BRAIN SURGERY - CRANIOTOMY

What is Brain Surgery ?

Craniotomy is the broad term used to describe any operation where a hole is made in the skull. It is one of the oldest operations known to man. Archaeologists have found healed craniotomy openings in the skulls of Stone Age man, presumably made to release evil spirits!

Why is Brain Surgery being performed ?

There are many reasons for performing a craniotomy. It may be done as an emergency following a head injury or brain haemorrhage. This is to remove blood clots which are pressing on the brain. It may be necessary to remove a brain abscess. As a planned procedure, a craniotomy may be essential to remove a tumour or to clip an aneurysm.

What Happens during Brain Surgery ?

If a craniotomy is planned, there will be full discussion of the procedure between the surgeon, you and your relatives. In an emergency, the operation may be performed before relatives are even aware that you are in hospital: speed can be life-saving. A craniotomy will only be performed after investigation of your condition. This usually involves computerized x-ray (CT) or magnetic resonance scanning (MRI). Angiography is often performed. This is an x-ray procedure for seeing the arteries in the brain. For this, dye is injected via a fine tube inserted in the groin. You will be starved from about 8 hours before the operation and usually commenced on steroid (cortisone) tablets to reduce brain swelling. These tablets can sometimes cause stomach upset: the doctor must be told if you have previously had a stomach ulcer. When asleep, tubes will be placed into veins and arteries in the arms in order to give drugs and closely monitor blood pressure. The head will have to be closely shaved; sometimes this is only around the wound; sometimes the whole head must be shaved. The risk of infection is too high if it is not done. You will be placed on the operating table and the wound area thoroughly cleaned. The skull is exposed by making a curved cut over the appropriate area, called a flap, and hinging the flap out of the way. A square of bone is then cut out. Between the brain and skull is a thick membrane called the dura which is opened to expose the brain. When the operation is completed, the dura is closed with stitches. The bone disc is put back and held in place with stitches or wire. The scalp flap is sewn back in place with a layer of stitches or skin staples. A tube to drain any blood from under the scalp is usually left in place and a dressing to the wound applied. Some surgeons then put a heavy bandage over the whole head, others don't.

Possible Complications during Brain Surgery

All operations carry some risks. Brain surgery carries more than most. Any operation can be complicated by heart trouble, chest infection, blood clots in the leg (thrombosis) and wound infection. The chances of these complications are greater in elderly or unhealthy patients and, in particular, those who smoke or drink heavily. The major specific complications of brain surgery are damage to the brain at the time of surgery and bleeding within the head after the operation. Meningitis and epilepsy occasionally follow craniotomy. When bleeding is suspected, you would have to return to theatre within a few hours of the operation for a reopening of the wound. Sometimes deterioration is due to brain swelling and the bone flap is left out, being stored frozen in antibiotic solution. It may then be replaced at a later date when the swelling has settled down. The actual risk in a particular case will depend on the complexity of the operation. This will be explained by the surgeon beforehand. Most craniotomies are performed with no major complications and good results for the patient.

After Brain Surgery

You will probably wake rapidly after surgery but for the next 24 hours will be constantly watched in a special ward. If well, you will be allowed to drink and eat next day and sit out of bed. Intravenous drips and drain tubes will be removed after about 48 hours and stitches (or staples) will be taken out between 2 and 10 days later, depending on the particular operation and surgeon. Steroid tablets will be reduced gradually over several days. When everyone considers that you should be able to manage at home, you will be discharged, but will be seen for further follow-up. Return to work will depend on the underlying reason for the operation. The DVLC will usually withdraw the driving licence for 1 year after the operation because of the slightly increased risk of epilepsy after brain surgery. This risk is usually not large enough to require anti-epileptic tablets. Flying as a passenger within a couple of weeks of a craniotomy is no problem. The area around the wound is usually numb or itches slightly for up to 6 months after surgery, which is normal. For operations on the front of the head, the muscle which opens the mouth is cut and this can leave the jaw stiff and hard to open wide. This usually recovers within a few weeks. Recovery is aided by chewing gum or tough meat.

If Brain Surgery is not performed

This operation is never performed unless absolutely essential.