Craniotomy Surgery: Meaning, Procedure, Types, Success Rate

A Craniotomy is a surgical procedure that involves the removal of a part of the bone from the skull or cranium to expose the brain. The surgeon uses specialised tools to remove the part of the bone called the bone flap. The bone flap is replaced with tiny plates and screws when the surgery is done. 

A craniotomy is generally performed to remove brain tumours and treat aneurysms. This procedure is conducted under general anaesthesia and usually takes about 2 to 3 hours to complete. 

Surgery Name	Craniotomy
Diseases Treated	Brain tumours, Cerebral oedema, Skull fractures, Increased intracranial pressure
Benefits of the Surgery	Removes blood clots, Repairs a membrane tear, Removes the excess blood inside the brain
Treated by	Neurologist

A craniotomy is a surgery that involves the removal of a part of the bone from the skull or cranium to expose the brain. 

Anatomy and Physiology of the Brain

The brain is one of the largest organs of the human body, which comprises more than 100 billion nerves that work together and help in communication. The different specialised areas of the brain are 

1. Cortex: The outermost layer of the brain cells is called the cortex, which controls thinking and voluntary movements. 
2. Cerebellum: It lies at the base and the back of the brain. It is responsible for coordination, posture, and balance. It consists of the cerebellar cortex and cerebellar nuclei. The cerebellum is connected to the brainstem part by the structure called cerebellar peduncles. 
3. Brain stem: The brain stem is between the spinal cores and the base of the cerebellum. It helps in essential functions such as sleeping and breathing. It consists of the midbrain, pons, and medulla.
4. The Cerebrum: This is divided into the right hemisphere and the left hemisphere. It consists of many ridges, folds, and convolutions on its surface. The function of the cerebrum is to coordinate and process the sensory and motor functions of the body. 

The brain is also divided into several lobes:

1. The frontal lobes are responsible for judgment and problem-solving. 
2. The parietal lobes manage body position, sensation, and handwriting. 
3. Temporal lobes are involved in hearing and memory.
4. Occipital lobes are involved in the brain's visuals.

A craniotomy can be performed to treat several conditions of the brain, including:

1. Brain tumours (growth of abnormal cells in the brain)
2. Aneurysm (enlargement of the artery caused by a weak spot in the arterial wall)
3. Blood clots from a leaking blood vessel
4. Intracranial infections or central nervous system infections may include brain abscesses (infected pus-filled pockets)
5. Cerebral oedema (swelling)
6. Bleeding inside the skull
7. Arteriovenous malformation or AVM (abnormal formation of blood vessels connecting arteries and veins, disrupting the normal blood flow)
8. Arteriovenous fistula or AVF (an abnormal connection between an artery and vein in which the blood flows from the arteries to your capillaries to your veins)
9. Skull fractures
10. Dura mater tear (a tear in the outermost layer of connective tissue that surrounds the brain and spinal cord)
11. Increased intracranial pressure (pressure within the brain)
12. Epilepsy (neurological disorder)
13. Movement disorders like dystonia or Parkinson’s disease

A craniotomy is performed in adults and children who are suffering from conditions within the skull, such as:

1. Brain tumours
2. Arteriovenous malformation
3. Arteriovenous fistula
4. Skull fractures
5. Increased intracranial pressure

As an invasive surgical procedure, it usually takes about 2 to 3 hours to complete. depending on the patient's age, medical condition of the patient and the complexity of the case. The procedure is done under general anaesthesia to keep the patient comfortable. A Neurologist along with other professional medical staff performs this procedure. Generally, craniotomy involves the following steps:

1. The patient will be made to relax on the operating table, positioned to offer the best access to the side of the brain to be operated on.
2. The team will use a head device to hold your head in place.
3. An intravenous (IV) line will be placed in the patient's arms or hands for fluids and medications. 
4. The team will insert a urinary catheter to drain the urine.
5. Someone from the team will clean the skin over the surgical site with an antiseptic solution.
6. Administration of anaesthesia
   The anaesthesiologist will inject general anaesthesia through an intravenous line to put the patient into a deep sleep. Once the patient is asleep, a breathing tube will be inserted down the throat to help the patient to breathe. 
7. Making an incision
   Various types of incisions will be used in craniotomy, depending on the brain’s affected area. Incisions will usually be made behind the hairline. The incisions will be smaller if an endoscope is used in the surgery. 
8. Opening the skull
   The surgeon will use a high-speed electric drill to create burr holes in the skull and cut the bone carefully. He/she cuts an outline of a part of the bone called a bone flap. The bone flap is removed to expose the thick outer covering of the brain called the dura mater. The bone flap is kept aside to be attached at the end of the surgery.
9. Exposing the brain
   The surgeon will open the dura mater to expose the brain. He/she will allow the excess fluid to flow out of the brain if needed. He/she uses microsurgical instruments, such as a microscope, to magnify the area to be treated. This will help the surgeon better examine the brain structures and differentiate between healthy and abnormal tissues. 
10. Correcting the problem
    The surgeon may place a drain or special monitor in the brain tissue to measure the intracranial pressure (ICP). He/she will use small instruments to work deep inside the brain. Finally, the problem will be corrected, and tissue samples may be removed to send to the lab for testing. 
11. Closing the craniotomy
    Once the surgery is completed, the neurosurgeon will sew the tissue back together. He/she will use plates, sutures, or wires to reattach the bone flap. Next, he/she will close the skin incision with stitches or surgical staples and apply a sterile bandage over the incision.

Before the craniotomy, the doctor/surgeon will discuss and prepare the patient for the surgery. These steps often involve:

Before Craniotomy

1. The doctor will advise the patient for a pre-anaesthetic checkup. 
2. The doctor will examine the patient's complete medical history and conduct a physical exam to ensure that the patient is in good health before the surgery. 
3. The patient will also have to undergo other tests such as blood tests, CT scans, and MRIs.
4. The patient will undergo a preoperative neurological exam to compare the postoperative results.
5. The healthcare team will ask the patient to fast after midnight, the night before the surgery.
6. The patient must inform his/her doctor about the medications (prescribed and over-the-counter) and herbal supplements he/she takes.
7. The patient may need to stop taking blood-thinning medications like aspirin before the procedure. 
8. If the patient smoke, the doctor will ask the patient to stop smoking as soon as possible to improve the recovery process. 
9. The doctor will ask the patient to wash his/her hair with an antiseptic shampoo the night before the surgery. 
10. The doctor will explain the procedure, duration of the hospital stay, estimated cost, and insurance formalities.

On the day of the Craniotomy

1. On the day of the surgery, the hospital staff will ask the patient to sign a consent form permitting the surgery. 
2. The team will ask the patient to remove jewellery, nail polish, hairpins, or other objects that may interfere with the surgery. 
3. The patient will be asked to remove the clothes and wear a hospital gown. 
4. If the patient has instructions about taking regular medications on the day of the surgery, he/she must take them with a sip of water. 
5. Someone from the team will shave the area around the surgical site. 
6. The doctor will record the patient's last meal and give him/her a sedative to help relax. 
7. The anaesthesiologist will monitor the patient's vitals, including heart rate, blood pressure, and breathing. 
8. The team will shift the patient to the operating room.

A patient who has undergone craniotomy can expect the following after the surgery:

The recovery process at the hospital

1. The patient will be taken to the recovery room immediately after the procedure for observation. 
2. Once the breathing, pulse rate, and blood pressure stabilise and the effect of anaesthesia wears off, the patient will be shifted to an ICU to be closely monitored. 
3. The doctor will give the patient medicine to reduce brain swelling. 
4. After staying in the ICU, the team will move the patient to a hospital room. 
5. The patient will be given oxygen for several days after the surgery. 
6. The nursing team will elevate the head of the patient's bed to prevent swelling of the face and head. 
7. The patient will be taught deep breathing exercises to prevent pneumonia. 
8. The medical staff will conduct frequent neurological tests to check the functioning of the patient's brain and body systems. 
9. The doctor will check the patient's pupils with a flashlight and evaluate the orientation by asking questions, such as name, date, etc. 
10. A physical therapist will help the patient get out of bed and walk around. He/she will evaluate mobility, strength and balance.
11. The doctor will place sequential compression devices (SCDs) on the patient's legs to prevent blood clot formation. 
12. The patient may be given liquids a few hours after the surgery. The diet will gradually include solid foods once the patient can handle them.
13. The urinary catheter will stay in the patient's bladder for a day or two or until he/she gets out of bed. 
14. The patient may need to stay at the hospital for about one week. 
15. Before the patient is discharged, the doctor will provide home care and follow-up instructions.

Recovery process/expectation after hospital discharge

1. The doctor will give specific bathing instructions to keep the incision clean and dry. 
2. Do not submerge the incision in a pool or tub. 
3. The doctor may advise the patient to wear a hat or a loose turban over the incision. 
4. Avoid wearing a wig until the incision completely heals. 
5. The patient may experience pain in the head and incision during deep breathing and coughing. Take a pain reliever as recommended by the doctor. 
6. Take the prescribed medications as directed.
7. Continue breathing exercises at home to prevent lung infections. 
8. The doctor will advise the patient to avoid exposure to irritants such as environmental pollution and tobacco smoke. 
9. Refrain from lifting heavy objects for several weeks after the surgery. 
10. The patient should gradually increase physical activity. Do not drive until the doctor permits. 
11. The patient may face issues with walking, talking, balance, and strength. The doctor may recommend physiotherapy, speech therapy, or occupational therapy to regain these functions. 
12. The patient must sleep with their head raised and apply ice 3 to 4 times daily to decrease pain and swelling. 
13. Full recovery may take up to eight weeks.

First follow-up appointment

1. The doctor will typically schedule the first follow-up appointment 10 to 14 days after the surgery.
2. During this visit, the doctor will remove the sutures or staples.
3. The doctor will examine the recovery and provide further follow-up instructions.

There are several benefits of a craniotomy, including:

1. Repairs a membrane tear
2. Removes the excess blood inside the brain
3. Removes blood clots
4. Drains brain abscesses
5. Helps diagnose and treat a brain tumour
6. Relieves pressure in the brain
7. Treats disorders such as Parkinson’s disease and epilepsy

No surgery is free of complications. Common side effects of the surgery may include:

1. Bleeding
2. Blood clots
3. Pneumonia
4. Risks associated with general anaesthesia
5. Unstable blood pressure

Possible complications of craniotomy include:

1. Head scarring
2. Brain swelling
3. Seizures
4. Stroke
5. Muscle weakness
6. Leakage of cerebrospinal fluid
7. Damage to the sinuses
8. Infection of the bone flap
9. Facial nerve damage

Some other rare complications include:

1. Speech problems
2. Memory problems
3. Balance issues
4. Paralysis
5. Coma

When is consultation with the doctor needed?

A craniotomy is a complicated procedure and has a more extended recovery period. Kindly contact your doctor immediately if you face any complications after the surgery.

1. Fever or chills
2. Increased pain, redness, and swelling around the incision site
3. Bleeding or drainage from the incision site
4. Changes in vision
5. Weakness in arms or legs
6. Confusion
7. Feeling excessively sleepy
8. Trouble with speech
9. Trouble in breathing
10. Seizure activity
11. Chest pain and anxiety
12. Blood-tinged sputum

The sequelae of delaying craniotomy include:

1. Patients may have signs of brain damage: Coma, limb paralysis, respiratory paralysis, blindness, forgetfulness, and personality changes.
2. Patients may have extensive brain infarction and severe brain swelling.

The cost of craniotomy ranges from ₹1,50,000 to ₹4,00,000. The cost varies based on the following factors:

1. Age of the patient
2. The type of procedure done
3. The technique and equipment used
4. The medical condition of the patient
5. The type of hospital facility availed - individual room or shared.

Procedure Name	Cost Value
Craniotomy	₹1,50,000 to ₹4,00,000