What is a craniotomy?
A craniotomy is a surgery where part of the skull bone is removed to access the brain. Your child’s neurosurgeon will make an incision on the scalp and remove part of the skull bone temporarily to access the brain. With surgical equipment, the section of bone (called a bone flap) is removed. Once the bone is removed, guidance equipment—together with medical imaging—is used by the neurosurgeon to locate the area that requires surgery. The brain is exposed for the procedure, and the bone is then replaced after the surgery is done.
There are different names for craniotomies depending on their location on the skull. For example, a frontal craniotomy is done in the front of the skull near the hairline, whereas a parietal craniotomy is done in the top-middle area and upper back part of the skull.
A craniotomy is different from a craniectomy—with a craniectomy, part of the skull bone is removed and not replaced at the time of the surgery due to brain swelling or infection. The bone flap may be replaced at a later date, or a custom implant may be made to repair the area once the swelling or infection is resolved.
Reasons for a craniotomy
A craniotomy may be done for several reasons, including to:
- remove blood in or on the surface of the brain
- remove an arteriovenous malformation (AVM)
- remove a brain tumour
- remove a brain abscess
- surgically clip an aneurysm
- treat epilepsy
- insert medical devices like a ventriculoperitoneal (VP) shunt, vagal nerve stimulator (VNS), or deep brain stimulator (DBS)
For more information on preparing your child for their procedure, see Coming for surgery.
Risks of a craniotomy
The risk of a craniotomy may vary depending on your child’s condition (reason for the craniotomy), their age and health. Risks include:
- pain, bruising or bleeding at the surgical site
- bleeding or blood clotting
- infection
- seizures
- changes in ability to think, move, speak and function normally
- brain swelling
- leakage of cerebrospinal fluid (CSF)
- those associated with general anesthesia
Preparing for a craniotomy
Sometimes, a craniotomy is required for urgent life-saving surgeries and, unfortunately, there is not much time to prepare. However, there are also times when a craniotomy is a planned surgery.
If your child is having a planned surgery, they will have a clinic visit and you will have an opportunity to meet with the neurosurgeon before the procedure. During the visit, you should expect the following:
- A health assessment to make sure your child is healthy and that it is safe to have general anesthesia and to go ahead with the procedure. Your child may also be referred to the pre-anesthesia clinic for further assessment and discussion.
- An overview of the procedure, discussion of the risks, and a review of the consent form.
- Pre-surgical bloodwork.
- A discussion about surgical planning if further imaging is needed.
- A meeting with a same-day admission nurse.
Giving consent before the procedure
Before the surgery, the neurosurgeon will go over how and why the procedure is done, as well as the potential benefits and risks. They will also discuss what will be done to reduce these risks and will help you weigh the benefits against the risks. It is important that you understand all potential risks and benefits of the surgery and that all your questions are answered. If you agree to the procedure, you can give consent for the craniotomy by signing the consent form.
How to prepare your child for the surgery
Before any surgery, it is important to talk to your child about what will happen. When talking to your child, use words they can understand. Let your child know that medicines will be given to make them sleep during the surgery.
Children feel less anxious and scared when they know what to expect. Children also feel less worried when their parents are calm and supportive.
You can ask your child’s health-care team if there are any resources that are available for you and/or your child to help prepare for surgery.
If your child becomes ill within two days before the surgery
It is important that your child is healthy on the day of their surgery. If your child starts to feel unwell or has a fever within two days before the surgery, let your child’s neurosurgeon or the same-day admission nurse know. Your child’s surgery may need to be rescheduled.
Food, drink and medicines before the procedure
- Your child’s stomach must be empty before general anesthetic.
- If your child has special needs during fasting, talk to their health-care provider to make a plan.
- Discuss with your child’s health-care provider about taking their regular morning medicines with a sip of water up to two hours before the procedure.
- Medicines such as acetylsalicylic acid (ASA), naproxen or ibuprofen, warfarin, or enoxaparin may increase the risk of bleeding. If your child is on any of these medications, consult with your child’s neurosurgeon before the craniotomy to create a plan of care.
On the day of the craniotomy
Arrive at the hospital two hours before the planned time of your child’s surgery. Once you are checked in, your child will be dressed in a hospital gown, weighed and assessed. You will also be able to speak to the neurosurgeon who will be doing the surgery and the anesthesiologist who will be giving your child medication to make them sleep during the procedure.
During the procedure, you will be asked to wait in the surgical waiting area.
Your child will have medicine for pain
Children are given medicine for treatments that may be frightening, uncomfortable or painful. For craniotomies, all children are given general anesthesia. Post surgery, they will also be given medications to help manage their pain.
How is a craniotomy done?
Once under general anesthesia, your child will have a number of intravenous (IV) lines and, sometimes, a bladder catheter inserted. Their head is washed with a surgical soap that kills germs, and an area of hair will be shaved near where the incision will be made. The neurosurgeon then makes an incision, or opening, in the skin. Using surgical tools, a piece of skull is removed (called a bone flap). Next, the neurosurgeon will use guidance equipment called neuro-navigation to locate and treat the area requiring surgery. Once surgery is over, the bone is returned and attached using small plates and screws. The incision is then closed with either stitches or staples, and a dressing is applied.
After a craniotomy for the removal of an AVM, a cerebral angiogram is done immediately to ensure that all of the AVM has been removed.
After craniotomy surgery
After your child wakes up from surgery, they are either transferred to the pediatric intensive care unit (PICU) or the post anesthetic care unit (PACU) for a period of monitoring and treatment of any immediate pain. They are then transferred to the neurosurgical care unit.
Your child’s neurosurgeon will meet with you to discuss the surgery.
When you see your child, they will have a dressing on their head.
In the days following surgery, the plan of care will depend on why the craniotomy was done. This may include post-operative imaging (computed tomography [CT] or magnetic resonance imaging [MRI] scan) to assess the surgical area. This may also include assessments and therapy by the rehabilitation team.
Your child may have symptoms, such as pain or nausea, which can be managed with medications if needed.
At home
It is important to follow the incision care instructions that your child’s health-care team has provided to promote healthy incision healing and reduce the risk of infection.
Hair washing
For incisions on the head, your child’s hair should be washed once a day. Use a gentle shampoo (like a baby shampoo) to work up to a lather and gently massage over the incision to clean off any scabs, dried blood, discharge, or petroleum jelly (like Vaseline). Next, rinse their hair well. If washing in the shower, do not have the shower head spraying water directly at the incision but allow the water to run across and around it. If using a bathtub, do not use the water from the tub to wash the hair. Use fresh water from the tap. You can wash your child’s body after you have washed their hair.
Incision care
- Incision care should be done once a day, starting on the second day after surgery.
- Use a clean face cloth with fragrance-free soap and water to wash the incision. Gently remove any scabs, dried blood, discharge, or petroleum jelly. If using a bar soap, use a new designated bar of soap. Use a second clean face cloth with just water to wash/rinse the incision. Pat dry with a clean dry cloth or towel.
- Apply a thin layer of petroleum jelly over the incision*. Use a new designated container of petroleum jelly.
- *If the incision is covered with surgical glue, do not apply petroleum jelly.
- *If the incision is covered with adhesive strips, do not apply petroleum jelly until the strips have completely fallen off (usually around 7 days). After the strips have fallen off, continue soap and water once a day with a thin layer of petroleum jelly for one week.
- *If the incision is covered with surgical glue, do not apply petroleum jelly.
- Leave the incision open to air. Cover with a clean dressing if your child is likely to pick or scratch at the incision.
- Continue with this care until sutures or staples have been removed.
- Protect the incision from sun exposure by covering it with a clean clothing item (for example, clean hat, scarf, or bandana). You may use sunscreen with SPF only after sutures/staples have been removed and the incision has completely healed.
If there are any concerns with the incision or signs of infection (redness, swelling, discharge or fever), or if there are still staples or sutures after two weeks, contact the neurosurgery clinic nurse. For all other surgical concerns, contact the nurse practitioner (NP) associated with your child's surgeon.
At SickKids
If there are any concerns with the incision or signs of infection (redness, swelling, discharge or fever) or if there are still staples or sutures after two weeks, contact the neurosurgery clinic nurse at neurosurgeryclinic.nurses@sickkids.ca. For all other surgical concerns, contact the nurse practitioner (NP) associated with your child's surgeon.
If you have any concerns after discharge, you can call the Hospital for Sick Children switchboard at (416) 813-7500 and ask them to page the neurosurgery resident or fellow on call.
For more information on preparing your child for their procedure see Coming for surgery.
