CRANIOTOMY

Group Assignment for OTN Students

 Craniotomy

A craniotomy is the surgical removal of part of the bone from

the skull to expose the brain. Specialized tools are used to
remove the section of bone called the bone flap.

The bone flap is temporarily removed, then replaced after the

brain surgery has been done.
 Anatomy and Physiology Craniotomy
• There are many types of craniotomies described in the literature,
and a basic understanding of anatomy and physiology is
necessary to perform an adequate craniotomy with fewer
complications.

• The type of craniotomy is named depending on the skull bone,

which is opened. Typical skull bones targeted for craniotomy
include the frontal, parietal, temporal, and occipital bones.
 Cont.……

• Depending on the location of the pathology to be addressed,

supratentorial or infratentorial (posterior fossa) craniotomies can be
utilized.

• One of the most traditional craniotomies utilized is the pterional

craniotomy, a supratentorial craniotomy that can be utilized for
aneurysms of the anterior circulation, basilar tip artery aneurysms,
direct surgical approaches to the cavernous sinus, frontal and temporal
lobe tumors, as well as suprasellar tumors such as pituitary adenomas
and craniopharyngiomas.
 Cont.….
• Another type of supratentorial craniotomy is the temporal or subtemporal
craniotomy, which can be utilized for temporal lobe biopsy, temporal
lobectomy, temporal epilepsy surgery, temporal lobe tumors, as well as
access to the floor of the middle cranial fossa.

• The frontal craniotomy is used to access the frontal skull base and the
frontal lobe of the brain for approaches to the third ventricle or sellar
region tumors, craniopharyngiomas, plenum sphenoidale meningioma's,
frontal lobe tumors, and repair of anterior cerebrospinal fluid fistulas.
Cont.….
• Other types of craniotomies include parietal, occipital, retrosigmoid,
among many others.
 Indication craniotomy
A craniotomy may be used in the treatment and/ or diagnosis of a number of
conditions including

• Brain tumors.

• Brain haematoma.

• Aneurysms.

• Blood clots.

• Increased intracranial pressure (ICP), common after traumatic brain injury.

• Arteriovenous malformations (AVMs).

• Arteriovenous fistulas (AAVFs).

Cont.…..
• Arteriovenous malformations (AVMs).

• Arteriovenous fistulas (AVFs).

• Brain abscesses.

• Dura mater tear.

• Skull fractures.

• Epilepsy.

• To implant stimulator devices for movement disorders.

•

•
•
•
Contraindications craniotomy
There are very few contraindications to performing a craniotomy, and most
are related to the patient's general condition:

• Advanced age

• Poor functional status

• Severe cardiopulmonary disease

• Severe systemic collapse (sepsis, multiorgan failure)

• Pathologies that can be addressed by a single burr hole

• Altered preoperative coagulation parameters

• Bleeding disorders
 Types of craniotomy
• There are many types of craniotomies. Each type is named for the
technique or location used in the surgery.

A/ Stereotactic craniotomy
• If a craniotomy uses an MRI or CT scan, it’s called a stereotactic
craniotomy.

• In this procedure, your surgeon uses imaging tests to create three-

dimensional images of your brain. It allows them to distinguish
Cont.….
• Stereotactic techniques also help your surgeon find the best spot for a
scalp incision. This makes it easier to make smaller cuts and perform
minimally invasive procedures.

B / Endoscopic craniotomy
In an endoscopic craniotomy, your surgeon makes a tiny incision in
your skull. They insert an endoscope, which is a small lighted device
with a camera. This technique is often used with keyhole
craniotomies.
C/ Awake craniotomy

• An awake craniotomy is done while you’re awake. During

the surgery, your surgeons ask you questions while
monitoring your brain activity.

• As you reply, they’ll indicate what parts of the brain are

involved in speech, movement, and vision. This helps them
avoid these areas while performing the surgery.
D. Keyhole craniotomy

• A keyhole craniotomy is used to remove brain tumors. It’s a

minimally invasive surgery that’s associated with less scarring
and a shorter recovery time.

• Your surgeon makes a small cut behind your ear. They

remove the brain tumor through this incision.
E/ Supra-orbital ‘eyebrow’ craniotomy

• A supra-orbital “eyebrow” craniotomy is done to

remove brain tumors in the front of your brain.

• Your surgeon makes a small cut in your eyebrow.

It’s a minimally invasive approach that causes
minimal scarring.
F/ Pteronial (frontotemporal) craniotomy

• In the skull, the pterion is where the frontal, temporal,

sphenoid, and parietal bones meet. It’s found on the
side of your skull near your temple.

• A pteronial craniotomy, or frontotemporal craniotomy,

involves removing part of the pterion. Your surgeon
makes an incision behind your hairline, letting them
access numerous parts of the brain.
G/ Orbitozygomatic craniotomy
• Difficult tumors and aneurysms may be treated with an
orbitozygomatic craniotomy.

• It involves a small scalp incision behind your hairline. Your

surgeon temporarily removes part of the bone that creates
the curve of your orbit, or eye socket, and cheek.

• This lets your surgeon reach deeper regions of your brain

 H/ Posterior fossa craniotomy

• The posterior fossa is the lower part of the skull. It’s near the
brainstem and cerebellum, which controls balance and coordination.
• If there’s a tumor in the posterior fossa, it can place pressure on the
cerebellum, brainstem, and spinal cord.
• A posterior fossa craniotomy can remove the tumor and alleviate this
pressure. This is done through an incision at the base of your skull.
 I./Translabyrinthine craniotomy
• In a translabyrinthine craniotomy, your surgeon makes a cut behind your ear.
They remove part of the mastoid bone and the semicircular canals, which
help you balance.

• It’s used to remove an acoustic neuroma, also called a vestibular

schwannoma. An acoustic neuroma is a noncancerous tumor that forms on
the nerve that connects your inner ear and brain. It causes hearing loss and
balance issues.

• Removing the semicircular canals results in hearing loss. However, the surgery
 J/ Bifrontal craniotomy
• A bifrontal craniotomy, or extended bifrontal craniotomy,
is done to remove difficult tumors in front of the brain. It’s
often used if the tumor is too complex for minimally
invasive surgery.

• Your surgeon makes a cut behind your front hairline. They

remove a piece of the bone that forms the curve of your
forehead, letting them access the front of your brain.
Types of craniotomy picture
 Nursing Diagnosis
 Nursing diagnoses are developed from interpreting
and analyzing patient information to determine
whether there are specific (actual) or potential (risk
for) problems that the perioperative nurse needs to
consider in the plan of care. Neurosurgery patients
share common problems that the perioperative nurse
should address.
Nursing diagnosis
Anxiety related to surgery or surgical outcome

Deficient Knowledge related to diagnostic tests and

surgical procedures

Ineffective Breathing Pattern related to location of tumor,

surgical position, or effects of general anesthesia

Risk for Hypothermia

Risk for Perioperative Positioning Injury

 Outcome Identification
The patient will verbalize that anxiety is reduced or controlled.

 The patient or family will verbalize an understanding of the

diagnostic tests, surgical procedure, and postoperative plan of care.

The patient will maintain effective breathing patterns.

The patient will remain norm thermic.

The patient will be free from signs and symptoms of positioning

injury.
 Pre-operative Preparation

Physical examination:- In addition to a complete medical history,

your doctor will conduct a physical exam to ensure you are in good
health before you undergo surgery.

Blood tests:- Complete blood count (CBC) is ordered to know the

person's immunity and platelet status.

Arteriogram:- An arteriogram also referred to brain angiogram

involves insertion of catheter into a blood vessel and the
subsequent introduction of a contrast agent through the catheter.
 Cont.….
X-ray images are taken of the blood vessel that in turn reveals the extent of

damage of the blood vessel.

Brain scan:- MRI or CT scan is ordered for helping the surgeon study the

inner structures and brain nerves that are actually damaged and require

surgery for treatment.

Electrocardiogram:- An electrocardiogram gives idea of heart health of

patient to surgeon and whether the heart is capable to handle surgical

Cont.….

Preoperative neurological exam: -There will be a

preoperative neurological exam whose results will be
compared with a post operative exam.

Pregnancy:- If you suspect that you are pregnant or think

that you might get pregnant in few days before surgery,
discuss this with your doctor.
Cont.…
Sensitivities and allergies: It is better to tell your doctor
beforehand if you have allergies to certain anesthetic agents,
drugs, medicines, latex etc.

Medicines you are taking: Also show all your medicine

prescriptions to the doctor so that they know what all
medications you are on beforehand.
 Cont.…
Blood thinners:- If you are on any blood thinning prescription
drugs, do discuss the bleeding disorder with doctor. It may be
required to be discontinued as that causes blood clotting.

Quit smoking: -If you smoke, you should stop smoking as soon
as possible before the procedure to improve your chances of a
successful recovery from surgery and to improve your overall
health status.
 Equipment for craniotomy
A craniotomy is a surgical procedure that requires specific equipment. The
following are the requirements for being able to perform a craniotomy:

• High-speed pneumatic cranial drill (craniotome)

• Hudson brace handheld manual drill

• Freer elevator

• Penfield dissector

• Cranial plate fixation tray

Head-holder system if necessary, depending on the pathology to be addressed
 Procedure for a craniotomy

The general procedure for craniotomy includes the following steps.

The hair on your scalp is shaved.

You are given a general anesthetic.

Your head is placed on a round or horseshoe-shaped

headrest so that the area where the brain injury is thought to
lie is easily accessible. If head movement must be minimised,
your head is clamped into place with a head pin fixing device.
 Cont.…
Through preoperative imaging, the neurosurgeon determines the most

appropriate site for the craniotomy. The procedure begins by first cutting

through the scalp.

Small holes (burr holes) are drilled into the exposed skull with an instrument

called a perforator.

An instrument called a craniotomy is used to cut from one burr hole to the

next, creating a removable bone flap.

The membrane covering the brain is opened, usually as a flap.

 Complications from a craniotomy

Some of the possible complications of surgery can include:

Allergic reaction to the anaesthetic

Injury from the head pin fixing device

Injury to facial muscle

Injury to the sinuses

Infection of the bone flap

CONT…

• Seizures

• Bleeding

• Brain damage

• Brain swelling

• Stroke
 Post Procedure craniotomy

Immediately after procedure, you will be shifted either to a recovery room or

intensive care unit (ICU)depending on your condition. The respiratory support
is kept working till you regain consciousness and effects of anesthesia wear off.
You will be shifted out of ICU, once the vital signs are stable. Also, vital signs
are checked constantly even after shifting you to recovery room.

Few tests for assessing your nervous system changes and functioning are

done at regular intervals during your hospital stay.

CONT…

 A urinary catheter is placed in the bladder for collecting and draining

urine. A physiotherapist will teach you deep breathing exercises. Other
exercises are also taught to increase your mobility and strength.

 Compression devices will be placed on the legs that prevent formation

of blood clots.

 You are given instructions to come back to hospital in a week for taking
out sutures placed during surgery.
Call your doctor right away if you experience any of the
following symptoms after surgery:

• Fever .Confusion
Changes in vision .Seizures
• Bleeding or drainage from the incision site

• Extreme fatigue

• Speech troubles

•
 Summary cramniotomy

• In a craniotomy, your surgeon temporarily removes a piece of your skull and

operates on parts of your brain. They might do this to remove a tumor or
treat an aneurysm, among other reasons.

• Like all surgeries, a craniotomy can cause complications. Your surgeon will
create the best treatment plan to reduce your risk.

• Follow your doctor’s directions for at-home care. Contact them immediately
if you experience severe headaches, seizures, or signs of a wound infection.