CRANIOTOMY

A Craniotomy (opening a "window" in the skull) provides access to the brain in order to address abnormal conditions in the brain.

These conditions can be caused by:

• Trauma that results in swelling, bleeding, or tearing of the brain.
  
• Brain tumor that results from abnormal growth of cells. The surgeon's goal is to remove as much of the growth as possible.
  
• Aneurysm caused by ballooning of artery walls. The artery is repaired in order to prevent bleeding into the brain.
  
• An abnormal tangle of blood vessels called arteriovenous malformation (AVM) prevents normal blood flow and increases the risk of bleeding in the brain. The abnormal vessels are blocked so that blood flow resumes the normal pathway.

HOW ARE THESE CONDITIONS DIAGNOSED?

Your doctor will take a thorough history in the office, observing your gait, hearing, sight, thinking, memory, balance, coordination, reflexes, and assess the nature of sensations you experience.

Your doctor may order imaging tests in order to get pictures of the brain.
These tests could include:

• CT (computed tomography) or CAT scan. You will be placed in a scanner for a period of time so that a computer can record the x-rays. In order to enhance some of the structures of the brain, dye or "contrast" may be used.
  
• MRI (magnetic resonance imaging). This produces images using a magnet and radio waves. You will be placed on a sliding table that slides into a tube. You must lie absolutely still for a period of time while the magnet makes quite a racket. This may be ordered with or without contrast.
  
• Arteriogram: Dye is injected, then x-rays that show the arteries are taken. Be sure to tell the technician if you are allergic to iodine or shellfish.

PREPARATION FOR SURGERY

Medications:

• When surgery is elective, there are certain medications that are important to monitor before surgery. Your doctor will discuss this with you. The major medicine that needs to be discontinued includes blood thinners such as Coumadin, Heparin, and any kind of aspirin containing product or anti-inflammatory medication which is labeled as a non-steroidal anti- inflammatory (NSAID). NSAIDs include aspirin, ibuprofen, Advil, Motrin, Daypro, and Naprosyn. These medications have been associated with an increased incidence of blood clots after surgery, and we recommend that the medication be discontinued at least 7 days before surgery. This should be discussed with your surgeon and with the doctor who prescribes the medication.
  
• Your surgeon will order an exam before surgery. If you have a chronic condition such as heart problems, diabetes, or high blood pressure, be sure to advise your surgeon of that.

RISKS AND POSSIBLE COMPLICATIONS OF THE CRANIOTOMY:

As with any surgery, there are possible complications. For the craniotomy these include:

• Additional loss of brain function, including memory.
  
• Recurrence or continuation of the condition that required this operation.
  
• Stroke.
  
• Blindness, deafness, inability to smell, double vision, coordination loss, seizures, pain, weakness, numbness, and paralysis.
  
• Swelling or bleeding in the brain.
  
• Blood clots.
  
• Infection.
  
• Death.

There are four possible outcomes from any surgery:

1. Your symptoms or pain may be completely removed.
2. Your symptoms or pain may be partially removed.
3. Your symptoms or pain may be the same as before surgery.
4. Your symptoms or pain may be worse than before surgery.

Please discuss any questions or concerns with your doctor.

THE NIGHT BEFORE SURGERY

Eat or drink nothing at least 8 hours before surgery. General instructions are to eat or drink nothing after midnight. This includes food, water, coffee, and chewing gum. If you take medication regularly, you may take it with a small sip of water.

THE SURGERY

The surgeon makes an incision in your scalp. Small burr holes are drilled in the skull, marking the corners of a square or rectangle. The bone between the holes is cut and lifted away. The surgeon removes the least amount of bone possible. The brain is exposed by opening the dura, the outer covering of the brain.

The next step depends upon your particular condition.

• If there has been a brain injury, bleeding is stopped, and blood is removed. Damaged tissue may be removed.
  
• In the event of an aneurysm, the artery is sealed at the leak in order to prevent blood from leaking into the brain. If the aneurysm has ruptured, after the leak is sealed, the escaped blood is removed.
  
• In the event of a brain tumor, as much of the tumor as possible is removed.
  
• For an Arteriovenous Malformation (AVM), the abnormal arteries and veins are clipped in order to redirect blood flow to normal vessels and thereby prevent leaking blood into the brain.

When the problem has been addressed, the dura is closed. Usually the bone is replaced and may be held in place with screw plates or wire mesh. A small tube may be placed at the incision site to allow blood or fluid remaining in the brain tissue to drain for a few days. Usually, however, the burr holes are filled and covered immediately after surgery and the skin incision is closed with staples or stitches.

OTHER BRAIN PROCEDURES

SHUNTS may be done alone or in conjunction with other surgeries. A shunt is a drain that is used when there is excess spinal fluid. The drain directs excess fluid from the brain to the abdomen through a tube that is tunneled under the skin. The fluid is absorbed by the body once it reaches the abdomen.

STEREOTACTIC SURGERY involves three dimensional identification and targeting of intrabody structures which allows accurate access to parts of the brain that were previously difficult to reach. CT or MRI scans are used to locate the problem and precisely define the approach to it. A special frame for the head may be used to facilitate the surgery.

IN THE HOSPITAL

The Admission Procedure

• Report to the admission desk at the given time. When you get your wrist band, check for correct name and allergies.
  
• You will be escorted to a holding area where you will be given a gown and asked to remove any jewelry, watches, hairpins, etc.
  
• You will be given general anesthesia during surgery and the anesthesiologist will visit to discuss the anesthesia. Make certain you provide information about any medication or anything you are allergic to.
  
• The nurse will provide you with a consent form to sign. This acknowledges that you understand the procedure you are about to have as well as the risks and potential complications. If you have any questions that you need to ask your surgeon, be sure to let the nurses know.
  
• You will sign the "Texas Directive To Physicians" or advanced directives stating your wishes regarding life support should that need occur, and who you want to make decisions for you in the event you are unable to do so.
  
• It is permissible for one or two family members to be with you while you are in the holding area.
  
• An IV will be started.
  
• All or part of your head may be shaved in order to reduce the risk of infection.
  
• Craniotomy often takes 3 - 5 hours or more to complete.
  
• Family may wait in the surgical waiting area. The surgical nurses will usually call with updates during the surgical procedure. After the surgery is completed, the surgeon will speak to them. You will go to the post-anesthesia area for one to two hours and then will be taken to your room in an Intensive Care Unit where you can be closely monitored. Your family will be notified about your room number. You will later be moved from ICU to a hospital room.

AFTER SURGERY

You may have a headache upon waking after surgery and your surgeon will have given orders for medication for this. There may be monitors to measure pressure in the skull and heart rate. Until you are walking regularly, you will have special leg stockings to prevent blood clots. In the initial period after surgery, you may be placed on a ventilator to help you breathe.

When you are in a hospital room, you will be given breathing exercises to keep your lungs clear and you will be encouraged to increase your physical activity as soon as possible.

REHABILITATION

Occupational therapists and physical therapists will assess your strength and ability to perform daily activities. Therapists can work with you to improve strength, balance, speech, and daily living skills. The occupational therapist will evaluate your needs for safety at home and may suggest installing hand rails in bathrooms and in hallways.