Craniotomy - Procedure, Indications and Contraindications

Introduction:

A craniotomy is a surgery in which a portion of the skull is removed transiently to uncover the brain and execute an intracranial procedure. The typical conditions that can be handled through this method include tumors, brain aneurysms, arterio-venous disorders, subdural empyemas, subdural hematomas, and intracerebral hematomas. Technical instruments and tools are utilized to extract the bone segments, called a bone flap. This bone flap is extracted transiently, kept at the instrument table, and then repositioned post-surgically.

What Is Craniotomy?

A craniotomy is a procedure done to remove a part of the skull. Based on the cause and indication, the bone can be scrapped and kept in the abdominal subcutaneous area. The approach is called a craniectomy if the flap is scrapped or not repositioned into the skull in operation. Decompressive craniectomy is used in treating cancerous brain edema, and the flap is repositioned after the swelling is reduced. While in the second procedure, the surgical method to rebuild and reposition the flap into the skull is called cranioplasty. Based on the kind of lesion occurring intracranially, its pathology, and the approach used, craniotomy processes can be done by neuronavigation guidance depending on magnetic resonance imaging. It also uses computed tomography scans for the process using the least incision. Neuronavigation is a computerized technology that supports surgeons in localized disease. It gives a higher grade of confidence and an improved postoperative result.

What Are the Anatomic and Physiologic Considerations in Craniotomy?

• There are various craniotomy procedures. The type of craniotomy is based on the open top portion of the skull. Characteristic skull bones are selected for craniotomy, involving the frontal, parietal, temporal, and occipital bones. Based on the pathology, supratentorial or infratentorial craniotomies can be used.

• One of the conventional craniotomies employed is peritoneal craniotomy. It is a supratentorial craniotomy employed for front region blood circulation aneurysms, basilar tip artery, straightforward surgical procedures to the cavernous sinus, frontal lobe tumors, temporal lobe tumors, suprasellar tumors like pituitary adenomas and craniopharyngiomas. Another kind of supratentorial craniotomy is the temporal craniotomy or subtemporal craniotomy, which can be used for biopsy procedures, especially for the temporal lobe, lobectomy, epilepsy procedure, and lobe. It also provides an entrance to the middle cranial fossa.

• The craniotomy of the front portion is utilized to reach the frontal skull floor and the frontal lobe for procedures to the third ventricle tumors or sellar area tumors, craniopharyngiomas, planum sphenoidal meningiomas, tumors, and restoration of anterior cerebrospinal fluid fistulas.

What Are the Indications of Craniotomy?

The craniotomy procedure is indicated in numerous conditions requiring the opening of the skull. It is done to find the disease and also for its treatment.

Common conditions in which craniotomy is indicated are-

• Brain aneurysm.

• Vascular malformations include arterio-venous disorganization, cavernous angioma, and fistula in the vessels.

• Brain tumors include the meningioma, elevated-grade and inferior-grade glioma, epidermoid, ependymoma, oligodendroglioma.

• Orbital tumors or tumors in the eyes.

• Pituitary adenomas.

• Tumors in the cerebellopontine angle.

• Pain management like microvascular decompression.

• Abscess.

• Empyema.

• Intracerebral hematomas, epidural hematoma, subdural hematoma.

• Decompressive.

• Lobectomy.

• Epilepsy procedure.

• Craniosynostosis.

• Depressed ruptures.

• Intracranial foreign bodies.

• Cerebrospinal fluid leak restoration.

What Are the Contraindications of Craniotomy?

There are some contraindications to achieving this procedure, and those depend on the patient's disease condition.

Some contraindications are -

• Older age.

• Inadequate functional grade.

• Extreme cardiopulmonary condition.

• Severe systemic collapses like sepsis and multiple organ failure.

• Diseases that a single bur hole can manage.

• Changed preoperative coagulation parameters.

• Bleeding disorders.

How Is Pre-operative Preparation Done in Craniotomy?

• The patient must be in good condition to accept the process. The patient should be fasting and with an empty stomach. Anticoagulants (blood-thinning medications) should be stopped three to ten days before the procedure.

• Craniotomy processes are executed under general anesthesia, demanding a need for anesthesiological discussion to get practical etiological reasons to be managed. In a few cases, craniotomy is accomplished under local anesthesia, so communication between patient and surgeon is possible during the procedure involving motor and vocabulary rooms.

• Periodic antibiotics are given preoperatively before the process, which is given for infection prevention along with other drugs, such as anticonvulsants and corticosteroids. Original equipment like a neuronavigation system, microscope, and nerve monitoring is achieved. Preoperatively confirm the availability of intensive care units.

What Are the Complications Of Craniotomy?

A craniotomy can also cause certain complications like other surgical procedures. There is a complication they should be aware of preoperatively; thus, these complications can be managed by taking certain precautions to get better outcomes.

They are,

• Loss of blood that occurs intraoperatively.

• Sinus perforation.

• Intracerebral, epidural, or subdural hematomas.

• Laceration occurs with the craniotome.

• Seizure.

• Stroke.

• Coma and death.

• Hydrocephalus.

• Neurologic deficit.

• Infection.

• Osteomyelitis of the bone flap.

• Meningitis can be bacterial or fungal.

• Headache occurring postoperatively.

• Drill perforator plunge.

• Embolism.

What Is the Clinical Significance Of Craniotomy?

The process of craniotomy is an essential method in advanced healthcare for neurological diseases. Before the beginning of the approach, some patients would not survive circumstances managed daily. Conditions varying from tumors, pathologies of the vascular system, and concussion are treated regularly, which may cause a devastating patient injury if entry to the intracranial cavity is restricted. The procedure has been updated and resumed with the beginning of the latest technology. It produces a process for neurosurgical and neurological management.

Conclusion:

Distinct improvement techniques are developed to enhance patient management, and doctors' team results are split into preoperative, intraoperative, and postoperative. Postoperative patient management includes an interprofessional team which includes an intensive care unit, nurses, and a few cases require speech pathologists, physicians, physical therapists, respiratory doctors, and a discharge scheduling team.