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A craniotomy is a surgical procedure that involves the exposure of the brain by removing a portion of the bone from the patient’s skull. This bone flap is removed temporarily, then covered or placed back with screws and plates after the craniotomy is done.

As a surgical procedure, craniotomies vary in complexity and size. Some small craniotomy procedures are referred to as burr holes. While on the other hand, larger bone flaps are required for procedures such has hematoma evacuation and brain tumour surgery.

How is a craniotomy performed?

The procedure is performed under general anaesthesia. Hair at surgical site is usually shaved off. This done to minimize the risk of getting infections.

The surgeon marks an incision on the scalp using neuronavigation techniques. This helps to optimise incision and bone flap size. He or she then makes the incision.

To remove the bone flap, a surgical drill is used. The surgeon then cuts the dura matter (the outermost membrane of the brain) to access the patient’s brain surface to perform the intended surgery.

Once the surgery is done, the surgeon closes the duramater and other soft tissue with sutures and replaces the bone flap with plates.

He or she then closes the incision carefully and applies a sterile bandage.

The entire procedure of craniotomy takes approximately 2 to 3 hours to complete.

Types of craniotomy procedures

Extended Bifrontal Craniotomy

This is a traditional method that treats complex tumours in the front part of the brain. It is considered a safer approach to remove the extra part of the bone than to disturb the brain unnecessarily. The types of complex brain tumours treated with an extended bifrontal craniotomy are esthesioneuroblastomas, meningiomas, and various malignant skull base tumours.

Minimally Invasive Supra-Orbital “Eyebrow” Craniotomy

As the name suggests, it is a minimally invasive procedure involving a small incision in the eyebrow region. This allows surgeons to reach tumours located in the pituitary gland or the frontal part of the brain. This technique involves minimal scarring, very little pain, fast recovery. Minimally Invasive Supra-Orbital “Eyebrow” Craniotomy is mainly recommended for skull base tumours, Rathke’s cleft cysts, and some types of pituitary tumours.

Orbitozygomatic Craniotomy 

This traditional method treats complex tumours and aneurysms. The procedure involves an incision in the patient’s scalp at the back of the hairline and then removal of the bone that forms the contour of the cheek and orbit. In this method, the bone flap is put back at the end of surgery. Orbitozygomatic Craniotomy treats pituitary tumours, craniopharyngiomas, and meningiomas.

Retro-Sigmoid “Keyhole” Craniotomy 

This is also considered a ‘keyhole surgery’ as it is minimally invasive. It involves a small incision at the back of the patient’s ear so that the surgeon can easily access the brainstem and cerebellum. A Retro-Sigmoid “Keyhole” Craniotomy is usually performed for acoustic neuromas (vestibular schwannomas), meningiomas, metastatic brain tumours, and skull base tumours.

Translabyrinthine Craniotomy

This tradition method involves making an incision at the back of the ear in the scalp. The surgeon then removes some of the inner ear bone especially, the semicircular canals that contain balance receptors, and the mastoid bone. The surgeon then locates and treats the tumour. Translabyrinthine craniotomy is usually recommended for treating acoustic neuromas.

Stereotactic craniotomy 

If any craniotomy surgery is performed with the help of CT or MRI scans, then it is known as a stereotactic craniotomy. In this type of surgery, the treating surgeon makes use of imaging tests to produce 3D images of the patient’s brain. It allows them to clearly distinguish between normal and abnormal or diseased tissues. With this method, the surgeon can also locate the best spot for making a scalp incision. This makes it much easier for the surgeon to make smaller incisions and accomplish the treatment using minimally invasive procedures.

What conditions does a craniotomy treat?

Craniotomy surgery is performed to treat the following medical conditions that involve the brain:

  • Aneurysm
  • Tumor
  • Cerebral edema or swelling
  • Infection
  • Bleeding inside the skull
  • Brain abscess
  • Blood clots
  • Skull fracture
  • Arteriovenous malformation
  • Arteriovenous fistula
  • Dura mater tear
  • Intracranial pressure
  • Epilepsy
  • Memory problems
  • Paralysis
  • Speech problems
  • Abnormal coordination or balance
  • Coma
  • Implantation of neurostimulatory devices for movement disorders such as Dystonia or Parkinson’s disease

How to prepare for a craniotomy?

The patient should take care of some of the following points before the craniotomy surgery:

  • Stop taking any medications like anti-inflammatory and blood-thinners
  • Quit smoking, alcohol, and tobacco intake for at least 2 weeks before the procedure
  • Avoid drinking or eating anything at least 8 to 12 hours before the surgery
  • Inform the treating surgeon about any allergies or past surgeries

What are the risks with this procedure?

With any surgery, there are always some risk factors or possible complications. The following are some common risks associated with craniotomy:

  • Infection
  • Seizures
  • Accumulation of fluid inside the brain
  • Bleeding
  • Inflammation
  • Pneumonia (lung infection)
  • Strokes
  • Paralysis
  • Swelling in the brain
  • Any other loss of function such as speech or memory depending on the area of the brain being operated on
  • Leakage of cerebrospinal fluid (the fluid that surrounds and cushions the brain)
  • Risks related to general anaesthesia such as nausea, vomiting, confusion, and diarrhoea

Some complications that are rare and mostly depend on the related areas being treated in the brain include:

  • Memory problems
  • Paralysis
  • Speech problems
  • Abnormal coordination or balance
  • Coma

Craniotomy does involve some other risk factors that depend on the health of the patient undergoing this surgery. Therefore, it is important to discuss all the concerns with the treating doctor beforehand.

The recovery from a craniotomy

The recovery time after the craniotomy ranges between 1 to 4 weeks. This is dependent on the underlying problem being treated and the overall health of the patient. Full recovery may take up to 8 weeks.

To recover faster walking is recommended after the surgery. It might take several weeks for a patient to return to normal routine activities. Also, it’s vital to carefully follow their recovery guidelines post-surgery.

Frequently asked questions

What is normal after a craniotomy?

  • Pain at the incision site
  • Headache during coughing
  • Deep breathing
  • Exertion

What does your head feel like after a craniotomy?

The patient probably feels very tired for several weeks after surgery. There may also be headaches or concentrating problems. The overall recovery takes around 4 to 8 weeks. The incisions on the head may be sore for nearly 5 days post-surgery.

Does the skull grow back after a craniotomy?

If the bone flap has been removed at the time of surgery, a few weeks to months, the patient may have to undergo a follow-up surgery known as cranioplasty. During a cranioplasty, the absent piece of bone is replaced with the patient’s original bone, a metal plate, or a synthetic material.

How long do headaches last after a craniotomy?

The International Headache Society (IHS) states that chronic post-craniotomy headache is a headache, that occurs in the treated area and develops within one-week post-craniotomy. It continues for at least 3 months. Whereas an acute post-craniotomy headache lasts for less than 3 months and has almost the same characteristics as the chronic one.

Is craniotomy a major surgery?

Yes, craniotomy is major surgery as it involves exposing the brain by drilling into the skull.

What is an awake craniotomy?

Awake craniotomy is a procedure primarily used for an intra-axial mass lesion residing in or adjacent to eloquent brain. Essentially, the mapping and resection of affected lesions in extremely important parts of the brain where imaging techniques is not adequately sensitive. 

These most commonly involve the motor and speech areas. The awake craniotomy technique has become popular due to the benefit of better neurological and other associated perioperative results like analgesia and post-surgical vomiting and nausea.

What is the difference between a craniotomy and a craniectomy?

A craniotomy is a surgical procedure that involves the exposure of the brain by removing a portion of the bone from the patient’s skull. In this, some section of bone known as the bone flap is also removed with the help of some fine instruments. This bone flap is removed temporarily, then laced back after the craniotomy is done.

  • The bone flap is removed surgically and later after the surgery, it is returned to the skull or its original position.
  • It is usually performed so the brain can be accessed for any further planned surgery.

A craniectomy surgery also involves the removal of a bone flap, but this bone flap is not returned to its original location post-surgery. This may happen if there is any trauma to the bone involved, the brain is too inflamed to allow the replacement of the bone flap, or if the treating surgeon feels it is best for the patient. It may also be discarded if there is an infection in the treated area.

  • The bone flap is removed surgically but is not placed back after surgery.
  • Usually recommended relieving pressure exerted on the brain.