Craniotomy

What is a Craniotomy?

The term “craniotomy” refers to the surgical removal of a part of the bone from the skull to expose the brain. Surgeons used specialized tools to temporarily remove the portion of bone called a bone flap ¹. This portion replaced in its original position after the surgery has completed and fastened into place with low-profile titanium plates and screws.

Types of Craniotomies

The name of craniotomy depends upon several factors like the location, size, and technology used in the procedure. Craniotomy performed in specific bone mentioned after the name of these bones such as frontal craniotomy, temporal craniotomy, occipital craniotomy, parietal craniotomy, etc. The commonly performed craniotomy includes:

Pterional Craniotomy

In this procedure, neurosurgeons make a small incision at the junction point of 4 bones within the skull (frontal, temporal, sphenoid, and parietal) to access and remove the tumor.

Eyebrow Craniotomy

Performed by making an incision within the eyebrow this type of Craniotomy accesses tumors in the front i.e. Rathke’s cleft cysts, skull base tumors, and pituitary tumors.

Keyhole Craniotomy

This procedure performed through a small hole behind the ear to remove lesions located deep into the brain i.e. meningioma, brain tumor, acoustic neuroma.

Orbito-zygomatic Craniotomy

This approach used to target and remove the difficult tumors and aneurysms by making an incision in the scalp behind the hairline and removing the bone that forms the contour of the orbit and cheek.

Trans-labyrinthine Craniotomy

This craniotomy also involves making an incision in the scalp behind the ear to remove the mastoid and some part of the inner ear bone, i.e. acoustic neuroma.

Awake craniotomy

During an awake craniotomy, the surgical team wakes up the patient during the surgery to check the response of the patient i.e. epilepsy surgery ².

Stereotactic craniotomy

This type of craniotomy performed by using a three-dimensional imaging technique like magnetic resonance imaging (MRI) or computerized tomography (CT) to detect the treatment area.

What are the indications of a Craniotomy?

A craniotomy gives access to the inside of the skull and performed for several reasons. Basic indications of craniotomy include:

• To remove brain tumors;
• To clip or repair a cerebral aneurysm (weakness of blood vessels);
• To remove hematoma (blood clot);
• To remove an arteriovenous malformation (AVM);
• To drain abscess;
• To repair fractures in the skull;
• To repair tissues covering the brain (dura mater);
• To relieve intracranial pressure by removing damaged or bulging areas of the brain;
• To remove epileptogenic lesion;
• To perform microvascular decompression surgery;
• To treat epilepsy;
• To implant hardware like deep brain stimulators, ventriculoperitoneal shunt, subdural electrodes to treat conditions like Parkinson’s disease, tremor, or dystonia;

Contraindications of a Craniotomy

The associated risk factors for craniotomy involve:

• Early age;
• Duration of operation;
• Surgical site;
• Cardio-pulmonary disease;
• Antibiotic prophylaxis;
• Steroid use;

During any surgery, complications may occur. Most common postoperative complications include ^4–6:

• Infections in soft tissue and bone flap;
• Intracranial hemorrhage and hematoma (blood clots);
• Leakage of cerebrospinal fluid (CSF);
• Extradural abscesses and subdural empyema;
• Cerebral infarct;
• Pneumocephalus (air in the cranial cavity);
• Unstable blood pressure;
• Neurologic impairments like dysphasia, seizures (3%) ¹, deterioration of consciousness;
• Memory problems;
• Speech difficulty;
• Paralysis;
• Coma;

The postoperative mortality after surgery for brain tumors by patients in the United States reported 1.3% in insured patients and 2.6% for uninsured patients ⁷.

Care and recovery after craniotomy

The amount of time required to recover after craniotomy always different for each person. Each patient’s vital signs monitored as they awake from anesthesia. A follow-up appointment for 10 to 14 days for every patient required after surgery. The recovery time varies from 1 to 4 weeks depending on the patient’s health condition. Full recovery may take up to 8 weeks. If a patient suffers from a significant pre-operative problem, an immediate appointment may require with the doctor.

References

1. Jiménez-Martínez E, Cuervo G, Hornero A, Ciercoles P, Gabarrós A, Cabellos C, Pelegrin I, García-Somoza D, Adamuz J, Carratalà J, et al. Risk factors for surgical site infection after craniotomy: A prospective cohort study. Antimicrobial Resistance and Infection Control. 2019;8(1):4–11. doi:10.1186/s13756-019-0525-3
2. Ghazanwy M, Chakrabarti R, Tewari A, Sinha A. Awake craniotomy: A qualitative review and future challenges. Saudi Journal of Anaesthesia. 2014;8(4):529–539. doi:10.4103/1658-354X.140890
3. Korinek A. Risk factors for neurosurgical site infections after craniotomy: a prospeKorinek, A. (1997). Risk factors for neurosurgical site infections after craniotomy: a prospective multicenter study of 2944 patients. Neurosurgery. Retrieved from http://journals.lw. Neurosurgery. 1997;41(5).
4. Chughtai KA, Nemer OP, Kessler AT, Bhatt AA. Post-operative complications of craniotomy and craniectomy. Emergency Radiology. 2019;26(1):99–107. doi:10.1007/s10140-018-1647-2
5. Lonjaret L, Guyonnet M, Berard E, Vironneau M, Peres F, Sacrista S, Ferrier A, Ramonda V, Vuillaume C, Roux FE, et al. Postoperative complications after craniotomy for brain tumor surgery. Anaesthesia Critical Care and Pain Medicine. 2017;36(4):213–218. doi:10.1016/j.accpm.2016.06.012
6. Tlimour IB, Cabantog AM, Bernstein M. Complications of First Craniotomy for. 1993:213–218.
7. Momin EN, Adams H, Shinohara RT, Frangakis C, Brem H, Quiñones-Hinojosa A. Postoperative mortality after surgery for brain tumors by patient insurance status in the United States. Archives of Surgery. 2012;147(11):1017–1024. doi:10.1001/archsurg.2012.1459