Craniotomy

About Craniotomy

Craniotomy is the surgical removal of a section of the skull, called a bone flap, to gain access to the brain, with the bone usually replaced at the end of the operation. It is performed to remove brain tumors, clip aneurysms, remove arteriovenous malformations, evacuate blood clots after trauma or hemorrhage, treat epilepsy and relieve pressure. After planning with image guided neuronavigation, the surgeon makes a scalp incision, drills small burr holes, cuts the bone flap with a craniotome, opens the dura mater and performs the intended procedure, then closes the dura and secures the bone with small plates and screws. Awake craniotomy with brain mapping is used for tumors near areas that control speech or movement, allowing the surgeon to test function during the operation and maximize safe removal. Intraoperative MRI and fluorescence guidance with 5 aminolevulinic acid help surgeons see the boundaries of some gliomas. For aneurysms, a titanium clip is placed across the neck of the aneurysm to exclude it from the circulation, although endovascular coiling and flow diverting stents are now common alternatives. When brain swelling is severe, the bone flap may be left out temporarily in a decompressive craniectomy. Complications include infection, bleeding, seizures, stroke, cerebrospinal fluid leak and new neurological deficits. Stereotactic biopsy through a small burr hole can obtain tissue for diagnosis with minimal invasiveness. Brain tissue itself has no pain receptors, which makes awake surgery possible. The American neurosurgeon Harvey Cushing is regarded as a founder of modern neurosurgery.