Brain - Surgery
Craniotomy
Ruptured Cerebral Aneurysm
Recovery
Craniotomy
What is it?
Craniotomy is the surgical opening of the cranium, the bones of the skull. Crani- refers to the cranium, and -otomy means to cut into.
Why is it done?
A craniotomy is performed to treat various brain problems surgically, such as tumors, aneurysms, blood clots, head injuries, and abscesses. The operation described and illustrated in this website is craniotomy for cerebral hemisphere tumors - tumors that occur around or inside the cerebrum.
The goal of all brain tumor surgery is to take out as much of the tumor as can safely be removed with as little injury to the brain as possible. This may be especially complicated if the boundaries of the tumor cannot easily be identified.
What happens afterwards?
For malignant brain tumors, radiation therapy and/or chemotherapy after surgery may be recommended.
Successful recovery from craniotomy for brain tumor requires that the patient and his family approach the operation and recovery period with confidence based on a thorough understanding of the process. The surgeon has the training and expertise to remove all or part of the tumor, if its removal is possible; however, recovery may at times be limited by the extent of damage already caused by the tumor and by the brain's ability to heal.
If a neurologic deficit remains, a period of rehabilitation will be necessary to maximize improvement. This process requires that the patient and his family maintain a strong, positive attitude, set realistic goals for improvement, and work steadily to accomplish each goal.
The Operation
After a general anesthetic has been given, the patient is positioned according to the area of the brain that must be reached. Often a dehydrating agent, such as Mannitol, is given - again in an attempt to control brain swelling. The operation usually is performed with the patient lying on his or her back. The hair over the incision area is then clipped and shaved.
Incision
A curved incision is made in the scalp over the appropriate location. The scalp flap is then laid back to expose the skull.
Craniotomy
Next, small burr holes are drilled in the skull with a power drill.
A surgical saw is used to connect the holes and create a "window" in the skull through which surgery will take place. The removed bone piece is kept sterile for replacement at the end of the operation.
Exposure of the brain
When the dura is exposed, an ultrasound probe is used to confirm the location and depth of the underlying tumor and help the surgeon plan his approach. Then the dura is cut with a scalpel or scissors and is laid back to uncover the brain, as seen in.
Removal of the tumor
The tumor is carefully dissected from normal brain tissue with special microsurgical instruments. For an intracranial tumor, a small incision is made through the surface of the brain and into brain tissue until the tumor is reached. Ultrasound frequently is used to monitor the tumor's removal.
Specialized instruments may be used by the neurosurgeon to visualize, cut into, and remove the tumor, including a surgical microscope or special magnification glasses, a surgical laser that vaporizes the tumor (literally causing it to "go up in smoke"), and an ultrasonic tissue aspirator that breaks apart and suctions up the abnormal tissue. At this time the biopsy is sent to the laboratory for analysis.
Unlike elsewhere in the body, where some extra tissue around a tumor may be surgically removed "just to be sure," only tissue that can clearly be identified as abnormal may be removed from the brain-and even then only if its removal is possible without devastating consequences. With meningioma and metastatic tumors, usually easy to distinguish from healthy dura and brain tissue around them, the surgeon is more likely to be able to "get it all" than in the case of glioma, where the boundaries of the tumor are unclear and may be impossible to identify.
Replacement of bone
After the dura has been stitched closed, the piece of bone is replaced and sutured into place. An ICP monitoring device may then be implanted.
Incision closure
The operation is completed when the incision is closed in several layers. Unless dissolving suture material is used, the skin sutures (stitches or staples) will have to be removed after the incision has healed.
Ruptured Cerebral Aneurysm
The Operation
Surgery for most cerebral aneurysms takes place deep inside the brain, between its lobes and near vital arteries and nerves.
After a general anesthetic has been given, the patient is positioned according to the area of the brain that must be reached. Usually, the operation is performed with the patient lying on his or her back. The hair over the incision area is then clipped and shaved.
The patient's blood pressure may be lowered with medication to allow the operation to proceed with less risk of re-bleeding.
After a general anesthetic has been given, the patient is positioned according to the area of the brain that must be reached. Usually, the operation is performed with the patient lying on his or her back. The hair over the incision area is then clipped and shaved.
The patient's blood pressure may be lowered with medication to allow the operation to proceed with less risk of re-bleeding. 
Incision
A curved incision is made in the scalp over the appropriate location. The scalp flap is then laid back to expose the skull.
Craniotomy
Next, a small burr hole is drilled in the skull with a power drill. A surgical saw is used to connect the holes and create a "window" in the skull through which surgery will take place. The removed bone piece is kept sterile for replacement at the end of the operation.
Exposure of the brain
The exposed dura is cut with a scalpel or scissors and is laid back to uncover the brain. A surgical microscope is used as the procedure is continued. 
Identifying and clipping the aneurysm
The brain's lobes are gently retracted (pulled back) until the location of the aneurysm is reached, using the surgical microscope and microsurgical instruments.
The tissue-paper-thin aneurysm is carefully freed from the scar tissue surrounding it, and its junction with the brain's blood vessels is identified. One of various kinds of clips is placed across the base of the aneurysm and is adjusted until its position is accurate. This allows the aneurysm to collapse as shown in, but spares the essential blood vessels around it.
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At times the aneurysm will rupture again while surgery is taking place. The surgeon then carefully tries to control the hemorrhage while continuing the delicate clipping procedure.
Replacement of bone
After the dura has been stitched closed, the piece of bone is replaced, using wires made of surgical steel (which will remain in place permanently). An intracranial pressure (ICP) monitoring device may then be implanted. 
Incision closure
The operation is completed when the incision is closed in several layers. Unless dissolving suture material is used, the skin sutures (stitches or staples) will have to be removed after the incision has healed.
Recovery
Healing and Recovery
Healing is the body's natural process of restoring its own tissues to a normal or nearly normal state. Although healing may be improved by general good health, proper nutrition, rest, and physical fitness, it will occur without one's having to work at it.
Recovery is the process during which one works to become well. It requires a gradual but persistent effort to increase physical strengths and minimize weaknesses. One must concentrate on improvement, not on what symptoms remain. This focus on progress, combined with the constant effort to improve, maintains the positive attitude that will speed the return to normal daily activity.
Hospital Recovery
Observation
The patient will be transferred from the recovery room after surgery to the intensive care unit (ICU), where his condition can be more closely monitored. This is a highly specialized area providing close observation with specialized nursing care. lntracranial pressure may be continuously measured as the patient recuperates. When fully conscious and stable, he will be returned to his regular room.
Pain
A dull headache is usually all the post-operative pain to be expected. Pain medication will be ordered for generalized discomfort.
Incision care
The incision will be covered with a turban-like dressing. When this dressing is removed, some other head covering may be used. The skin sutures usually are removed within a week.
Nutrition
Intravenous (I.V.) fluids will be ordered during the early recovery period and continued until liquids may be taken by mouth. For the first few days, all fluids taken will be carefully monitored. As the danger of brain swelling lessens, more fluids may be taken. When there is no nausea or vomiting, and the patient is fully awake, both liquids and diet may be increased.
Emotional changes
It is normal to feel discouraged and tired for several days after surgery. These feelings may be the body's natural reaction to the cutback of extra hormones it put out to handle the stress of surgery. Although emotional let-down is not uncommon, it must not be allowed to get in the way of the positive attitude essential to recovery and the return to normal activity.
Discharge from the hospital
The amount of time spent in the hospital may be different for each patient. Discharge will be planned when the patient's recovery can be handled at home or in an alternate facility.
Home Recovery
The home recovery program will be individualized for each patient. It will depend largely on the extent of brain injury caused by the tumor, the patient's ability for self-care, and the progress of his recovery.
Fever, a severe headache, or any swelling or drainage around the incision should be reported to the physician immediately.
During home recovery, changes in the patient's speech, movement, or mental ability may be noticed. These should be discussed with the physician during post-operative visits. Speech, occupational, or physical therapies may then be ordered.