degree of lesion removal. Duration of craniotomy averages two hours but may require several hours longer.
Sometimes no hair is shaved. Sometimes a limited clipping is performed, and sometimes a full head hair removal is required. The scalp is prepped with sterilizing soap and alcohol.
The procedure starts with an opening of the scalp and then opening of the skull with a power drill and saw. The bone flap is preserved in a sterile manner to be replaced at the conclusion of the operation. The dura (lining of the brain) is opened next followed by dissection of the brain. Sometimes the brain tissue is held in position with a delicate mechanical retractor arm. The operating microscope is oftentimes used to magnify the intracranial structures for accurate microdissection. In addition, stereotactic navigation with imaging guidance similar to a GPS in an automobile is used to accurately identify the lesion and important adjacent neurologic structures. The lesion is removed with various instruments including microdissecting instruments. An ultrasonic micro aspirator, occasionally a laser, and ultrasound are sometimes used. The intraoperative MRI scan can be performed if needed to confirm the amount of lesion removal. Bleeding is controlled with various coagulation and hemostatic agents. Closure starts by suturing the dura, replacement of the bone flap (secured with plates and screws) and then closure of the soft tissues including the scalp. Various bandages are applied to the scalp.
All craniotomies are observed first in the post-anesthesia care unit (recovery room) and then in the intensive care unit for a minimum of one to three days. A postoperative CT scan of the brain is performed the morning after surgery to check for delayed bleeding, swelling, or fluid retention in th e brain. A postoperative angiogram may be required at some time. After ICU, the patient is observed in a regular hospital ward for two to five days. Physical therapy and occupational therapy may or may not be required. Ventilator support is rarely but sometimes required in the ICU after craniotomy. Discharge home with adult supervision is recommended for the first two days up to a few weeks depending on the outcome of the surgery and the diagnosis. Office work can be resumed approximately four weeks postoperatively. Driving is resumed as instructed by the physician and medical staff postoperative.
Possible stroke, paralysis, numbness, vision change, memory loss, personality change or seizures are recognized potential complications. These are carefully evaluated and treated by the medical staff and are the reasons for postoperative observation in the hospital. These conditions are oftentimes just temporary, but they could be permanent. Death or permanent coma is a rare complication of modern craniotomy techniques.
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