CRANIOTOMY Craniotomy can involve more than one skull
bones, for example, frontotemporal
What is Craniotomy?
Craniotomy is a surgical procedure where an
opening is made in the skull to enable to
access and expose the brain.
What are the Types of Craniotomy?
Craniotomy can be classified into several
types depending on the location. The skull
consists of the frontal bone located at the
forehead, the temporal bones at the temples,
the parietal bones on both sides, and the
occipital bone at the back of the head.
 Frontal craniotomy is performed
through the frontal bone
 Temporal craniotomy is performed
through the temporal bone
 Parietal craniotomy is performed
through the parietal bone
 Occipital craniotomy is performed
through the occipital bone
 Pterional craniotomy is performed
at the junction of the frontal,
temporal, greater wing of sphenoid
and parietal bones. The sphenoid is
a bone at the base of the skull.
craniotomy, frontotemporoparietal craniotomy
Other types of craniotomies include:
 Keyhole Craniotomy, where the
surgery is carried out through a
small hole. It is done for lesions that
are not immediately just below the
brain.
 Stereotactic Craniotomy, where a
3-dimensional coordinates system is
used to precisely locate the problem
area that needs surgery.
 Awake Craniotomy, where the
patient can be woken up during the
surgery. It is commonly done for
epilepsy surgeries, or when the
lesion is close to a critical area of
the brain. The patient’s responses
are checked during the surgery to
make sure that the vital parts of the
brain are not being affected.
What are the Indications for Craniotomy?
A craniotomy gives access to the inside of the
skull. Indications for craniotomy include:
 Surgical removal of a tumor or
blood clot, or draining of an abscess
within the skull. Brain injury
following trauma is one of the
commonest indications for
craniotomy
 Clipping of an aneurysm:
An aneurysm is a dilated artery with
weakened walls, which has the
 routine tests done before any surgery. These
include:

 Imaging Tests like CT scan (most

potential to burst and result in life-
threatening consequences. Clipping
of the aneurysm reduces blood flow
through it and therefore decreases
its size and its potential to burst.
 Removal of an arteriovenous
malformation: An arteriovenous
malformation is an abnormal
communication between an artery
and a vein. It can bleed and result in
grave consequences.
 Surgery for epilepsy: Certain cases
of epilepsy do not respond to
medication and require surgery
 Ventricular shunting. Ventricular
shunting is a procedure performed
to reduce pressure in the skull due to
excess fluid accumulation.
common), MRI and functional MRI
are performed to identify and locate
the lesion. An angiography may also
be done in selected cases to identify
the blood supply to the lesion.
 Routine Tests which are done
before any surgery include:
 Blood tests like
hemoglobin levels, blood
group, and liver and
kidney function tests; tests
to ensure that the blood
coagulation system is
intact
 Urine tests
 ECG to study the
electrical activity of the
heart
 Chest x-ray

 Other procedures like inserting deep

In older patients, a detailed assessment of the
brain stimulators for the treatment
heart may be required to make sure that they
of conditions like brain tumours,
are fit for surgery.
Parkinson’s disease, essential
tremor and dystonia.
Medications that are administered prior to the
surgery depending on the type of lesion
What are the Tests Done Prior to
include:
Craniotomy?

Tests done prior to craniotomy include the  Anti-seizure medications to prevent

tests required to diagnose the pathology and the development of seizures

locate it precisely within the skull, as well as  Corticosteroids to reduce swelling

  An antibiotic to prevent infection
due to the surgery
Blood thinners should be stopped a few days
before the surgery to prevent excess bleeding
How is Craniotomy Performed?
Type of Anesthesia - A combination
of general anesthesia and local anesthesia is
often used for the craniotomy procedure. If
you are under general anesthesia, you will be
asleep during the procedure and will not be
aware of what is going on. If you are
undergoing a sleep-awake-sleep craniotomy,
you may be given general anesthesia but will
be woken up during the surgery. The local
anesthetic is mixed with epinephrine to reduce
bleeding from the incision.
Pre-operative Check-up - Routine tests as
indicated above are ordered a few days before
the surgery. Admission is usually required a
day before the surgery.
Fasting Before Surgery - Overnight fasting
is required and occasionally intravenous fluid
maybe required to keep you well hydrated.
Sedation is sometimes required for good
overnight sleep before the surgery.
Shift from the Ward or Room to the
Waiting Area in the Operating Room - An
hour or two before the surgery, you will be
shifted to the operating room waiting area on
a trolley.
Once the surgical room is ready, you will be
shifted to the operating room.
Shift to the Operating Room - The ambience
in the operating room can sometimes be very
daunting and a small amount of sedation can
help overcome your anxiety. From the trolley,
you will be shifted on to the operating table.
As you look up, you will see the operating
light console and at the head end will be the
anesthesia machine. There will also be
monitors to check oxygen levels, ECG and
other vital parameters. A constant beeping
sound may be present from the monitors,
which may sometimes be irritating.
Anesthesia Before Surgery - If you have to
undergo general anesthesia, the anesthetist
will inject drugs through an intravenous line
and make you inhale some gases through a
mask that will put you in deep sleep. Once
you are in deep sleep, a tube will be inserted
into your mouth and windpipe to administer
the anesthetic gases to overcome pain and
keep you comfortable. If local anesthesia is
used, an anesthetic drug will be injected in the
region where the incision will be taken.
Incision for Craniotomy - The location of
the incision for the craniotomy procedure
depends on which part of the brain has to be
operated. The inner part of the skull is divided
by tissue called tentorium cerebelli into an
upper supratentorial part and a lower and
posterior infratentorial part.
 For a surgery in the supratentorial
part, the incision is made through
the frontal, temporal, parietal or
occipital bones, or through more
than one bone
 For a surgery in the infratentorial
part, the incision is made through
the back of the skull just above the
neck
The desired location of the incision is marked
on the skin. The hair in the area may be
shaved off and a scalp flap is made. The
incision should preferably be behind the
hairline for cosmetic effect. A local anesthetic
with epinephrine is usually injected just
before the incision is made to reduce bleeding.
The muscles below the scalp are separated to
reach the bone of the skull.
Craniotomy - Four to five holes are bored
into the skull. The holes are connected with a
saw and a bone flap is cut out after carefully
separating it from the dura below. The dura is
then cut and retracted, exposing the brain.
Once the surgery on the brain is done, the
bone is usually replaced and kept in position
with soft wire, or plates and screws. The
overlying tissues are replaced and the scalp is
then sutured into position.
Waking up from General Anesthesia - If
you have received general anesthesia during
surgery, once the surgery is over you will
wake up and the tube down the wind pipe will
be removed. You will be asked to open your
eyes before the tube is removed. You will be
sedated and the voice of the anesthetist may
be faint. Once the tube is out, you may have
cough and sometimes nausea. Your doctor
will do some tests to make sure that your
nerves are not damaged during the surgery.
There may be a tube going into the stomach
called a nasogastric or Ryle’s tube to keep it
empty. There will also be an intravenous line.
You will remain on oxygen (usually through a
face mask). Once fully awake, you will be
shifted to the recovery room.
Recovery Room - In the recovery room, a
nurse will monitor your vitals and observe you
for an hour or more before shifting you to an
intensive care unit, where you will be
monitored carefully.
Post-operative Recovery - You will remain
in the hospital for a few days following the
procedure. Light foods may be allowed
following the surgery.
Chest physiotherapy maybe started after 24
hours to prevent chest infection.
DVT Prophylaxis - Early movement of your
legs and some mobilization prevents DVT
or deep vein thrombosis, where a clot is
formed in the deep veins of the legs. The clot
can travel up to the lungs and even be fatal.
Other measures like small dose of heparin and  Diabetes incipidus due to damage to
special stockings may also be used. the pituitary gland, an important
endocrine gland in the brain
After you are discharged from the hospital,
 Seizures
you will have to revisit your doctor after 5 to
 Damage to cranial nerves, the
10 days for removal of the sutures.
nerves supplying the head and neck
region
What are Risks Associated with
 Respiratory problems
Craniotomy?

Craniotomy is a highly complex surgery.

Complications of craniotomy can be life
threatening and include:

 Headache
 Leakage of cerebrospinal fluid
(CSF), the fluid surrounding the
brain, through the cut area if it is not
closed properly
 Bleeding resulting in the formation
of a hematoma. The hematoma may
be required to be removed with
repeat surgery
 Spasm of blood vessel resulting in
reduced blood supply to a particular
part of the brain, thereby resulting in
damage to that part
 Infection
 Air embolism, where air enters a
blood vessel and interferes with
blood supply to a particular part.
Insertion of a CVP line (central
venous pressure line) just before the
surgery helps to remove any
possible air embolisms