Research Assessment #16

Date: Oct, 15, 2018

Subject: Craniotomy

MLA Citation:

“Craniotomy.” Craniotomy | Johns Hopkins Medicine Health Library,

www.hopkinsmedicine.org/healthlibrary/test_procedures/neurological/craniotomy_92,
p08767.

Analysis:

As I was in the mentorship underneath the help of Dr. Mignucci, I was able to
experience different situations in each and every case. As I have learned, Dr. Mignucci is an
extremely talented gentleman with many years of experience in the field of neurosurgery.
However, when I asked questions concerning the surgery of the brain, his response was always
a bit more complicated and I didn’t understand many of the terms as he explained. One of the
terms he had used in his explanation one time would be the word craniotomy which I was
extremely confused about. How is a craniotomy something that I was confused about, well
because there were so many versions of them and the surgeon had to know on the spot what
surgery he had to do based on the case. It is the preciseness of the surgeon and the complexity
of the surgery which really intrigued me.

First thing I had to understand when the word craniotomy came up was what it really is
not just aa simple definition of a brain surgery. As explained by the renowned university, Johns
Hopkins, they state that it is a surgery where a surgeon would remove a piece of bone from the
skull to expose the brain for further surgery. I at first was in awe when this definition was
placed in the website because I first thought that a craniotomy would be a surgical removal of a
piece of brain tissue that had been useless within the body. As I quickly learned this, I was soon
to be in for a surprise.

Craniotomy is not one procedure but could be changed up based on what kind of
situation a patient is in. As explained by Johns Hopkins, there are 5 kinds of craniotomies that a
patient could get due to their condition. The procedures are an Extended Bifrontal Craniotomy,
a Minimally Invasive Supra-Orbital “Eyebrow” Craniotomy, a Retro-Sigmoid “Keyhole”
Craniotomy, an Orbitozygomatic Craniotomy, and a Translabyrinthine Craniotomy. Johns
Hopkins seems to go into detail what each one is, but the overview of each one would be as
explained in the following sentences.

Extended Bifrontal Craniotomy would be a typical surgery of craniotomy where a bone

from the skull is taken out to produce ample room for the brain to be worked on. This bone
would be replaced at the end of the surgery. Minimally Invasive Supra-Orbital “Eyebrow”
Craniotomy would be a technique used by neurosurgeons to remove tumors where the patient
would be from the eyebrow region. The next type of surgery would be the Retro-Sigmoid
“Keyhole” Craniotomy which would be a technique used by surgeons to remove tumors by
going in through behind the ear to remove it. The eyebrow and keyhole surgeries are very
minimally invasive meaning that there will also be a super-fast recovery time and very less
scarring. The Orbitozygomatic Craniotomy would be a surgery where the surgeon would make
“an incision in the scalp behind the hairline and removing the bone that forms the contour of
the orbit and cheek.” This means that the area would be free space and there would be an easier
approach to helping the patient without trying to cause severe damage by a minimally invasive
process. This on usually used for the aneurysms or some superficial (deep within) tumors.
Lastly, a Translabyrinthine Craniotomy is a type of craniotomy which is just like the “keyhole”
except that the bone taken out is for some reason not replaced.

In the end, I feel that I have learned about what a key part to brain surgery is. I was
ignorant at first that I had missed such an important detail of how the brain is worked on and
missed the important fact that the skull protects the brain and needs to be surpassed to start a
surgery on the brain. I have also understood the different kinds of surgeries that a surgeon
would do based on the condition of the patient. I also was intrigued about how more than one
procedure could be combined to perform a surgery if there are more than 1 tumors within the
patient’s brain at a time. I have to be able to take notes the next time I go in for a mentor visit, so
that I can write down important or medical terms to search up later and learn more about what
is happening within the clinic.

(Article starts on Page 3 below.)

What is a 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.

Some craniotomy procedures may use the guidance of computers and imaging (magnetic
resonance imaging [MRI] or computerized tomography [CT] scans) to reach the precise location
within the brain that is to be treated. This technique requires the use of a frame placed onto the
skull or a frameless system using superficially placed markers or landmarks on the scalp. When
either of these imaging procedures is used along with the craniotomy procedure, it is called
stereotactic craniotomy.

Scans made of the brain, in conjunction with these computers and localizing frames, provide a
three-dimensional image, for example, of a tumor within the brain. It is useful in making the
distinction between tumor tissue and healthy tissue and reaching the precise location of the
abnormal tissue.

Other uses include stereotactic biopsy of the brain (a needle is guided into an abnormal area so
that a piece of tissue may be removed for exam under a microscope), stereotactic aspiration
(removal of fluid from abscesses, hematomas, or cysts), and stereotactic radiosurgery (such as
gamma knife radiosurgery).

An endoscopic craniotomy is another type of craniotomy that involves the insertion of a lighted
scope with a camera into the brain through a small incision in the skull.

Aneurysm clipping is another surgical procedure which may require a craniotomy. A cerebral
aneurysm (also called an intracranial aneurysm or brain aneurysm) is a bulging weakened area
in the wall of an artery in the brain, resulting in an abnormal widening or ballooning. Because
of the weakened area in the artery wall, there is a risk for rupture (bursting) of the aneurysm.
Placement of a metal clip across the "neck" of the aneurysm isolates the aneurysm from the rest
of the circulatory system by blocking blood flow, thereby preventing rupture.

Craniectomy is a similar procedure during which a portion of the skull is permanently removed
or replaced later during a second surgery after the swelling has gone down. .

Other related procedures that may be used to diagnose brain disorders include cerebral
arteriogram, computed tomography (CT) scan of the brain, electroencephalogram
(EEG), magnetic resonance imaging (MRI) of the brain, positron emission tomography (PET)
scan, and X-rays of the skull. Please see these procedures for additional information.
Our Approach to Craniotomy
Johns Hopkins neurosurgeons are highly skilled and experienced in all types of craniotomy
including newer, less invasive options for brain tumor surgery, aneurysm surgery and other
procedures. In addition, a specialized clinic offers patients safe repair of skull deformities after
brain surgery.

Learn more about Johns Hopkins’ Comprehensive Brain Tumor Center.

Types of Craniotomy
Extended Bifrontal Craniotomy
The extended bifrontal craniotomy is a traditional skull base approach used to target difficult
tumors toward the front of the brain. It is based on the concept that it is safer to remove extra
bone than to unnecessarily manipulate the brain.
The extended bifrontal craniotomy involves making an incision in the scalp behind the hairline
and removing the bone that forms the contour of the orbits and the forehead. This bone is
replaced at the end of surgery. Temporarily removing this bone allows surgeons to work in the
space between and right behind the eyes without having to unnecessarily manipulate the brain.

The extended bifrontal craniotomy is typically used for those tumors that are not a candidate
for removal by minimally invasive approaches because of either the anatomy of the tumor, the
possible pathology of the tumor or the goals of surgery.

Types of tumors treated with the extended bifrontal craniotomy include meningiomas,
esthesioneuroblastomas and malignant skull base tumors.
Minimally Invasive Supra-Orbital “Eyebrow” Craniotomy
Supra-orbital craniotomy (often called "eyebrow" craniotomy) is a procedure used to remove
brain tumors. In this procedure, neurosurgeons make a small incision within the eyebrow to
access tumors in the front of the brain or pituitary tumors. This approach is used instead
of endonasal endoscopic surgery when a tumor is very large or close to the optic nerves or vital
arteries.
Because it is a minimally invasive procedure, supra-orbital “eyebrow” craniotomy may offer

 Less pain than open craniotomy

 Faster recovery than open craniotomy

 Minimal scarring

The supra-orbital craniotomy may be part of the treatment for Rathke’s cleft cysts, skull base
tumors and some pituitary tumors.

Retro-Sigmoid “Keyhole” Craniotomy

Retro-sigmoid craniotomy (often called "keyhole" craniotomy) is a minimally-invasive surgical
procedure performed to remove brain tumors. This procedure allows for the removal of skull
base tumors through a small incision behind the ear, providing access to the cerebellum and
brainstem. Neurosurgeons may use this approach to reach certain tumors, such as meningiomas
and acoustic neuromas (vestibular schwannomas).

Benefits of "keyhole" craniotomy includes less pain after the procedure than after an open
craniotomy, less scarring and a more rapid recovery.

The retro-sigmoid craniotomy may be performed for the following types of brain tumors:

 Acoustic neuromas (vestibular schwannomas)

 Meningiomas
 Metastatic brain or spine tumors
 Skull base tumors

Orbitozygomatic Craniotomy
The orbitozygomatic craniotomy is a traditional skull base approach used to target difficult
tumors and aneurysms. It is based on the concept that it is safer to remove extra bone than to
unnecessarily manipulate the brain.

Typically used for those lesions that are too complex for removal by more minimally invasive
approaches, orbitozygomatic craniotomy involves making an incision in the scalp behind the
hairline and removing the bone that forms the contour of the orbit and cheek. This bone is
replaced at the end of surgery. Temporarily removing this bone allows surgeons to reach
deeper and difficult parts of the brain while minimizing severe damage to the brain.

Brain tumors that may be treated with orbitozygomatic craniotomy include

craniopharyngiomas, pituitary tumors and meningiomas.

Translabyrinthine Craniotomy
A translabyrinthine craniotomy is a procedure that involves making an incision in the scalp
behind the ear, then removing the mastoid bone and some of the inner ear bone (specifically,
the semicircular canals which contain receptors for balance). The surgeon then finds and
removes the tumor, or as much of the tumor as possible without risk of severe damage to the
brain.

Acoustic neuroma (vestibular schwannoma) is treated with one of three approaches for
translabyrinthine craniotomy: suboccipital, translabyrinthine approach and middle fossa.

When there is no useful hearing or hearing is to be sacrificed, the translabyrinthine approach is

often considered. During the translabyrinthine craniotomy, the semicircular canals of the ear are
removed in order to access the tumor. Complete hearing loss occurs as a result of the removal of
the semicircular canals.

Although hearing is lost with the translabyrinthine craniotomy, the risk of facial nerve injury
may be reduced.

Reasons for the procedure

A craniotomy may be done for a variety of reasons, including, but not limited to, the following:

 Diagnosing, removing, or treating brain tumors

 Clipping or repairing of an aneurysm

 Removing blood or blood clots from a leaking blood vessel

 Removing an arteriovenous malformation (AVM). An abnormal mass of blood vessels
(arteries and veins)

 Draining a brain abscess. An infected pus-filled pocket

 Repairing skull fractures

 Repairing a tear in the membrane lining the brain (dura mater)

 Relieving pressure within the brain (intracranial pressure) by removing damaged or swollen
areas of the brain that may be caused by traumatic injury or stroke

 Treating epilepsy. A neurological condition involving the brain that makes people more
susceptible to seizures.

 Implanting stimulator devices to treat movement disorders such as Parkinson's disease or

dystonia (a type of movement disorder)

There may be other reasons for your doctor to recommend a craniotomy.

Risks of the procedure

As with any surgical procedure, complications may occur. Brain surgery risk is tied to the
specific location in the brain that the operation will affect. For example, if the area of the brain
that controls speech is operated on, then speech may be affected. Some more general
complications include, but are not limited to, the following:

 Infection

 Bleeding

 Blood clots

 Pneumonia (infection of the lungs)

 Unstable blood pressure

 Seizures

 Muscle weakness

 Brain swelling
 Leakage of cerebrospinal fluid (the fluid that surrounds and cushions the brain)

 Risks associated with the use of general anesthesia

The following complications are rare and generally relate to specific locations within the brain,
so they may or may not be valid risks for certain individuals:

 Memory problems

 Speech difficulty

 Paralysis

 Abnormal balance or coordination

 Coma

There may be other risks depending on your specific medical condition. Be sure to discuss any
concerns with your doctor prior to the procedure.

Before the procedure

 Your doctor will explain the procedure to you and you can ask questions.

 You will be asked to sign a consent form that gives permission to do the surgery. Read the
form carefully and ask questions if something is not clear.

 In addition to a complete medical history, your doctor will do a physical exam to ensure you
are in good health before you undergo the surgery. You may also need blood tests and other
diagnostic tests.

 You will receive a preoperative neurological exam that will be used to compare with
postoperative exams.

 You will be asked to fast before the procedure, generally after midnight.

 If you are pregnant or think you may be, tell your healthcare provider.

 Tell your doctor if you are sensitive to or are allergic to any medicines, latex, tape and
anesthetic agents (local or general).

 Tell your doctor of all medicines (prescribed and over-the-counter) and herbal supplements
that you are taking.
 Tell your doctor if you have a history of bleeding disorders or if you are taking any
anticoagulant (blood-thinning) medicines, aspirin, or other medicines that affect blood
clotting. It may be necessary for you to stop these medicines before the procedure.

 If you smoke, you should stop smoking as soon as possible before the procedure to improve
your chances for a successful recovery from surgery and to improve your overall health
status.

 You may be asked to wash your hair with a special antiseptic shampoo the night before the
surgery.

 You may receive a sedative before the procedure to help you relax.

 The areas around the surgical site will be shaved.

 Based on your medical condition, your doctor may request other specific preparation.

During the procedure

A craniotomy generally requires a hospital stay of 3 to 7 days. You may also go to a
rehabilitation unit for several days after your hospital stay. Procedures may vary depending on
your condition and your doctor's practices.

Click Image to Enlarge

Generally, a craniotomy follows this process:

 You will be asked to remove any clothing, jewelry, or other objects that may interfere with
the procedure.

 You will be given a gown to wear.

 An intravenous (IV) line will be inserted in your arm or hand.

 A urinary catheter will be inserted to drain your urine.

 You will be positioned on the operating table in a manner that provides the best access to the
side of the brain to be operated on.

 The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing,
and blood oxygen level during the surgery.

 Your head will be shaved and the skin over the surgical site will be cleansed with an
antiseptic solution.

 There are various types of incisions that may be used, depending on the affected area of the
brain. An incision may be made from behind the hairline in front of your ear and the nape of
your neck, or in another location depending on the location of the problem. If an endoscope
is used, the incisions may be smaller.

 Your head will be held in place by a device which will be removed at the end of the surgery.

 The scalp will be pulled up and clipped to control bleeding while providing access to the
brain.

 A medical drill may be used to make burr holes in the skull. A special saw may be used to
carefully cut the bone.

 The bone flap will be removed and saved.

 The dura mater (the thick outer covering of the brain directly underneath the bone) will be
separated from the bone and carefully cut open to expose the brain.

 Excess fluid will be allowed to flow out of the brain, if needed. Microsurgical instruments,
such as a surgical microscope to magnify the area being treated, may be used. This can
enable the surgeon a better view of the brain structures and distinguish between abnormal
tissue and healthy tissue. Tissue samples may be sent to the lab for testing.

 A device, such as a drain or a special type of monitor, may be placed in the brain tissue to
measure the pressure inside the skull, or intracranial pressure (ICP). ICP is pressure created
by the brain tissue, cerebral spinal fluid (CSF), and blood supply inside the closed skull.

 Once the surgery is completed, the surgeon will suture (sew) the layers of tissue together.

 The bone flap will be reattached using plates, sutures, or wires.

 If a tumor or an infection is found in the bone, the flap may not be replaced. Also, if
decompression (to reduce pressure in the brain) is required, the bone flap may not be
replaced.

 The skin incision (scalp) will be closed with sutures or surgical staples.

 A sterile bandage or dressing will be applied over the incision.

After the procedure

In the hospital
Immediately after the procedure, you will be taken to a recovery room for observation before
being taken to the intensive care unit (ICU) to be closely monitored. Or, you may be taken
directly to the ICU from the operating room.

In the ICU, you may be given medicine to decrease the brain swelling.

Your recovery process will vary depending upon the type of procedure done and the type of
anesthesia given. Once your blood pressure, pulse, and breathing are stable and you are alert,
you may be taken to the ICU or your hospital room.

After staying in the ICU, you will move to a room on a neurosurgical nursing unit in the
hospital. You will remain in the hospital for several more days.

You may need oxygen for a period of time after surgery. Generally, the oxygen will be
discontinued before you go home.

You will be taught deep-breathing exercises to help re-expand the lungs and prevent
pneumonia.

Frequent neurological checks will be done by the nursing and medical staff to test your brain
function and to make sure your body systems are functioning properly after your surgery. You
will be asked to follow a variety of basic commands, such as moving your arms and legs, to
assess your brain function. Your pupils will be checked with a flash light, and you will be asked
questions to assess your orientation (such as your name, the date, and where you are). The
strength of your arms and legs will also be tested.

The head of your bed may be elevated to prevent swelling of your face and head. Some swelling
is normal.

You will be encouraged to move around as tolerated while in bed and to get out of bed and
walk around, with assistance at first, as your strength improves. A physical therapist (PT) may
be asked to evaluate your strength, balance, and mobility, and give you suggestions for
exercises to do both in the hospital and at home.
You will likely have sequential compression devices (SCDs) placed on your legs while you are
in bed to prevent blood clot formation. SCDs have an air compressor that slowly pumps air into
and out of fitted sleeves that are placed on the legs. They help prevent blood clots from forming
by passively compressing the leg veins to keep blood moving.

Depending on your situation, you may be given liquids to drink a few hours after surgery. Your
diet may be gradually changed to include more solid foods as you can handle them.

You may have a catheter in your bladder to drain your urine for a day or so, or until you are
able to get out of bed and move around. Be sure to report any painful urination or other urinary
symptoms that occur after the catheter is removed, as these may be signs of an infection that can
be treated.

Depending on your status, you may be transferred to a rehabilitation facility for a period of time
to regain your strength.

Before you are discharged from the hospital, arrangements will be made for a follow-up visit
with your doctor. Your doctor will also give you instructions for home care.

At home
Once you are home, it is important to keep the incision clean and dry. Your doctor will give you
specific bathing instructions. If stitches or surgical staples are used, they will be removed
during a follow-up office visit. If adhesive strips are used, keep them dry and they will fall off
within a few days.

You may choose to wear a loose turban or hat over the incision. You should not wear a wig
until the incision is completely healed (about 3 to 4 weeks after surgery).

The incision and head may ache, especially with deep breathing, coughing, and exertion. Take a
pain reliever for soreness as recommended by your doctor. Aspirin or other blood thinning
medicines may increase the chance of bleeding. Be sure to take only recommended
medicines and ask if you are unsure.

Continue the breathing exercises used in the hospital to prevent lung infection. You will be
advised to avoid exposure to upper respiratory infections (colds and flu) and irritants, such as
tobacco smoke, fumes, and environmental pollution.

You should gradually increase your physical activity as you can handle them. It may take
several weeks to return to your previous level of energy and strength.

You may be instructed to avoid lifting heavy items for several weeks to prevent strain on your
surgical incision.
Do not drive until your doctor gives you permission.

Call your doctor to report any of the following:

 Fever or chills

 Redness, swelling, drainage, or bleeding or other drainage from the incision site or face

 Increased pain around the incision site

 Vision changes

 Confusion or excessive sleepiness

 Weakness of your arms or legs

 Trouble with speech

 Trouble breathing, chest pain, anxiety, or change in mental status

 Green, yellow, or blood-tinged sputum (phlegm)

 Seizure activity

Following a craniotomy, your doctor may give you other instructions, depending on your
particular situation.