Craniotomy - Surgery of the Brain

Why is a craniotomy done? Craniotomy is the term used for any operation that involves entering the skull. All brain operations are craniotomies, or some variation of it. The exact design of the procedure is individually tailored to the patient and their needs.

Tumors:
For patients who are diagnosed with a brain tumor, the goal of surgery is to determine what type of tumor is present and to remove as much of the tumor as can be removed safely, with as little disturbance of the normal surrounding brain as possible. Some tumors are more clearly separated from the normal tissue, and the aim is to remove these tumors completely. Other tumors may have very unclear boundaries and the surgeon must use his best judgment as to how much of the tumor can be removed safely. We always enter a procedure planning to remove the tumor in its entirety, but this may not always be the prudent thing to do for a particular patient.

Head Injuries:
Performing craniotomies for victims of a head injury is usually done on an emergency basis and usually performed to relieve increased pressure on the brain. The goal is to remove blood clots or non-functioning, severely damaged brain tissue that has been damaged beyond repair and is causing risk to the patient's life.

Blood Clots:
Blood clots can form in or around the brain either spontaneously (from chronic hypertension, or use of blood thinners) or from trauma (injury). The clots can be either acute (fresh) or chronic (old). The clot is a problem to the patient mainly because of the pressure that it exerts on the normal brain and blood vessels. A craniotomy is performed to relieve the pressure and to remove as much of the clot as is possible.

Infections or Abscesses:
Occasionally patients have localized infections or abscesses within the brain. The craniotomy is performed to drain the infection and to determine what type of organism (bacteria) is involved. The surgery is combined with antibiotic therapy to fully treat the condition.

Abnormal Blood Vessels:
An aneurysm is an abnormal local dilatation (ballooning) of the wall of a blood vessel, usually an artery, due to a defect, disease, or injury to it. True aneurysms are rounded, berrylike out pouchings that arise at arterial branching points.

For aneurysms, which are similar to blisters on the wall of a normal artery, the surgeon will usually attempt to place a specially designed metal clip (like tying off a balloon) to seal it off. In some instances, the surgeon may instead coat the area with a material which would be expected to add strength or reinforcement to the weakened spot. Some aneurysms are suitable for a specialized treatment involving threading a coil into it to clot it off.

AVM's:
AVM's (arteriovenous malformations): are tangles of abnormal arteries and veins within the substance of the brain. The craniotomy is performed to remove the, mass of vessels completely while leaving normal blood vessels and the brain intact. Again, the surgeon must judge how much of the abnormality can be removed safely.

With some of the craniotomies, the possibility of significant blood loss may exist. Patients may choose to donate some of their own blood several weeks prior to surgery. In case a transfusion would become necessary, the surgeon will discuss this with the patient, and help to make any appropriate arrangements. In an emergent situation, the surgical team will do what is best for the patient.

Risks That You Should Know
All surgeries are associated with risks. Although every precaution is taken to avoid complications, the most common risks that are possible with a craniotomy include: infection, excessive bleeding (hemorrhage), stroke, paralysis, further brain injury (causing weakness, loss of vision or speech, numbness, and confusion), coma, or death.

Careful consideration and judgment goes into planning for surgery on the brain. Still, it must be understood that unforeseen circumstances can arise during ANY surgical procedure. Even though such complications are very infrequent, the patient and family are strongly encouraged to discuss the risks in greater detail with the surgeon.

WHAT YOU CAN EXPECT FROM SURGERY

About Your Hospital Stay
Most patients stay in the hospital for approximately one week following a craniotomy. Keep in mind, however, that each patient is different, and, the hospital stay can vary greatly between each patient.

After surgery, the patient, is moved from the Recovery Room to the Intensive Care Unit (ICU) for one to several days. The ICU is a scary and unnatural environment full of monitors, IV lines, beeping sounds, and people hurrying around. This is all for the safety of the patient. When stable, the patient is then moved to the floor of the hospital for neurosurgery patients, where specially trained nurses continue to monitor the patient's recovery. In general, most patients can expect to wake up in the recovery room or in the ICU. Immediate family is permitted to visit with the patient right after surgery, however, visits must be kept brief and need to be approved by the nurses in charge of the unit.

About Your Neurological Progress

It is very difficult to predict a patient's neurological condition after surgery because of the many different conditions that may exist before the operation. Also, the specific area of the brain where the surgery takes place may affect mental status, vision, speech or movement control. These functions will be assessed regularly by the nurses and the surgeon.

Brain swelling and seizures are a main concern after surgery. Medications and special head positions are used to help control swelling. During the healing process, the brain is susceptible to irritation which can cause the brain cells to fire irregularly and cause seizures and convulsions. At times, anti-seizure medications are prescribed, sometimes for several months.

There is usually a moderate headache after the craniotomy. Mild pain relievers are sufficient to keep the patient comfortable. Very strong medications are avoided so that the staff may perform accurate assessments of the neurological progress of the patient.

It is not unusual to feel tired or discouraged after undergoing a major operation, such as a craniotomy. These feelings are normal and are most likely related to hormonal changes that are associated with the stress of the surgery. Although it may be challenging, we encourage our patients to do their best to maintain a positive attitude - which is essential to recovery and return to normal activities.

About Your Return To Daily Activities

Eating:
Most often for the first one or two days, the patient will receive fluids and nutrition through IVs. This is vital in keeping accurate records of fluid input and output until the risk of brain swelling has subsided. Liquids by mouth and then finally solid foods will slowly be added to the patient's diet. This may be delayed, however, if there is persistent nausea or any specific problems with swallowing.

Bathing:
Patients are permitted to bathe or shower as soon as their condition allows. Shampooing of the scalp should be avoided, however, until after the staples are removed from the incision (about one week). This is important in reducing the risk of infection to the scalp tissue.

Walking:
Patients are allowed out of bed as soon as their condition permits this. In most instances, the Physical Therapy Department may be asked to evaluate the patient and to provide strengthening and coordination exercises.

If there are any difficulties with the patient's abilities for self-care or the progress of the recovery, it may be recommended that the patient be transferred to a Rehabilitation Unit where intensive physical, occupational, and speech therapies can be arranged.

About Your Discharge to Home

Once in stable condition, the patient is able to be discharged directly to home. We strongly advise that a family member or friend accompany the patient at home in case any difficulties arise. It is important that surgeon be notified in the case of fevers, severe headaches, or any swelling or drainage around the incision area.

The staples are to be removed seven to ten days after your craniotomy. PLEASE CALL TO SCHEDULE FOLLOW-UP VISIT AT OUR OFFICE.

In General

The Day of Surgery

You will be taken to the Operating Room holding area on a stretcher. Here, you will be checked in by the nursing staff. Your identification, what is being done, and by whom will be verified. The anesthetist will place an intravenous (IV) in your arm. This is a small plastic tubing through which the medications will be given to put you to sleep. Later additional access lines will be placed, as are required for your surgery.

Your family, friends, etc will be directed to the O.R. waiting area, where I will look for them after surgery. Cranial surgery can take several hours. They will also receive periodic updates, as needed. They can always ask the waiting room staff for an update.

When the O.R. suite is ready you will be wheeled back to surgical suite. It will be a busy place. There will be several nurses, assistants, orderlies, and your surgeon busily preparing for your surgery. We will try to keep you as comfortable as possible. The anesthetist will give you a little sedation to relax you.

Once you been put to sleep and a breathing tube placed into your throat;

• A catheter (tube) will be placed in your bladder, and any additional monitoring equipment situated.
• You will be positioned appropriately for the surgery
• A head fixating device will be applied to hold your head still during surgery.
• As much hair as needed will be shaved to expose the planned surgical site, and decrease the chance of infection.
• Many of your body functions and parameters will be monitored throughout the procedure. Blood samples will be taken, and adjustments made appropriately.
• The surgical area will scrubbed and cleaned with antiseptic solution

Once all is in order, your surgeon will begin working. An incision is made and a window of bone is temporarily removed to gain access to the problem. If we are dealing with a tumor, as much tumor will be removed as is safe. It is often not possible to remove every cell without causing more problems. Throughout your surgery many different tools will be used, such as the microscope, laser, ultrasonic aspirator, micro-instrumentation, etc.

Once the work is completed, and the surgical site has been closely inspected, we will close.

Intensive Care (ICU)

A head bandage will be applied and you will be taken to the ICU. The breathing tube may or may not be removed at this time. The lines used to monitor your body will most likely remain in place, until we are satisfied that it is safe to remove them.

The ICU is a busy place and you will hear unfamiliar beeps and sounds. These are for your protection. Bright lights may be turned on for long periods of time, and your nurse will be adjusting your monitoring equipment and checking you constantly.

If you are in pain, let your nurse know. Don't be afraid to report any unexpected feelings to your nurse. The IV and other lines, as well as the breathing tube, will be removed when it is safe to do so. The nurse will be checking your vital signs regularly, monitoring your fluid intake and urine output, drawing blood studies, and adjusting equipment as needed. You will have post-operative CT scans and X-Rays regularly. While in the hospital, in addition to the nursing staff, you will be cared for by your primary care physician, a pulmonary specialist, and your surgeon. You may also be evaluated by physical therapy, speech therapy, occupational therapy, and by any other care provider that is needed.

Your stay in ICU could be one day or several days, depending upon your condition. You will then be transferred to the regular nursing floor. When you are ready, you will be discharged home. Some patients are more appropriately transferred to a skilled nursing facility or to a rehabilitation unit. This decision will not be made without you and your family.

In spite of the complicated nature of this surgery, outcomes are usually good. This outcome is dependent upon many factors. The attitude and general health of the patient, the experience of the surgeon and team, the location and exact nature of the problem with which we are dealing, the reasonable expectations set prior to surgery, etc. The exact tumor type will determine the long-term outcome, and the need for additional treatment, such as radiation therapy, chemotherapy, and additional surgery.

Risks and Possible Complications

I have performed more than 2,000 cranial surgical procedures successfully. However, complications do occur:

1. Infection of the skin and/ or bone. This may require further surgery.
2. Bleeding which may require a blood transfusion and may result in brain damage. This may be permanent.
3. Leakage of spinal fluid through the wound. This may require further surgery.
4. Stroke or stroke - like complications which can cause weakness in the face, arms and/ or legs. This may be temporary or permanent.
5. Epilepsy which may require medication. This may be temporary or permanent.
6. Loss of vision which may be temporary or permanent.
7. The lesion may not be cured by surgery and may need further treatment.
8. Increased risk in obese people of wound infection, chest infection, heart and lung complications, and thrombosis.
9. Increased risk in smokers of wound and chest infections, heart and lung complications and thrombosis.
10. Small areas of the lungs may collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy.
11. Clots in the legs (deep vein thrombosis or DVT) with pain and swelling. Rarely part of this clot may break off and go to the lungs which can be fatal.
12. A heart attack because of strain on the heart or a stroke.
13. Death is possible after any surgical procedure, including this one.

These possible complications pertain to anyone having cranial surgery. Dr. Pagnanelli, the O.R. team, and anesthetia personnel will do everything in their power to ensure that your procedure is carried out in a safe, professional, and responsible manner. The possibility of these risks is low, but still present.