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Craniotomy
The purpose of this document is to help prepare for upcoming brain surgery. It includes information about what to expect before, during, and after your operation. Please read it carefully. If you still have questions or concerns regarding your procedure after reading this guide, please discuss them with your CINN Outpatient Center Nurse or your CINN physician.
Understanding Your Surgical Procedure
The surgical procedure you will undergo is called a craniotomy. A craniotomy is a temporary opening of part of the cranium, or skull. A neurosurgeon performs a craniotomy to gain access to the disease or injury affecting the brain or its blood vessels.
A craniotomy is performed to:
remove a lesion such as a tumor, nodule, cyst or neoplasm;
remove a blood clot known as a hematoma;
repair a leaking blood vessel known as an aneurysm;
remove an abnormal collection of blood vessels known as an arteriovenous malformation or AVM;
drain an infection or abscess;
reroute circulation around a blocked blood vessel through techniques known as Microvascular Anastomosis or Extracranial-Intracranial (EC-IC) by pass;
repair fractures of the skull that resulted from injury;
remove pressure from a trigeminal nerve which is called a microvascular decompression; or
remove pressure from the brainstem (Chiari decompression).
Your CINN physician has recommended a craniotomy because he or she believes this procedure is the best method for treating your condition.
Your Preadmission Testing Appointment
The CINN staff will arrange preadmission testing for you. Preadmission testing will last one to four hours depending on your diagnosis. During the appointment, you may undergo several tests and evaluations.
You may be evaluated by physical, occupational, and speech therapists. These therapists will assess your flexibility, muscle strength, and sensation. They will also assess your speaking and thinking skills and determine how your illness or injury may have affected your ability to work, care for yourself, and participate in the activities you enjoy.
A clinical psychologist may perform a behavioral medicine evaluation, which will help identify issues that may have an impact on your recovery. This evaluation will enable your CINN care providers to help you through the stress of surgery and any difficulties that may arise in the future. You may undergo blood tests, an electrocardiogram, a chest x-ray and perhaps Computed Tomography (CT), Magnetic Resonance Imaging (MRI) or other tests. A physician or nurse practitioner or physician assistant will conduct a comprehensive medical evaluation to assess the non-neurological aspects of your health. This caregiver will take a detailed medical history and conduct a thorough physical exam.
You may request a tour of the the intensive care unit where you will be after your surgery. A tour will allow you the opportunity to meet the nursing staff, and be given an explanation of the intensive care medical equipment.
The Week Before Surgery
You should stop from taking any over-the-counter medications containing Aspirin (Anacin, Bufferin, Ascriptin, etc.), Ibuprofen (Advil, Motrin, Nuprin, Aleve, etc.) or any other blood-thinning medications for one week prior to your surgery. Other medications you should not take 7-10 days prior to surgery are: Fiorinal, Darvon Compound 65 or Percodan. If you are on Coumadin, this will also need to be stopped about 5 days prior to surgery and a Prothrombin time checked on the morning of your surgery. Your medical doctor will advise you about the exact date of stopping the Coumadin in conjunction with your neurosurgeon. You may take Tylenol for pain if needed.
The Day Before Surgery
An anesthesiologist will evaluate your prior to your surgery. This evaluation will include asking you questions about your general health, allergies, previous surgeries, and past reactions to different anesthetics and may be done over the phone or at the hospital depending upon your specific needs.
You will be asked not to eat or drink any food or water after midnight the evening before your admission. You may brush your teeth and rinse your mouth, but do not swallow the fluid. Ask your Outpatient Clinic Nurse or your doctor about taking your usual medications the morning of your surgery.
The Day Of Surgery
If you have films from another hospital or facility, please remember to bring them with you the day of surgery. The hospital will call you several days prior to your admission to tell you what time you should arrive. When you arrive at the hospital, you will register at the Patient Registration/Admission Office. You will be asked to sign a surgical consent form that specifies the operation that you will undergo and that has been described to you by your doctor. You will then be directed to the General Care Unit or pre-operative holding area.
Your family and friends may remain with you until you leave your room for surgery. Depending on the reason for surgery, the length of the operation is from four to six hours or possibly longer. Ask your CINN physician the approximate length of your surgery.
If your surgery is scheduled for the morning, you will leave your room for surgery at approximately 7:00 a.m. If your surgery is scheduled for later, your nurse will inform you of the time it will take place. Your physician will try to prevent delays, but they can occur because of emergencies. If your surgery is delayed, your nurse will tell you when you can expect it to begin.
Preparing for Surgery
Before leaving your room, you will be asked to disrobe, put on a hospital gown, and empty your bladder. For your safety, you will be asked to remove hairpins, nail polish, make-up, jewelry, dentures, partial plates, hearing aids, contact lenses and glasses. Please store dentures, glasses, contact lenses, and hearing aids in containers labeled with your name. You should send your jewelry, wallet, and other valuables home with your family for safekeeping.
Accommodations for your Family
A surgical waiting area is available for your family to use while you are in surgery. During surgery, the operating room nurse will call the waiting area and provide your family with updates about your progress.
Entering the Operating Room
A transporter will assist you onto a cart and take you to the hospital's specially equipped neurosurgical area. When you arrive, the operating room nurse, anesthesiologist, and neurophysiology technician will talk with you and answer any questions you may have about the procedure.
Surgical Preparation
An intravenous (IV) catheter will be placed in your hand or arm at this time. The catheter allows for fluids and medications to be given to you during surgery. You will be given medication via the catheter and you will fall asleep. After you are asleep, the anesthesiologist will place a breathing tube in your throat to help you breathe during surgery.
After you are asleep, it may be necessary for the anesthesiologist to insert another catheter into an artery in your wrist in order to measure your blood pressure more accurately. It may also be necessary for the anesthesiologist to insert an IV catheter into your neck or upper chest area so that your blood pressure, fluid volume status or both can be measured accurately. Your heart rate and rhythm, breathing, blood pressure, and oxygen saturation will all be monitored closely by the anesthesiologist. Another catheter called a Foley catheter, will be gently placed into your bladder in order to accurately measure your urinary output. These catheters are all temporary and will be taken out within a few days of surgery. In order to maintain adequate blood circulation in your legs during surgery, tight white stockings called "TED Hose" and compressive boots will be placed on your legs. You will wear these during the entire surgery and during your recovery period.
Undergoing Surgery
Your body will be positioned according to the area of the brain that must be reached. A portion of your head may be shaved and washed with an antiseptic cleansing solution.
Your physician will make an incision in your scalp over the predetermined location. He or she will then make a window or bone flap in the cranium. It is through this bone flap that your physician will enter the brain and perform your surgery.
Your physician may use specialized instruments to perform the surgery. These instruments may include the Stealth Guidance System, surgical microscope, special magnification glasses, a surgical laser, and an ultrasonic tissue aspirator. If you are undergoing surgery for a tumor, a portion of the tumor that is removed will be given to a pathologist, who will analyze the tissue immediately. Based on the initial analysis of this tissue and other findings, your physician will choose to biopsy or remove the tumor. The pathologist will continue to analyze the tumor tissue and provide a detailed report about it approximately two to three days after surgery.
When your physician has completed surgery, the brain covering membrane (dura) is stitched closed, and the bone is replaced and sutured into place. The operation is completed when the skin has been closed with either stitches or staples. The breathing tube, used to help you breathe during surgery, will be removed. Your throat may be dry and a little scratchy. Your physician may decide, based on your physical condition, to keep the breathing tube in place overnight.
Beginning your In-Hospital Recovery
After your operation is completed you will be transported to the post-anesthesia care unit (PACU) where you will remain for two to four hours or you may go directly to the intensive care unit (ICU). The nurses will be frequently checking your heart rate and rhythm, blood pressure, temperature, and oxygenation. You will frequently be asked to move your arms, fingers, toes, and legs. A nurse will also check your pupils with a flashlight and will ask you questions such as "What is your name?" Your physician will discuss your surgery with your family after you have arrived in the PACU or ICU. He/she will also call or fax your referring or family physician to report on the operation.
Your Stay in the Intensive Care Unit (ICU)
Your nurse will continue to closely monitor your vital signs, such as blood pressure, pulse and temperature and perform neurologic examinations every 1-2 hours. You may experience a mild headache after the surgery. If so, you will be given a mild analgesic. You may also feel some tightness or discomfort in the area of your incision. If so, please alert your nurse. In the ICU, pain medicine is not given on a schedule; nurses administer it when needed. If you are in pain, request medication from your nurse.
When you are awake in the ICU, you will notice that you are connected to a monitor. The monitor will continually display your vital signs and may beep occasionally. The monitor uses patches connected to your chest and various cables to monitor your vital signs; it will not cause any discomfort. You may notice sounds in addition to the beeping of the monitor. You may hear beeps, buzzes, and alarms from equipment used in the ICU. These sounds are all normal and should not be cause for alarm.
When you first arrive in the ICU, your eyes may seem a little blurry from the ointment that the anesthesiologist placed in your eyes to keep them moist during surgery. Once your eyes are wiped you will be able to see clearly again. You may have some swelling that may increase for the first two days over your eyelids. You may also be thirsty, but you may not drink fluids for the first few hours after surgery due to the risk of choking or vomiting. Wet sponges can be obtained from the nurse to make your mouth more comfortable. When you are fully alert you will be allowed to have ice chips and will progress to a clear liquid breakfast the day following surgery and a regular diet for lunch as tolerated.
You will have a turban-like dressing or soft adhesive dressing over your incision. You will also notice compressive boots and "TED Hose." Both of these items need to be worn at all times in order to prevent blood clots from forming in your legs. You will be reminded by your nurses to perform deep breathing and leg exercises every one or two hours. Your nurses will also help you turn from side to side in bed. Turning in bed is very important while you are inactive; it helps in preventing complications caused by bed rest such as pneumonia.
If needed, you will be reevaluated by the physical, occupational, and speech therapists. These therapists will assess your flexibility, muscle strength, and sensation after surgery. They will also assess your speaking and thinking skills. The sooner therapy can start, the quicker the recovery.
Completing Your Hospital Stay
You will remain in the ICU for one to two days following surgery. Your family may visit according to visiting hours. When you leave the ICU, you may be transferred to a General Care Unit or "Step-Down" Unit. The Step-down Unit is an intermediate care unit where the nurse can monitor your neurological and vital sign status a little less frequently than in the ICU. You may remain in the step-down unit for 1 to 2 days.
Planning for your Discharge
The usual length of hospitalization is five days, but your length of stay may be different. Physical, occupational, and speech therapists, the psychologist, social worker and other members of the CINN team will closely monitor your progress and will plan with you and your family for your discharge. If further therapies or treatments are recommended, arrangements will be made for them prior to your departure from the hospital.
Instructions about your incision, medications, activity restrictions and follow-up physician visits will be explained and written for you at the time of your discharge. Your physician, nurse, and therapists will discuss the following issues with you before you leave the hospital:
when you will be able to return to work
when you will be able to drive,
what medicines you should take, and
when you should return for a post-surgical check up.
They will also discuss with you any restrictions you should follow on your recreational, household, or sexual activity; and restrictions on your traveling, alcohol consumption, diet, and exercise. Complete discharge instructions.
Your At Home Recovery
After you are discharged from the hospital, you will continue to see your physician periodically for continued evaluation of your progress. Your sutures or staples will be removed 7 to 10 days after surgery. You may have your sutures or staples removed closer to home, if preferred, by your family physician. If you were not scheduled for the removal of your sutures or staples at the time of your discharge, call the CINN Outpatient Clinic and schedule an appointment when you return home.
The incision site should remain dry while the sutures or staples are still in place. You will be able to shower and wash your head with a mild shampoo 24 hours after the sutures or staples are removed. Your incision should be kept clean. Do not place ointments or powders on the incision unless prescribed by your physician. If any redness, drainage, swelling, or fever occurs, call your doctor.
Expect your Outpatient Center Nurse to telephone you within one week after your discharge. He or she will ask you about your discharge instructions, medications, and incision. You may want to discuss your condition or ask questions. If you have any questions or concerns, please call the CINN office. The Outpatient Clinic is open Monday through Friday from 8:30 a.m. - 5:00 p.m.
Your next appointment will be scheduled for approximately one month after surgery. At that time you may undergo an MRI or CT scan to assess how you are healing and to have a post-operative baseline scan for comparison. You may also be evaluated by physical, occupational, and speech therapists to assess your progress.
You may feel fatigued for a period of 2 to 6 weeks after surgery. This is a normal part of healing and is expected. Remember to rest when you feel tired and not to overextend yourself. Pay attention to your body and avoid over-exertion. You may want to consider having your family or friends to assist you with child care, home maintenance and meals.
If you Have any Questions
Please remember that one of the CINN physicians is available 24 hours per day to answer any questions or deal with any issues that may occur before or after your surgery. Do not hesitate to utilize this service.
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Craniotomy For Excision Of A Cerebral Arteriovenous Malformation
WHAT YOU SHOULD KNOW:
You may need a craniotomy if your caregiver has told you that you have an arteriovenous malformation (AVM). A craniotomy is surgery to open your skull and operate on your brain. An AVM is an abnormal connection between your veins and arteries. Arteries are blood vessels that bring blood with oxygen to your different body organs. Veins are blood vessels that bring blood without oxygen to your heart. An AVM may be found anywhere in your brain. Normally, blood flows from your arteries, through your capillaries (very small blood vessels), then into your veins. In AVMs, capillaries are absent and blood flows directly from your arteries into your veins.
You may have had an AVM since birth or you may have developed an AVM during your life. You may need a craniotomy if your AVM causes your brain to bleed. You may also need a craniotomy if you have symptoms such as seizures (convulsions), headaches, or speech problems. Your caregiver will grade your AVM based on its size, location, and depth. This will help him decide whether a craniotomy is right for you. After a craniotomy, your headaches and other symptoms may decrease or stop. You may also find it easier to move and speak.
CARE AGREEMENT:
You have the right to help plan your care. To help with this plan, you must learn about your health condition and how it may be treated. You can then discuss treatment options with your caregivers. Work with them to decide what care may be used to treat you. You always have the right to refuse treatment.
RISKS:
You may get an infection. You may have headaches, eyesight problems, or seizures. You may be allergic to the anesthesia or medicine used during your surgery. You may bleed more than expected or have blood clots. Your brain and the layers of tissue that cover it may swell. You may need surgery again if some of the abnormal blood vessels were not removed.
Your AVM may also hemorrhage (bleed heavily) in your brain. You may have a stroke. If you have a stroke, you may feel confused or have trouble talking and moving. If you do not have a craniotomy, your AVM may rupture and bleed, and cause more symptoms. You may die if your bleeding continues. Call your caregiver if you have questions or concerns about your surgery, condition, or care.
WHILE YOU ARE HERE:
Before your surgery:
Informed consent: You have the right to understand your health condition in words that you know. You should be told what tests, treatments, or procedures may be done to treat your condition. Your doctor should also tell you about the risks and benefits of each treatment. You may be asked to sign a consent form that gives caregivers permission to do certain tests, treatments, or procedures. If you are unable to give your consent, someone who has permission can sign this form for you. A consent form is a legal piece of paper that tells exactly what will be done to you. Before giving your consent, make sure all your questions have been answered so that you understand what may happen.
Blood tests: You may need blood taken for tests. The blood can be taken from a blood vessel in your hand, arm, or the bend in your elbow. It is tested to see how your body is doing. It can give your caregivers more information about your health condition. You may need to have blood drawn more than once.
Embolization therapy: Your caregiver may put a substance into the arteries that lead to your AVM. This will block the arteries and stop blood from flowing into your AVM. If your AVM is large, embolization therapy may make its center smaller.
Tests:
Angiography: Your caregiver may do an angiogram to check the blood flow in your brain.
Computed tomography scan: This is also called CT scan. A special x-ray machine uses a computer to take pictures of your head. It may be used to look at your bones, brain tissue, and blood vessels. It may show the location of your AVM. It may also show if your blood vessels are bleeding or becoming hard.
Magnetic resonance imaging: This is also called an MRI. An MRI may be used to look at your brain and the abnormal blood vessels of your AVM. During the MRI, you may also have a test called magnetic resonance angiography or MRA. An MRA may be done to see the blood flow inside your AVM. This well help your caregiver see if your blood vessels have areas that are blocked or narrow.
IV: An IV is a tube placed in your vein for giving medicine or liquids. This tube is capped or connected to tubing and liquid.
Pre-op care: You may be given medicine to make you feel relaxed and sleepy right before your surgery. You are taken on a stretcher to the room where your surgery will be done.
General anesthesia: This is medicine that may be given in your IV or as a gas that you breathe. You may wear a face mask or have a tube placed in your mouth and throat. This tube is called an endotracheal tube or ET tube. Usually you are asleep before caregivers put the tube into your throat. The ET tube is usually removed before you wake up. You are completely asleep and free from pain during surgery.
Monitoring:
Neurologic signs: Neurologic signs are also called neuro signs, neuro checks, or neuro status. Caregivers check your eyes, your memory, and how easily you wake up. Your hand grasp and balance may also be tested. This helps tell caregivers how your brain is working after an injury or illness. You may need to have your neuro signs checked often. Your caregiver may even have to wake you up to check your neuro signs.
Heart monitor: This is also called an ECG. Sticky pads are placed on different parts of your body. Each pad has a wire that is hooked to a TV-type screen. This shows caregivers a tracing of the electrical activity of your heart.
Pulse oximeter: A pulse oximeter is a machine that tells how much oxygen is in your blood. A cord with a clip or sticky strip is placed on your ear, finger, or toe. The other end of the cord is hooked to a machine. Caregivers use this machine to see if you need more oxygen.
During your surgery:
You are put on a table where your craniotomy will occur. Your position on the table will depend on where the AVM is located in your brain. Sheets are put over you to keep the surgery area clean. A cut is made to open your scalp. Your caregiver carefully drills your skull to make an opening. He then removes a piece of your skull so he can see your brain and AVM. Your caregiver clips or ties the arteries to stop the blood flow to your AVM.
Your caregiver may inject a substance to block the arteries. This plugs up the arteries so blood cannot flow into your AVM. Your caregiver then removes the cluster of abnormal blood vessels from your AVM. Your caregiver ties the vein that was attached to the AVM. He makes sure there are no areas that are bleeding inside your brain. Your skull bone is put back in place and the cut is closed with stitches. Your caregiver then covers your stitches with bandages.
After your surgery: You will be taken to a room where you will rest until you wake up. Caregivers will watch you closely for any problems. Your breathing, blood pressure, and pulse will be checked often. When caregivers see that you are OK, you will be taken back to your hospital room. Do not get out of bed until your caregiver says it is OK. A caregiver may remove your bandages soon after surgery to check your wound.
Heart monitor: This is also called an ECG, electrocardiogram, or telemetry. Sticky pads are placed on your chest or different parts of your body. Each pad has a wire leading to a small portable box (telemetry unit), or to a TV-type screen. This lets caregivers see a tracing of the electrical activity of your heart. The heart monitor may help caregivers see problems with the way your heart is beating. Do not remove any wires or sticky pads without asking your caregiver first.
Vital signs: This includes taking your temperature, blood pressure, pulse (counting your heartbeat), and respirations (counting your breaths). To take your blood pressure, a cuff is put on your arm and tightened. The cuff is attached to a machine which gives your blood pressure reading. Caregivers may listen to your heart and lungs by using a stethoscope. Your vital signs are taken so caregivers can see how you are doing.
Medicines:
Anti-convulsants: This medicine is given to control seizures. It may also be used to help you relax and decrease your blood pressure.
Antihypertensives: You may receive antihypertensives, which is medicine to lower your blood pressure. Lowering your blood pressure may decrease the pressure in your brain.
Anti-nausea medicine: The feeling that you are about to throw up is called nausea. You may feel nausea or throw up (vomit) after receiving general anesthesia. Nausea and vomiting may cause your brain to bleed because the pressure inside is increased. This medicine may be given to help calm your stomach and help stop you from vomiting.
Barbiturates: This medicine may be used to keep you asleep. You may need to be kept asleep if you have too much pressure in your brain.
Steroids: This medicine may be given to decrease swelling in your brain.
Tests: After your craniotomy, your caregiver will do tests to make certain that your AVM was completely removed. Angiography may show if there are still abnormal vessels left in your brain. Your caregiver may also do a CT scan of your brain to check for bleeding.
Copyright © 2008 Thomson Healthcare Inc. All rights reserved. Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes.
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.
NeurosurgeonMBBS, FRACSPerth, Western Australia00Cranial surgery:CraniotomyAwake craniotomyPituitary surgeryPost-operative recoveryCranial surgery risksPostoperative problems with chewing and talkingHomeMy medical practiceCranial conditionsBrain tumoursLumbar spineLumbar spine 2Cervical spinePeripheral nerveComplicationsMy backgroundCraniotomyA craniotomy simply means an opening into the skull. The standard way to perform a craniotomy is to make a burrhole with a drill and then cut a bone flap through the bone with a different drill, much like using a can opener.Usually more than one burrhole is used. The patient's head is held in a 3-pin head holder so that there can be absolutely no movement of the head during the delicate parts of the surgery.My emphasis is not only on making the smallest craniotomy necessary - referred to as minimally invasive or keyhole surgery - but also on the cosmetic result.Minimally invasive or keyhole craniotomy doesn't necessarily mean that the surgery is performed through a small hole. Some operations require a large craniotomy... e.g. if there is a large tumour on the surface of the brain immediately beneath the skull. Such a tumour can only be properly removed with a large bone flap.00Minimally invasive surgery means the smallest craniotomy is used that will allow sufficient exposure without compromising the surgery.00There is no point making a tiny craniotomy but not being able to remove the entire tumour because of inadequate exposure.Cosmetic appearance is often underestimated by neurosurgeons.It is understandable that the main concern of the neurosurgeon is to adequately treat the intracranial problem, which is usually a serious condition.Therefore neurosurgeons often argue that the hair will grow back or that visible or palpable burrholes are a small price to pay for a serious disease.However, craniotomies can often be done with minimal change to the patient's appearance.The extent of hair shaving must be tailored for the individual patient and incisions can generally be made behind the hairline. This is a very important part of the pre-operative discussion.The extent of hair shaving is a particularly important issue to some patients whose recovery is improved if their appearance is kept as normal as possible. I prefer to do a generous hair shave because it makes some aspects of the surgery easier for me, but the shave can be made quite minimal if necessary.Some people don't care about the extent of head shave, some prefer a complete head shave and others wish to have the least noticeable amount of head shave. Some operations at the front of the skull can be made through an eyebrow incision, which heals amazingly well and with no evidence of scar.My emphasis is also to not leave unsightly bone defects in the skull, particularly on the forehead and temples. But even behind the hairline they can be annoying... e.g. every time the hair is combed.The neurosurgeon also has to be aware that scars or bone defects may become visible in the future if baldness develops.A bone flap is elevatedIf bone defects are made, they can be easily filled in with bone cement or other materials. This type of skull repair is called cranioplasty and is an often overlooked aspect of neurosurgery.Some operations involve interoperative navigation usingcomputer software and a television screenLocalisation of the pathology More complicated craniotomies may involve navigation assistance to accurately localise a tumour, which also helps minimise the size of incision and craniotomy.Often this involves a preoperative brain MRI (sometimes CT) scan with intraoperative navigation using computer software and a television monitor.This is called stereotactic navigation and provides a complex map of the brain, much like a street directory but in three dimensions. HYPERLINK "http://www.popovic.com.au/surgery_cranial.html" \l "top" TopAwake craniotomyMore complicated techniques involve awake surgery where the patient is not given a general anaesthetic. The scalp can be made totally numb by using local anaesthetic and this is well tolerated.Usually the patient is given intravenous sedation at the start and end of the operation because they only need to be awake when the brain is exposed. The patient does not need to be fully awake when the craniotomy is being made. Cutting the bone is painless, as is cutting and manipulating the brain.This is particularly helpful when tumours are in or near "eloquent" areas of brain... i.e. more important areas of the brain where removal would result in an obvious loss of function.For example, speech function is usually in the left half of the brain. To minimise brain damage and maximise the amount of tumour that can be safely taken, it's helpful to have the patient talk, read and follow commands while a tumour is being removed in that part of the brain. This is one type of brain mapping but another technique is to use an electrical stimulator on the brain which, when applied to the brain, can stop speech and comprehension in the speech areas, cause tingling of the body in the sensory (feeling) areas and produce movement in the motor areas.Electrical stimulation of motor areas can be done with the patient awake or asleep but speech and sensory testing require an awake patient.Brain exposed in an awake patientCertain tumours are best operated with other special equipment. For example, acoustic neuromas are best removed with an electrical stimulator which identifies the facial nerve (the nerve which moves the facial muscles) because this nerve is intimately related to these tumours and can be damaged with their removal. Intraoperative stimulation of the tumour can identify a very thinned out facial nerve by identifying facial muscles twitching in response to stimulation.Post-operativeCraniotomies are not particularly painful. Expect to wake with a thick bandage on your head, much like a turban. This may stay on for up to three days and helps keep pressure on the wound so there is less swelling. After surgery on the forehead or temple it is common to get bruising and swelling around one or both eyes which settles within two weeks.The night after surgery is usually spent in the Intensive Care Unit where you can be watched closely. The nurse has to wake you every hour to make observations. You usually have at least one intravenous line and often have an arterial line in your wrist to monitor blood pressure. A catheter in the bladder is generally kept in for the first night.The next day after surgery involves obtaining a check CT scan to see if there is any blood or complications at the operative site. If the CT scan looks fine you'll be sent to the ward and start Clexane injections into your abdomen to help reduce the risk of blood clot (DVT) in the legs. You will be encouraged to get up and walk on the day after surgery. Patients usually go home after a few days. HYPERLINK "http://www.popovic.com.au/surgery_cranial.html" \l "top" TopPostoperative problems with chewing and talkingFor many craniotomies the temporalis muscle needs to be incised. This muscle is important for closing the jaw.The muscle is repaired at the end of the operation and once healed will function normally. However, it is important that you complete the exercises below to ensure that your jaw does not become stiff after the operation.You may find that opening your mouth, chewing food and doing the exercises are uncomfortable. However, this will ease the more you exercise your jaw.It is recommended doing the exercises at least 10 times a day. They should only take a few minutes so doing them just prior to meals and at coffee break times will remind you. As healing time for a muscle is approximately six weeks, it is recommended you continue these exercises for at least this time.If pain or stiffness persists after six weeks, continue the exercises until there is no pain and you can move your jaw freely.ExercisesEnsure that you complete each exercise slowly and carefully.1. Open your mouth as widely as possible and hold open for five seconds. Do this 10 times.2. Open your mouth a small amount and move your jaw from side to side. Do this 10 times.3. Open your mouth widely and move your jaw from side to side. Do this 10 times.4. Make exaggerated chewing movements, as if chewing toffee, for 30 seconds. It is recommended chewing up to five sticks of chewing gum at the one time; this will really exercise the jaw muscle.If you have any further questions please talk to the speech pathologist or physiotherapist on the ward. HYPERLINK "http://www.popovic.com.au/surgery_cranial.html" \l "top" TopRisks of cranial surgeryInfectionThis may simply be an infection of the scalp which requires some dressings, removal of a stitch and/or antibiotics. Deeper infection can affect the bone, which may need to be removed and a plastic plate inserted after about six months. Deeper still, infection may affect the CSF (cerebrospinal fluid) around the brain, which is called meningitis, and requires hospitalisation and intravenous antibiotics.BleedingPostoperative bleeding is the greatest concern that we have following cranial surgery. When an operation is completed, there is no bleeding and it is then safe to close. However, delayed bleeding can occur, most often within the first 24 hours after surgery. This may occur if the blood pressure gets too high, if the patient is on blood thinning drugs (which should have been stopped preoperatively), if the patient gets agitated or for no obvious reason. Postoperative bleeding can be an emergency with the patient becoming unconscious or developing a deficit such as arm and leg weakness. This will usually require an urgent trip back to theatre to prevent a permanent deficit (or stroke).StrokeInjury may occur to the brain or to a major blood vessel supplying the brain, resulting in a stroke. This means that a part of the brain will not work normally. Often this improves, but may be permanent - e.g. impaired speech, weakness of an arm and leg.EpilepsyThe condition that requires surgery (e.g. a tumour) or the surgery itself may result in seizures or fits arising from a part of the brain. This is called epilepsy. This can usually be prevented by the use of a drug, often Dilantin (also called phenytoin), used before and after surgery. If epilepsy continues after surgery, it can usually be treated with drugs. For many (but not all) operations on the brain, a patient may be advised to not drive for three months because of the small risk of postoperative epilepsy. If epilepsy does occur before or after surgery, the patient will not be allowed to drive until the epilepsy has been completely controlled - that is, no seizures for usually at least a year or possibly twoCerebrospinal Fluid (CSF) leakThe brain and spinal cord are surrounded by CSF, which looks like water and is salty. When the head is closed at surgery, the outermost layer of the meninges (= the three outer coats of the brain and spinal cord), called the dura, is closed. CSF can leak through the dura and then through the skin and this will need to be fixed, otherwise there is a risk of meningitis. Just like a leak in the roof, there only needs to be a small hole to let water through and this can sometimes be troublesome to repair, but is virtually always correctable. Repair may require a simple skin stitch, a spinal drain tube inserted in the low back to drain the CSF via another route, or a trip back to theatre. Occasionally a CSF leak can be less obvious by leaking through the nose or ear - e.g. if there has been a skull opening into the paranasal sinuses or into the ear canals.Deep Vein Thrombosis (DVT)DVT means a blood clot developing in the leg. The patient may notice a painful swelling of the calf but a DVT may not be noticed. This clot may dislodge and travel to the lungs and heart to block the circulation, which is known as a pulmonary embolus (PE). A PE can be fatal and usually occurs about 1-2 weeks after surgery, or 1-2 weeks after a patient has commenced being confined to bed. Increased risks for DVT and PE are bed rest, prolonged surgery, obesity, cancer, past DVT, paralysed leg/s and heart failure. To prevent DVT, the patient is encouraged to get out of bed as soon as possible, usually the day after surgery. Before this, the patient can wiggle the toes and move the legs around in bed as soon as wakening from the anaesthetic. Prior to surgery, the patient will have elastic stockings put on. While in surgery the patient has leg pumps to improve the circulation. After surgery, blood thinning injections are commenced - I like to use Clexane injections into the stomach each morning until discharge from hospital.DeathDeath on the operating table is very rare. Death can occur with any surgery and usually occurs after the operation. The most common reasons are myocardial infarct (heart attack) due to the stress of the surgery, a rare reaction to a drug (anaphylaxis) or pulmonary embolus. I mention the risk of death or paralysis (stroke) to any patient having an operation, no matter how minor the procedure.
مقدمهکرانیوتومی برشی است که منجر به دسترسی به کرانیوم - جمجمه - می شود. در طی این جراحی یک بخش از جمجمه که فلپ استخوانی خوانده می شود برای دسترسی به لایه های زیرین آن برداشته می شود. فلپ استخوانی معمولا بعد از جراحی با استفاده از پیچ و صفحات مخصوص این کار سر جای خود گذاشته می شود. کرانیوتومی ممکن است بسته به مشکل، کوچک یا بزرگ باشد. ممکن است طی جراحی برای بیماریهای نورولوژیک، صدمات یا شرایطی مانند تومورهای مغزی، هماتوم ها (لخته شدن خون)، آنوریسم یا آنومالی شریانی وریدی و شکستگی استخوان جمجمه انجام شود. سایر دلایل برای کرانیوتومی وجود اشیای خارجی (گلوله)، تورم مغز یا عفونت است. بسته به دلیل، این جراحی به بستری شدن در بیمارستان از چند روز تا چند هفته نیاز خواهد داشت.
تومور هاي مغزي
نوعي ضايعه فضاگير داخل جمجمه اي است
• تقسيم بندي تومور ها • بر اساس شكل: كروي شكل • ارتشاحي و تهاجمي • از نظر بافت شناسي: خوش خيم • بدخيم نام گذاري: براساس بافتي كه منشا مي گيرند:• مننژيوما گليوما• نوروما اپانديوما بر اساس محل ايجاد : • سوپرا تنتوريال • اينفرا تنتوريال
تومورها : اوليه 80 درصد، در زنان و مردان مساوي
ثانويه: ريه، پستان، كولون، كليه، پوستعلل : تشعشعات يونيزهشيوع : دهه 5 ، 6 ،7 زندگي • آثار پاتوفيزيولوژيك تومورها • افزايش ICP و ادم مغزي• علائم كانوني، تشنج • هيدروسفالي• تغيير در عملكرد هيپوفيزانواع تومورها گليوما : شايع ترين نوع تومور است 45درصد و شايع ترين نوع تومور اين خانواده گليوبلاستوم مولتي فرم استميزان بدخيمي بستگي به: قدرت ميتوزي
دانسيته سلولي ظاهر تومر دارد مننژيوما : • 15درصد در گيري پرده عنكبوتيه • تومور كپسول دار خوش خيم، زنان بيشتر از مردان • در مناطق نزديك به سينوس هاي وريدي مغز ديده مي شود• اثر فشاري داردآدنوماي هيپوفيز: 8 - 12درصد• اثرات: فشاري • كياسماي اپتيك، هيپو تالاموس، بطن سوم تغييرات هورموني• علائم : • سردرد • اختلالات بينايي• اختلالات هيپوتالاموس: خواب، اشتها، درجه حرارت، روحي • افزايش ICP
تغييرات هورموني
• 1. پرو لاكتينوما • 2. افزايش هورمون رشد : ژيگانتيسم • آكرو مگالي • 3. افزايش ACTH سندرم كوشينگنوروماي اكوستيك:• درگيري عصب زوج هشت و زاويه CP • علائم: • كاهش شنوايي، وزوز گوش، سرگيجه، عدم تعادل• درصورت گرفتاري عصب زوج 5 درد همان طرف صورت
آنژيوما:• توده هاي حاوي عروق خون غير طبيعي 83درصد در مخچه ديده مي شود• خطر خونريزي دارد •
تظاهرات باليني : علائم عمومي
علائم كانوني• نشانه هاي افزايش ICP : سه علامت كلاسيك • سردرد : اعمال فشار ، تخريب ساختمان هاي مجاور ، ادم • ادم پاپي • استفراغ• علائم كانوني • تومورهاي كورتكس حركتي: تشنج جاكسوني • تومورهاي لوب پس سري: همونيموس همي آنوپيا • تومورهاي مخچه: سرگيجه، آتاكسي، نيستاگموس • تومورهاي پيشاني: اختلال رفتاري و شخصيتي • تومورهاي زاويه CP تشخيص:• تاريخچه و شرح حال • معاينه فيزيكي • MRI –CT • آنژيوگرافي درمان:• هدف از درمان: • برداشت جراحي • تخريب تومور• تسكين علائم و نشانه ها راديو تراپي داخلي كاشت راديو ايزوتوپ يد 131 خارجي جراحي
شيمي درماني: كارموستين BCNU ، لوموستين CCNU و تركيب PCV
چهارچوب استرئوتاكتيك
جراحی مغزی
اهداف جراحي مغزي: 1.خارج كردن تومور 2. درمان ICP 3. خارج كردن هماتوم 4. كنترل خونريزيانواع جراحي مغزي:كرانيو تومي: سوپرا تنتوريال اينفرا تنتوريال ترانس اسفنوئيدال كرانيكتومي كرانيو پلاستيدرمان قبل از جراحي 1. تجويز فني توئين 2. كورتيكو ستروئيد ها 3. آنتي بيو تيك ها 4. محدوديت مصرف مايعات 5. تجويز مانيتول 6. تجويز آرام بخش مراقبت پرستاري قبل از عمل جراحي:• ارزيابي سطح هوشياري: تكلم، اعصاب جمجمه اي واكنش مردمك ها • بررسي وضعيت حسي و حركتي بيمار، قدرت اندامها• آماده سازي جسماني و عاطفي بيمار
درمان پس از جراحي (اهداف)
كاهش ادم مغزيتسكين درد كنترل تشنج كنترل ICP كنترل درجه حرارت تجويز H2 بلوكر ها
مراقبت پس از جراحي
• بررسي سطح هوشياري بيمار • بررسي وضعيت تنفسي- هيپوكسي كنترل ABG• كنترل درجه حرارت بدن• بررسي پانسمان از نظر خونريزي و يا نشت مايع CSF • بررسي از نظر تشنج و بيقراري بيمار • بررسي علائم نقصان هاي نرولوژيك • پوزيشن بيمار پس از جراحي• كنترل ادم پري اوربيتال • تغذيه بيمار
عوارض جراحي مغزي:
افزايش ICP و ادم مغزي خونريزي داخل جمجمه اينقايص نرولوژيك عفونت عدم تعادل مايعات و الكتروليت ها SIADH ، ديابت بيمزه سكته مغزي تشنجترومبو آمبوليتومور مغزي
کرانیوتومی چیست؟ craniotomy
راهنمای آموزش به بیمار
عمل جراحی باز روی مغز است. سوراخی توسط جراح بر روی جمجمه ایجاد می شود به نحوی که عمل روی مغز امکان پذیر باشد. کرانیوتومی ممکن است در هر ناحیه ای از جمجمه انجام شود و می تواند در ابعاد مختلف باشد. تکه ای از استخوان سر که برداشته می شود معمولا مجدد سر جای خود گذارده می شود. برای چه کسانی کرانیوتومی انجام می شود؟برداشتن یک ضایعه مانند تومور مغزیبرداشتن لخته خون مانند هماتوم ساب دورال مزمنترمیم نشت عروق خونی مانند آنوریسم مغزیبرداشتن مجموعه ای از عروق خونی غیر طبیعی مانند ناهنجاری عروقی شریانی (arteriovenous malformation)تخلیه ترشحات مانند آبسه مغزیترمیم شکستگی جمجمه در ضربه مغزی ترمیم پارگی یکی از لایه های مغزکاهش فشار درون جمجمه ای (افزایش فشار به مغز در حفره جمجمه ای)