C.

Operation Performed
Craniotomy What is a craniotomy? Craniotomy is any bony opening that is cut into the skull. A section of skull, called a blone flap, is removed to access the brain underneath. There are many types of craniotomies, which are named according to the area of skull to be removed . Typically the bone flap is replaced. If the bone flap is not replaced, the procedure is called a craniectomy. Craniotomies are also named according to their size and complexity. Small dime-sized craniotomies are called burr holes or keyhole craniotomies. Sometimes stereotactic frames, imageguided computer systems, or endoscopes are used to precisely direct instruments through these small holes. Burr holes or keyhole craniotomies are used for minimally invasive proceduresto:

y y y y y y

insert a shunt into the ventricles to drain cerebrospinal fluid (hydrocephalus) insert a deep brain stimulator to treat Parkinson Disease insert an intracranial pressure (ICP) monitor remove a small sample of abnormal tissue (needle biopsy) drain a blood clot (stereotactic hematoma aspiration) insert an endoscope to remove small tumors and clip aneurysms

Large or complex craniotomies are often called skull base surgery. These craniotomies involve the removal of a portion of the skull that supports the bottom of the brain where delicate cranial nerves, arteries, and veins exit the skull. Reconstruction of the skull base is often necessary and may require the additional expertise of head-and-neck, otologic, or plastic surgeons. Surgeons often use sophisticated computers to plan these craniotomies and locate the lesion. Skull base craniotomies can be used to: y y y y remove or treat large brain tumors, aneurysms, or AVMs treat the brain following a skull fracture or injury (e.g., gunshot wound)

remove tumors that invade the bony skull There are many kinds of craniotomies. Ask your neurosurgeon to describe where the skin incision will y be made and the amount of bone removal. Who performs the procedure? A craniotomy is performed by a neurosurgeon; some have additional training in skull base surgery. A neurosurgeon may work with a team of head-and-neck, otologic, oculoplastic and reconstructive surgeons. Ask your neurosurgeon about their training, especially if your case is complex.

D.Nursing Management
What happens before surgery? (PRE-OPERATIVE) You will typically undergo tests (e.g., blood test, electrocardiogram, chest X-ray) several days before surgery. In the doctors office you will sign consent forms and complete paperwork to inform the surgeon about your medical history (i.e., allergies, medicines, anesthesia reactions, previous surgeries). You may wish to donate blood several weeks before surgery. Discontinue all non-steroidal anti-inflammatory medicines (Naproxin, Advil, etc.) and blood thinners (coumadin, aspirin, etc.) 1 week before surgery. Additionally, stop smoking, chewing tobacco, and drinking alcohol 1 week before and 2 weeks after surgery because these activities can cause bleeding problems.

DRAPING THE PATIENT a. The procedure of covering a patient and surrounding areas with a sterile barrier to create and maintain a sterile field during a surgical procedure is called draping. The purpose of draping is to eliminate the passage of microorganisms between nonsterile and sterile areas. Draping materials may be disposable or nondisposable. Disposable drapes are generally paper or plastic or a combination and may or may not be absorbent. Nondisposable drapes are usually doublethickness muslin. Drapes, of course, must be sterile. b. Since draping is very important in preparing a patient for surgery, it must be done correctly. The entire surgical team should be familiar with the draping procedure. The scrub must know the procedure perfectly and be ready to assist with it. During the draping procedure, the circulator should stand by to direct the scrub as necessary and to watch carefully for breaks in sterile technique. (1). The first step in draping is the placing of a drape sheet from the foot to the knees. The scrub will select the sheet and hand one end to the surgeon across the operating table, supporting the folds, keeping it high, and holding it taut until it is opened, then drop it (open fingers and release sheet). The second drape sheet is handled in the same manner. This sheet is placed below the incision site with the edge of the sheet just below the incision site. This draping sheet provides extra thickness of material under the area from the Mayo tray to the incision where instruments and sponges are placed. It also closes some of the opening in the laparotomy sheet, if necessary. (2) When disposable drapes are used, the towels usually have a removable strip with an adhesive on the folded edge. The third step in draping is placing the four sterile towels around the line of incision. The scrub unfolds first towel, passes the towel drape to the surgeon with the strip side facing the scrub, and then removes the adhesive strip. The surgeon places the towel within the scrubbed area on the near side of the line of incision, leaving only enough exposed skin for the incision. The second towel is placed in the same way, except the towel is placed on the lower side (toward feet) of the line of incision. The third towel is passed the same way, except the towel is placed on the upper side (toward head) the line of incision. The last towel is passed to the surgeon with the adhesive strip facing the surgeon and is placed on the far side of the line of incision. The adhesive area holds the towel drapes in place. NOTE: The only procedure changes that are made with nondisposable, muslin drapes (for example, hand towels) are as follow. The towels are cuffed by the scrub about 3 inches and the folded edge goes next to the line of incision. The first three towels are cuffed toward the scrub; the fourth towel is cuffed toward the surgeon. The towels are held in place by towel clips rather than by adhesive. (3) Finally, the scrub will select the surgical drape (lap sheet). This lap sheet has a fenestration (opening) in the drape for the incision. The scrub places the opening directly over the skin area outlined by the drape towels and in the direction indicated for the foot or head of the table. The lap sheet will have an arrow or some other indication to identify the head or foot portion of the drape. Drop the folds over the sides of the table, then open it downward over the patient's feet and upward over the anesthetist screen. c. Aseptic technique must be observed at all times in the draping process. You should: (1) Handle the drapes as little as possible. (2) Never reach across the operating table to drape the opposite side; go around the table. (3) Hold the drapes high enough to avoid touching nonsterile area but avoid touching the overhead light. (4) Hold the drape high until it is directly over the proper area, then drop (open fingers and release sheet) it down where it is to remain. NEVER ADJUST ANY DRAPE. If the drape is incorrectly placed, leave it in place and place another drape over it. (5) Protect the gloved hands by cuffing the end of the sheet over them. Do not let the gloved hand touch the skin of the patient.

(6) In unfolding a sheet from the operative site toward the foot or head of the table, protect the gloved hand by enclosing it in the turned back cuff of the sheet. (7) If a drape becomes contaminated, discard it immediately. (8) If the end of a drape falls below waist level, do not handle it further. Drop it and use another drape. (9) If in doubt about sterility, discard the drape. (10) If a hole is found in a drape after it is laid down, cover the hole with another drape or discard the entire drape. What happens during surgery? (INTRA-OPERATIVE) There are 6 main steps during a craniotomy. Depending on the underlying problem being treated andcomplexity, the procedure can take 3 to 5 hours or longer. Step 1: prepare the patient No food or drink is permitted past midnight the night before surgery. Patients are admitted to thehospital the morning of the craniotomy. With an intravenous (IV) line placed in your arm, generalanesthesia is administered while you lie on the operating table. Once asleep, your head is placedin a 3-pin skull fixation device, which attaches to the table and holds your head in position duringthe procedure (Fig. 2). Insertion of a lumbar drain in your lower back helps remove cerebrospinal fluid (CSF), thus allowing thebrain to relax during surgery. A brain-relaxing drug called mannitol may be given. Step 2: make a skin incision After the scalp is prepped with an antiseptic, a skin incision is made, usually behind the hairline. Thesurgeon attempts to ensure a good cosmetic result after surgery. Sometimes a hair sparing technique canbe used that requires shaving only a 1/4-inch wide area along the proposed incision. Sometimes theentire incision area may be shaved. Step 3: perform a craniotomy, open the skull The skin and muscles are lifted off the bone and folded back. Next, one or more small burr holes aremade in the skull with a drill. Inserting a special saw through the burr holes, the surgeon uses thiscraniotome to cut the outline of a bone flap (Fig. 3). The cut bone flap is lifted and removed to exposethe protective covering of the brain called the dura. The bone flap is safely stored until it is replaced atthe end of the procedure. Step 4: exposure the brain After opening the dura with surgical scissors, the surgeon folds it back to expose the brain (Fig. 4).Retractors placed on the brain gently open a corridor to the area needing repair or removal.Neurosurgeons use special magnification glasses, called loupes, or an operating microscope to see thedelicate nerves and vessels. Step 5: correct the problem Because the brain is tightly enclosed inside the bony skull, tissues cannot be easily moved aside toaccess and repair problems. Neurosurgeons use a variety of very small tools and instruments to workdeep inside the brain. These include long-handled scissors, dissectors and drills, lasers, ultrasonicaspirators (uses a fine jet of water to break up tumors and suction up the pieces), and computer image-guidance systems. In some cases, evoked potential monitoring is used to stimulate specific cranialnerves while the response is monitored in the brain. This is done to preserve function of the nerve andmake sure it is not further damaged during surgery. Step 6: close the craniotomy With the problem removed or repaired, the retractors holding the brain are removed and the dura isclosed with sutures. The bone flap is replaced back in its original position and secured to the skull withtitanium plates and screws (Fig. 5). The plates and screws remain permanently to support the area;these can sometimes be felt under your skin. In some cases, a drain may be placed under the skin for acouple of days to remove blood or fluid from the surgical area. The muscles and skin are sutured backtogether. A turban-like or soft adhesive dressing is placed over the incision

What happens after surgery? (POST OPERATIVE) After surgery, you are taken to the recovery room where vital signs are monitored as you awake from anesthesia. The breathing tube (ventilator) usually remains in place until you fully recover from the anesthesia. Next, you are transferred to the neuroscience intensive care unit (NSICU) for close observation and monitoring. You are frequently asked to move your arms, fingers, toes, and legs. A nurse will check your pupils with a flashlight and ask questions, such as "What is your name?" You may experience nausea and headache after surgery; medication can control these symptoms. Depending on the type of brain surgery, steroid medication (to control brain swelling) and anticonvulsant medication (to prevent seizures) may be given. When your condition stabilizes, you ll be transferred to a regular room where youll continue to be monitored and begin to increase your activity level. The length of the hospital stay varies, from only 23 days or 2 weeks depending on the surgery and development of any complications. When released from the hospital, youll be given discharge instructions. Stitches or staples are removed 710 days after surgery in the doctors office. Recovery The recovery time varies from 1 to 4 weeks depending on the underlying disease being treated and your general health. Full recovery may take up to 8 weeks. Walking is a good way to begin increasing your activity level. Start with short, frequent walks within the house and gradually try walks outside. Its important not to overdo it, especially if you are continuing treatment with radiation or chemotherapy. Ask your surgeon when you can expect to return to work. What are the risks? No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Specific complications related to a craniotomy may include: y y y y y y stroke seizures swelling of the brain, which may require a second craniotomy nerve damage, which may cause muscle paralysis or weakness CSF leak, which may require repair loss of mental functions

y permanent brain damage with associated disabilities What are the results? The results of your craniotomy depend on the underlying condition being treated Why awake craniotomy? 1.Intraoperative functional cortical mapping epileptogenic lesion ,tomor,AVM steriotactic surgery importance of alert,cooperative patient 2.Intraoperative electrocorticography

epileptogenic lesion importance of avoidance of confounding drugs Preoperative Evaluation The preoperative visit represent the most important factor contributing to a successful perioperative period Preoperative Evaluation P atient selection chronic refractory epilepsy candidate for GA uncomplicated airway P atient assessment anxiety psychological profile seizure pattern( preictal ,ictal and post-ictal,including behavioural concerns) D etailed verbal description of procidure noise ,sensation and environment PCA ,neurological testing Videotape session conduct of anesthetic conduct of the surgery P remedication anticonvulsant sedative drugsIntraoperative Management P ositioning temporal lobe surgery:lateral position patient comfort and safety Patient Comfort E xtra thick mattress warming blanket or warm room padded horse-shoe rigid back support Patient Comfort P illow between legs no urinary catheter

a hand to hold eye to eye contact Intraoperative Monitoring N IB P EKG P ulse oximetry Endtidal CO2 Additional monitoring added as appropriate for the patient arterial or central venous monitoring depending on cardiovascular status Intraoperative Conduct O xygen supplement:via nasal canular with capnography sampling S edation and Analgesia Antiemesis Antiepileptic S edation and Analgesia

administration of sedative is usually begun following placement of monitors and positioning of the patient neuroleptic analgesia:droperidol and fentanyl propofol sedation D uring the early intraoperative period,light sedation is the goal If local anesthetic blockade of the scalp and dura mater isadaquate,the procedure is comfortable during the the objective is to ensure a cooperative patient when cortical mapping is performed and to minimized sedation prior toECoG recording

To avoid anxiety, patient should be forewarned of these activities lound noise levels when burr

holes are drilled stimulation duringECoG recording

Instruments used