Craniotomy

A craniotomy is the surgical removal of a section of bone (bone flap) from the skull for the
purpose of operating on the underlying tissues, usually the brain. The bone flap is replaced
at the end of the procedure. If the bone flap is not replaced, the procedure is called a
craniectomy. A craniotomy is used for many different procedures within the head; for trauma,
tumor, infection, etc.

Anatomy

At birth the bones that make up the cranium or skull are separated, allowing the head to
pass through the birth canal. (figure 1) As the individual matures, the bones fuse together so
that by late teens the bones form a solid union.

Figure 1

The various bones of the skull are the frontal, parietal, temporal, occipital, and sphenoid
(Figure 2).
 Figure 2

The scalp covers the skull. Within the skull lie:

The brain
The meninges (the membranes that line the inside of the Skull (dura) and cover the
brain (pia-arachnoid)
The blood vessels that feed the brain
The fluid that bathes the brain

Additional anatomy information

All of the above structures may give rise to disease.

Pathology

There are a variety of lesions (abnormalities) that affect the skull and its contents that
require a craniotomy or craniectomy for exposure or removal.

Skull. The most common lesions of the skull are benign tumors
Brain. The most common lesions of the brain that require craniotomies are
o 1. tumors of the supporting cells of the brain called gliomas
o 2. cancers from other organs that have gone (metastasized) to the brain
(figure C)
 Figure C. Two metastatic tumors to the brain removed
using frameless stereotaxic image guided surgery through
small craniotomies (4 by 4 cm). Cerebrospinal fluid fills the
cavities left by removal of the tumors. The small
craniotomies directly over the tumors allowed the patient to
be discharged the day after surgery.
o 3. abscess (localized infection)
Meninges. These tissues give rise to mostly benign tumors called meningiomas that
may grow quite large and compress the brain causing damage (figure D)

Figure D. Large benign tumor (meningioma) before and

after removal. The cavity formed by removal of the tumor
is filled with cerebrospinal fluid.
Blood vessels. The vessels at the base of the brain may give rise to aneurysms
(weak areas that form like a blister on the vessel) that may rupture and cause
bleeding around the brain (subarachnoid hemorrhage). (see figure A and download
from figure B)
 Figure A. Angiogram of the vessels at the back of the brain
showing an aneurysm at the junction of the vertebral artery and
posterior inferior cerebellar artery (PICA). Inset shows the
position of the temporary (dotted line) and permanent (solid line)
clips shown in the video of figure B.

Figure B. Frame from a video from an operation for clipping of the

posterior inferior cerebellar artery (PICA) aneurysm seen in figure
A.. Note the use of a temporary clip across both the aneurysm
neck and PICA. The temporary clip is used to protect the
aneurysm from rupture while the aneurysm is manipulated for
placement of the permanent clip that clips the aneurysm and
leaves the PICA open.

An abnormal tangle of arteries and veins called an arteriovenous malformation may

bleed causing a clot within the brain (intracerebral hematoma). High blood pressure
 may rupture of a blood vessel in the brain and cause an intracerebral hematoma
(figure E).

Figure E. An arteriovenous malformation. The arterial blood

flows directly into veins.

Fluid that bathes the brain (cerebrospinal fluid). Obstruction to the flow of cerebrospinal fluid
produces hydrocephalus that on occasion requires craniotomy. Also see Shunt for
Hydrocephalus

The Procedure

The craniotomy is labeled by which part of the skull is opened. A frontal craniotomy indicates
the opening is in the frontal bone while a parietal craniotomy involves opening the parietal
bone. If part of two adjacent bones are opened then both bones are mentioned, for
example, fronto-temporal craniotomy. In the temporal and low occipital areas, which are
covered by muscle, the neurosurgeon may carry out a craniectomy in which the bone is not
replaced.

The incision in the scalp is designed to expose the skull over the lesion to be removed.

Removal of the bone flap is done in the following manner:

A series of small holes (burr holes) are made in the skull. The holes are positiones around
the periphery of the proposed bone flap. Making the holes may be accomplished in one of
three ways

The oldest method, which is still used by many surgeons, involves a set of three drill bits
and a hand drill. The first bit has a point and is used to just penetrate the bone. The second
and third bits, which have more of a curvature, widen the hole without cutting the underlying
dura, which lines the inner surface of the skull

Another method is by using a special air powered drill. The drill bit is made so that as soon
as the center of the drill bit penetrates the bone, the drill stops

The last method uses an air driven burr to gradually remove bone until the dura is seen.
This method allows the smallest holes, and the holes can also be tailored in shape (Figure
4).

Figure 4

The skull is cut between each two adjacent burr holes in a progressive manner until the
bone flap is separated from the surrounding skull. This is accomplished in one of two ways

The oldest method involves the passage of a thin metal strip between two adjacent holes.
The strip is placed between the skull and the dura. A small hook on the metal strip allows a
wire saw (Gigli saw) to be drawn under the skull in the same path as the strip (Figure 5).
 Figure 5

The manually driven saw then cuts the bone from inside out (Figure 6).

Figure 6

The air driven craniotome has for the most part replaced the manual method. The
craniotome resembles an air drill with a protective footplate. Cuts are then made with the
craniotome from hole to hole until the bone flap is free (Figure 7)
 Figure 7

After the bone flap is removed, the underlying dura is cut to expose the lesion (Figure 8).

Figure 8

The dura is then cut within the margins of the skull opening. If the lesion is a meningioma,
which is attached to the dura, the dura is cut around the tumor leaving a margin of normal
dura. When there is a loss of dura, various substitutes can be used such as bovine
pericardium (covering of the heart), banked human dura, Gortex plastic or an absorbable
collagen matrix.
What occurs next depends on the specific lesion that is found. When the surgery is for a
malignant brain tumor, the surgeon may wish to line the cavity left by removal of the tumor
with an absorbable wafer impregnated with an anticancer drug. This has been shown to
extend life by two to four months.

What occurs next depends on the lesion. When the surgery is for a malignant brain tumor,
the surgeon may wish to line the cavity left by removal of the tumor with an absorbable
wafer impregnated with an anticancer drug. This has been shown to extend life by two to
four months (Figure F).

F. MRI obtained after partial removal of a

malignant brain tumor (glioblastoma multiforme)
in which the tumor was treated with absorbable
wafers (arrows) impregnated with an anticancer
drug. Courtesy A. Sloan, M.D.

Following removal of the lesion, all bleeding is secured, the dura is sutured closed and the
bone flap restored to the skull with wire sutures or titanium miniplates and screws. Burr
holes in cosmetically exposed areas are covered with small titanium plates. If the bone
cannot be replaced (infected or invaded by tumor), a prosthesis can be used. These are
usually made of titanium mesh or plastic. (Figure G) The scalp is then sutured closed.
 Figure G. Titanium mesh cranioplasty used for replacement
of an infected bone flap.

Improvements

There are several instruments that have improved the ease and accuracy of a craniotomy.

Operating Microscope

The human hand can make very small and accurate movements as long as the eye can see
it. The magnification provided by the operating microscope has added another dimension to
operating. The magnification varies between 4 and 16x. This allows magnification of small
brain structures particularly the blood vessels and nerves at the base of the brain. The
microscope has markedly improved the surgery of aneurysms of the brain arteries and
tumors at the brain base.

Ultrasonic Aspirator

The ultrasonic aspirator is used to remove tumors from the brain with a minimum of brain
movement. The small tip of the instrument vibrates back and forth at thousands of times per
second, thus emulsifying the tumor tissue and allowing it to be easily sucked away with a
minimum of injury to the surrounding brain.

Intraoperative Ultrasound

The intraoperative ultrasound is used for localizing a lesion below the surface of the brain. It
is similar to the ultrasound used by an obstetrician to image a fetus in the womb. Sound
waves are sent out from the instrument (transducer) that strike the target lesion and bounce
back to the recording portion of the transducer. A picture is thus produced which can guide
the surgeon to the lesion.

Stereotaxic Image Guided Craniotomy

In the last few years, a significant improvement in brain surgery is made possible by the
marriage of modern imaging studies (CT and MRI) and computer graphics. This frameless
stereotaxic image guided surgery is a major advance in the removal of lesions inside the
skull, particularly small lesions and lesions beneath the surface of the brain. It has only
slightly affected large lesions, diffuse brain lesions and surgery for ruptured cerebral
aneurysm.

Prior to surgery, small markers (feducials) that show up on CT or in the MRI are applied to
the head of the patient. The patient is then placed in the CT or MRI unit and a series of
images are obtained. The electronic data that are the source of the images are transferred
to a computer in the operating room. This computer reconstructs the CT or MRI images and
produces a three dimensional picture of the head containing the lesion as well as a
reconstruction of the head and lesion in three planes.

After the patient is anesthetized, the head is pinned in a head holder to rigidly hold it in
place. The feducials are registered on the CT or MRI are matched to the corresponding
feducials on the patients head. The latter is accomplished with a pointer containing an array
of light emitting diodes. A receiver positioned near the operating table registers the position
of the diodes and thus the position of the head feducials. This information is transferred
directly to the computer. The pointer or any other instrument containing the diode array can
then be used to direct the surgeon to the lesion with no more than a 1-2 mm. error.

Using this technique, the surgical trauma to the brain is reduced and the size of the
craniotomy is minimized. This is translated into a faster and better recovery with discharge
from hospital frequently occurring in 24 hours. (Figures C,H)
Figure H. A. MRI of left frontal metastatic brain tumor (arrow). Note: MRI images show the
left side to the viewer's right B. Computer screen as seen by the neurosurgeon during
image guided surgery. Note the images have been flipped from side to side so that the
surgeon has a left sided image to his own left side. The arrows point to a yellow line that
represents the direction of 'attack' chosen by the surgeon. The red 'cross hairs' is the
position of the instrument being used by the surgeon. The right lower image shows the skin
surface of the patient with multiple donut shaped feducials on the surface. The red asterisk
lies on the tumor imaged in blue C. Post-operative MRI showing complete removal of the
tumor

Complications

Complications following craniotomy are primarily related to involvement of the brain and its
coverings. Some of the complications are:

Infection
Hemorrhage
Leak of cerebrospinal fluid
Brain swelling
Raised intracranial pressure (pressure inside the head)
Paralysis
Loss of sensation
Loss of vision
Loss of speech
Memory loss

Recovery

Following surgery the patient is usually admitted to the intensive care unit.

Level of consciousness is carefully observed for any change

Blood pressure is carefully monitored along with the pulse. An indwelling catheter in
an artery may be used to continuously monitor the blood pressure
Intracranial pressure may be monitored through a small catheter placed within the
head and connected to a pressure gauge
Blood may be drawn to determine to determine the level of red blood cells, and to
determine the concentration of sodium and potassium
In some cases, a tube may be left in the windpipe to control respiration
Antibiotics are usually given to prevent infection
Medication is frequently given to suppress the possibility of seizures
If there are no serious problems, the patient may be discharged the following day.
However, if there are problems such as weakness, loss of speech, hospitalization
may be delayed. Transfer to a rehabilitation unit may be necessary.

Further care

After care following a craniotomy is for the most part not necessary except for infections and
tumors.

Infections. A craniotomy for an infection is usually for a brain abscess. Frequently

the patient must be kept on specific antibiotics for the infectious agent causing the
abscess. On occasion antibiotics may be necessary for several months
Brain tumors. The after care for a brain tumor differs depending on whether it is
benign or malignant
1. Patient with benign tumors usually have to be followed for several years to
be sure there is no recurrence. If there is recurrence, the alternatives are
usually repeat surgery or radiation therapy
2. Malignant tumors of the brain usually have a gloomy outlook

Additional therapies include

Radiation therapy is usually given following removal of both metastatic tumors and
tumors that originate in the brain such as a glioblastoma multiforme. Survival
following surgery doubles if radiation therapy is given
 Chemotherapy has been used for glioblastoma but often helps only slightly and
frequently has unwanted side-effects
Immunotherapy involves stimulating the patient's own immune system to fight the
tumor. The patient's tumor (glioblastoma multiforme) taken at the time of surgery is
used to make a vaccine (like the polio vaccine). The vaccine is given to the patient,
which stimulates blood cells to create lymphocytes that will find and attack the
tumor. Early trials have shown that immunotherapy improves survival in some
patients with minimal side-effects

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