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CRANIOTOMY

Prepared By:
Gutierrez, Karell Eunice E.
BSN3-5 GROUP20

Submitted to:
Mrs. Roslyn Mariano RN
CRANIOTOMY

DISCUSSION

The most basic form of craniotomy is the burr hole, a limited opening
through which blood or fluid may be evacuated or instruments inserted
to divide neural tracts. Additional uses of the burr hole include biopsy
of an intracranial mass/lesion and aspiration of the contents of an
abscess. A craniectomy refers to the procedure of which a section of
the cranium is removed. Trephination refers to a procedure performed
through burr holes that are larger than those usually made to
performed limited maneuvers. When applicable, a twist drill is used in
lieu of a burr. Computed Tomography (CT) scan, magnetic resonance
imaging (MRI), angiography or magnetoencephalography,
electroencephalogram (EEG) mapping, angiographic stress tests and
ultrasound modalities are employed with tomography and three-
dimensional (3D) coordinates to localize a lesion. Image guided
steriotactic burr hole biopsy, employing a CRW3 (or similar) head
frame, provides accurate craniocortical entry transit and targeting
minimizing craniocerebral trauma.
Approaches employing endoscopy and stereotactic procedures
decrease morbidity and mortality, some cranial procedures performed
in specialized readiology departments or specially equipped operating
rooms are "same-day" noninvasive procedures, such as those
employing the Gamma knife. Intracerebral hematomas can be
evacuated endoscopically through a burr hole; the cortical incision is
approximately 6mm. In diameter. For removal of an intracranial
hematoma, the cortical incision is made from a location with the
shortest trajectory to the clot. Endoscopic procedures may require
more than one burr (port).
During craniotomy or burr hole procedure, intracranial pressure
when elevated is reduced as a result of entry. In addition. As
underlying tissued are manipulated, the location of the previously
defined lesion shifts. In some institutions, highly sophisticated
intraoperative MRI systems are in use. This may be in the form of
cylindrical MRI chamber, a section of which can be advanced for
imaging and retracted to continue the surgery. When a limited-access
endoscopic procedure is not applicable, burr holes are made and a
portion (a "flap") of the cranium is lifted. The craniotomy prosthesis
can be a plate made of polymethylmethacrylate (PMMA) cement,
titanium, or Vitallium, or various plastics may be used for making the
substitute Burr holes can be repaired with silicone or other materials.
Numerous neurosurgical conditions treated by
craniotomy include the following:
• Intracranial Aneurysm is an arterial dilation secondary to
muscular weakness prone to rupture or hemorrhage. Controlling
the blood pressure is essential during the repair. The aneurysm
is isolated, and clips may be applied, or the aneurysm can be
coated with PMMA or cyanoacrylate to strengthen the aneurysm
wall and provide external support to the blood vessel. When
feasible, endovascular approach (via femoral artery) with
placement of embolitic materials, like plastic spheres, muscle
fragments, or Gugleilmi detachable coils, effectively thrombose
the aneurysm; however, collateral channels may develop
subsequently, requiring further intervention.
• Intracranial Arterial Occlusion may be treated by
microsurgical anastomosis; the involved vessel is bypassed distal
to the point of obstruction. In this instance, the superficial
temporal artery is dissected free for an appropriate distance and
passed intracranially through a frontotemporal burr hole incision
preparatory to anastomosis.
• Intracranial tumors include astrocytoma, glioblastoma
multiforme, meningioma, oligodendroglioma, medulloblastoma,
lesions of neural; vascular, and connective tissue origin, and
metastases from other sites. The lesions are treated according to
their location, size, degree of malignancy, status of the patient.
Chordomas, mengiomas, and others may be treated
endoscopically. Treatment of acoustic neuroma and tumors
about the pituitary are noted below.
• Hydrocephalus results from conditions where the flow
cerebrospinal fluid is obstructed by ontraventricular lesions or
arachnoid or parenchymal cysts, aqueductal or foraminal
stenoses, hemorrhages, tumors, and infarction or when there is
an overaccumulation of cerebrospinal fluid that collects in the
ventricles or the subarachnoid space, causing undue pressure on
the brain.

ANATOMY AND PHYSIOLOGY

The Nervous System


The nervous system is a network
of specialized cells that communicate
information about an animals
surroundings and its self, it processes
this information and causes reactions in
other parts of the body. It is composed
of neurons and other specialized cells
called glia, that aid in the function of
the neurons.
The nervous system is divided broadly into two categories; the
peripheral nervous system and the central nervous system. Neurons
generate and conduct impulses between and within the two systems.
The peripheral nervous system is composed of sensory neurons and
the neurons that connect them to the nerve cord, spinal cord and
brain, which make up the central nervous system. In response to
stimuli, sensory neurons generate and propagate signals to the central
nervous system which then process and conduct back signals to the
muscles and glands.
The neurons of the nervous systems of animals are
interconnected in complex arrangements and use electrochemical
signals and neurotransmitters to transmit impulses from one neuron to
the next. The interaction of the different neurons form neural circuits
that regulate an organism’s perception of the world and what is going
on with its body, thus regulating its behavior. Nervous systems are
found in many multicellular animals but differ greatly in complexity
between species
The central nervous system (CNS) is the largest part of the
nervous system, and includes the brain and spinal cord. The spinal
cavity holds and protects the spinal cord, while the head contains and
protects the brain. The CNS is covered by the meninges, a three
layered protective coat. The brain is also protected by the skull, and
the spinal cord is also protected by the vertebrae.
Brain is a part of the Central Nervous System, it plays a central
role in the control of most bodily functions, including awareness,
movements, sensations, thoughts, speech, and memory. Some reflex
movements can occur via spinal cord pathways without the
participation of brain structures.
The cerebrum is the largest part of the brain and controls
voluntary actions, speech, senses, thought, and memory.
The surface of the cerebral cortex has grooves or infoldings (called
sulci), the largest of which are termed fissures. Some fissures separate
lobes.
The convolutions of the cortex give it a wormy appearance. Each
convolution is delimited by two sulci and is also called a gyrus (gyri in
plural). The cerebrum is divided into two halves, known as the right
and left hemispheres. A mass of fibers called the corpus callosum links
the hemispheres. The right hemisphere controls voluntary limb
movements on the left side of the body, and the left hemisphere
controls voluntary limb movements on the right side of the body.
Almost every person has one dominant hemisphere. Each hemisphere
is divided into four lobes, or areas, which are interconnected.

• The frontal lobes are located in the front of the brain and are
responsible for voluntary movement and, via their connections
with other lobes, participate in the execution of sequential tasks;
speech output; organizational skills; and certain aspects of
behavior, mood, and memory.

• The parietal lobes are located behind the frontal lobes and in
front of the occipital lobes. They process sensory information
such as temperature, pain, taste, and touch. In addition, the
processing includes information about numbers, attentiveness to
the position of one’s body parts, the space around one’s body,
and one's relationship to this space.

• The temporal lobes are located on each side of the brain. They
process memory and auditory (hearing) information and speech
and language functions.

• The occipital lobes are located at the back of the brain. They
receive and process visual information
• The Cardiovascular System
• The heart and circulatory system make up the cardiovascular
system. The heart works as a pump that pushes blood to the
organs, tissues, and cells of the body. Blood delivers oxygen and
nutrients to every cell and removes the carbon dioxide and
waste products made by those cells. Blood is carried from the
heart to the rest of the body through a complex network of
arteries, arterioles, and capillaries. Blood is returned to the heart
through venules and veins.
• The one-way circulatory system carries blood to all parts of the
body. This process of blood flow within the body is called
circulation. Arteries carry oxygen-rich blood away from the heart,
and veins carry oxygen-poor blood back to the heart. In
pulmonary circulation, though, the roles are switched. It is the
pulmonary artery that brings oxygen-poor blood into the lungs
and the pulmonary vein that brings oxygen-rich blood back to
the heart.
• Twenty major arteries make a path through the tissues, where
they branch into smaller vessels called arterioles. Arterioles
further branch into capillaries, the true deliverers of oxygen and
nutrients to the cells. Most capillaries are thinner than a hair. In
fact, many are so tiny, only one blood cell can move through
them at a time. Once the capillaries deliver oxygen and nutrients
and pick up carbon dioxide and other waste, they move the
blood back through wider vessels called venules. Venules
eventually join to form veins, which deliver the blood back to the
heart to pick up oxygen.
• Vasoconstriction or the spasm of smooth muscles around the
blood vessels causes and decrease in blood flow but an increase
in pressure. In vasodilation, the lumen of the blood vessel
increase in diameter thereby allowing increase in blood flow.
There is no tension on the walls of the vessels therefore, there is
lower pressure.
• Various external factors also cause changes in blood pressure
and pulse rate. An elevation or decline may be detrimental to
health. Changes may also be caused or aggravated by other
disease conditions existing in other parts of the body.
• The blood is part of the circulatory system. Whole blood contains
three types of blood cells, including: red blood cells, white blood
cells and platelets.
• These three types of blood cells are mostly manufactured in the
bone marrow of the vertebrae, ribs, pelvis, skull, and sternum.
These cells travel through the circulatory system suspended in a
yellowish fluid called plasma. Plasma is 90% water and contains
nutrients, proteins, hormones, and waste products. Whole blood
is a mixture of blood cells and plasma.
• Red blood cells (also called erythrocytes) are shaped like slightly
indented, flattened disks. Red blood cells contain an iron-rich
protein called hemoglobin. Blood gets its bright red color when
hemoglobin in red blood cells picks up oxygen in the lungs. As
the blood travels through the body, the hemoglobin releases
oxygen to the tissues. The body contains more red blood cells
than any other type of cell, and each red blood cell has a life
span of about 4 months. Each day, the body produces new red
blood cells to replace those that die or are lost from the body.
• White blood cells (also called leukocytes) are a key part of the
body's system for defending itself against infection. They can
move in and out of the bloodstream to reach affected tissues.
The blood contains far fewer white blood cells than red cells,
although the body can increase production of white blood cells to
fight infection. There are several types of white blood cells, and
their life spans vary from a few days to months. New cells are
constantly being formed in the bone marrow.
• Several different parts of blood are involved in fighting infection.
White blood cells called granulocytes and lymphocytes travel
along the walls of blood vessels. They fight bacteria and viruses
and may also attempt to destroy cells that have become infected
or have changed into cancer cells.
• Certain types of white blood cells produce antibodies, special
proteins that recognize foreign materials and help the body
destroy or neutralize them. When a person has an infection, his
or her white cell count often is higher than when he or she is well
because more white blood cells are being produced or are
entering the bloodstream to battle the infection. After the body
has been challenged by some infections, lymphocytes remember
how to make the specific antibodies that will quickly attack the
same germ if it enters the body again.
• Platelets (also called thrombocytes) are tiny oval-shaped cells
made in the bone marrow. They help in the clotting process.
When a blood vessel breaks, platelets gather in the area and
help seal off the leak. Platelets survive only about 9 days in the
bloodstream and are constantly being replaced by new cells.
• Blood also contains important proteins called clotting factors,
which are critical to the clotting process. Although platelets alone
can plug small blood vessel leaks and temporarily stop or slow
bleeding, the action of clotting factors is needed to produce a
strong, stable clot.
• Platelets and clotting factors work together to form solid lumps
to seal leaks, wounds, cuts, and scratches and to prevent
bleeding inside and on the surfaces of our bodies. The process of
clotting is like a puzzle with interlocking parts. When the last part
is in place, the clot is formed.
• When large blood vessels are cut the body may not be able to
repair itself through clotting alone. In these cases, dressings or
stitches are used to help control bleeding.
• In addition to the cells and clotting factors, blood contains other
important substances, such as nutrients from the food that has
been processed by the digestive system. Blood also carries
hormones released by the endocrine glands and carries them to
the body parts that need them.
• Blood is essential for good health because the body depends on
a steady supply of fuel and oxygen to reach its billions of cells.
Even the heart couldn't survive without blood flowing through
the vessels that bring nourishment to its muscular walls. Blood
also carries carbon dioxide and other waste materials to the
lungs, kidneys, and digestive system, from where they are
removed from the body.

PREPARATION OF THE PATIENT

Described is a generic-type approach. Planning is essential prior


to the surgery. The position of the patient depends on the procedure to
be performed, the approach, and the location of the lesion. Equipment
for positioning and surgical instrumentation, should be in the room
prior to the patients arrival. A warming mattress, Multi-thermia
blanket, may be used, or a forced-air warming blanket may be
employed. The patient is assisted, as necessary to move from the
gurney to the table. When assistance is required, the circulator is
responsible for obtaining adequate number of persons to safely
transfer the patient from the gurney to the table. Antiembolic hose are
applied to the patient's legs to prevent venous stasis. Whn ordered, a
sequential compression device with disposable leg wraps may be
placed over antiembolic hose. Leads are placed for EEG and
electrocardiogram (ECG). An IV and right atrial line may be inserted. All
bony preminences and areas vulnerable to skin and neurovascular
pressure or trauma are adequately padded.
General anesthesia (with endotracheal intubation) is
administered.

POSITIONS

The patient is positioned at the discretion of the anesthesia


provider; the patient is never moved without the anesthesia provider's
permission. Special frames, positioning aids, padding, headrests,
and/or fixation devices are secured to the table to hold the skull in
position for the most frequently employed positions; these are
mentioned below. The circulator most ensure adequate assistance to
position the patient to avoid injury to the patient and the staff.

Supine. An extension may be secured to the table with a headrest


device. The skull is fixed in position by steel pins. As the pins are
placed in the headrest device, sterility of the pins should be
maintained; the pins are inserted into the cranium. Alternatively, the
head may be positioned on either a padded donut, or gel-filled
horseshoe headrest may be used. The arms may be extended on
padded armboards alongside the patient, or the arms may be padded
and tucked in at the patients sides. A pillow may be placed behind the
lumbar spine or under the knees.

Sitting. In fowler's position, the top section of the table is removed,


and a table extension and the headrest are secured to the table to
support the patient's head and neck, sterile pins that were placed in
the headrest attachment are inserted into the patient's skull. The table
is raised from the middle break, and the foot of the table is lowered,
the knees are positioned over the lower break of the table. A pillow
may be placed behind the legs, and a padded footboard supports the
feet. The arms are placed into the patient's lap on a pillow and secured
with padded restraints. The safety strap is secured across the thighs.
The table may be turned 90 degrees with the anesthesia provider
opposite the operative side. Extra caution must be taken to avoid
injury to the patient's fingers when the foot of the table is raised at the
conclusion of the procedure.

Prone. The patient is intubated on the gurney and, at the discretion


of the anesthesia provider, carefully rolled over onto the table. The
head may be placed in a padded donut, or more often, the head is
placed in a gel-filled horseshoe attachment that replaces the top
section of the table. Care is taken to ensure that the patient's eyes are
protected from excessive pressure. Chest rolls are placed under the
patient's torso, from the acromioclavicular joints to the iliac crests, to
facilitate respiration. The arms may be extended on padded armboards
with the forearms pronated, or the arms may be padded and tucked in
at the patient's sides. A roll is placed in front of the ankles to protect
the toes. Pillows are placed in front of the legs. Padding is placed under
the elbows, knees, and other points of contact by bony prominences.
Female breasts and male genitals are protected from pressure. The
safety strap is secured across the back of the patient's thighs.

Lateral. The patient may be intubated on the gurney and, at the


direction of the anesthesia provider, carefully turned to lateral position
onto the table, using coordinated teamwork. The torso may be
stabilized with padded kidney rests, or a beanbag device that conforms
to the patient's body is used. Use of a heating mattress is
contraindicated when the beanbag is used, as trapped heat could burn
the patient. After checking the chart for patient allergies, the position
is stabilized with wide adhesive tape or a folded towel or a blanket may
be placed under the tape. A mayo stand, padded with a pillow,
supports the uppermost arm, or a padded double armboard may be
used.The leg on the dependent side is flexed;the upper leg may be
straight or slightly flexed(to stabilize the position)with a pillow placed
between the legs; padding, foam, or gel pads are placed around the
feets and ankles.

Skin Preparation

Most surgeons prefer to cut the hair and shave the scalp. Check
with the surgeons regarding the area to be prepped and the solution to
be used for the skin prep (by the circulator). Antibiotic ointment (e.g.,
Polysporin) may be put in the eyes, and and eye pads and nonirritating
tape may be used to tape lids shut; plastic eye shields are helpful to
avoid undue pressure on the eyes. Care is taken to avoid getting prep
solution in the eyes. Small cotton pledgets or cotton balls are placed in
the ears (some surgeons prefer removing them with a mosquito
forceps before draping). To avoid a fire hazard, prep solutions are not
allowed to pool on the drapes. The surgeon usually marks the line of
incision before draping. The prepped area must be carefully dried;
otherwise, the plastic drape will not stick. Use aterile technique when
removing the towel. If a bone grafting is anticipated, the bone graft
area is prepped and draped at the same time.
Draping

Surgeons usually prefer to do the draping. Folded towels are


placed around the operative site and secured by towel clips, staples, or
sutures; the scrub person prepares ahead heavy silk sutures(e.g.,#2)
on cutting needles, two needle holders, toothed forceps, and suture
scissors. A large drape sheet is placed below the head. A craniotomy
sheet with an adhesive plastic backing in the fenestration is used, or a
sterile, plastic adhesive drape is placed, followed by a drape sheet
under the head, and a sheet with an aperture sized for craniotomy
exposure is used. The prepped area must be dry, or the adhesive
drape will not stick. An impervious drape (e.g., plastic) with a collection
pouch is usually preferred. If an overhead table (e.g., Mayfield)is used,
a large drape sheet, fanfolded at the front edge of the table, is used.
The fanfolded sheet is brought down to close off the space between
the unsterile area under the table and the operative field. The
disposable craniotomy sheet will eliminate the need for additional
drape sheets; otherwise, a fenestrated sheet and drape sheets, as
necessary, are placed to avoid contamination.
Additional draping may be required for the microsope, C-arm,
stand, drills and saws, and table with the andoscopes etc.
For iliac bone graft, add: towels, sterile, plastic adhesive drape,
a drape sheet with a medium-sized fenestration, and a towel or sheet
to cover the graft site until exposure is necessary.

NURSING CONSIDERATIONS

Preoperative Medical and Nursing Management.

(1) Instruct patient and family about the necessity and


importance of diagnostic tests to determine the exact
location of the tumor.
(2) Monitor and record vital signs and neurological status
accurately q2-4h, or as ordered. Report changes to
professional nurse immediately.
(3) Institute measures to prevent inadvertent increases in
intracranial pressure.
(a) Elevate head of bed 30º.
(b) Stool softeners to prevent straining at stool
(which increases intracranial pressure).
(4) Institute seizure precautions at patient's bedside.
(Tongue blade airway.)
(5) Supportive nursing care is given depending upon the
patient's symptoms and ability to perform activities of daily
living.
(6) Administer all doses of steroids and antiepileptic agents
on time.
(a) Withholding steroids can result in adrenal
crisis.
(b) Withholding of antiepileptic agents
frequently precipitates seizure.

(7) Surgery (craniotomy) is performed to remove neoplasm


and alleviate symptoms.

Post Operative Nursing Care Considerations

(1) Meticulous nursing management and care aimed at


prevention of postoperative complications are imperative
for the patient's survival.
(2) Accurately monitor and record all vital signs and
neurological signs.
(a) Postoperative cerebral edema peaks
between 48 and 60 hours following surgery.
(b) Patient may be lucid during first 24 hours,
then experience a decrease in level of
consciousness during this time.
(3) Administer artificial tears (eye drops) as ordered, to
prevent corneal ulceration in the comatose patient.
(4) Maintain skin integrity.
(5) Bone flap may not have been replaced over surgical
site; turning patient to the affected side, if the flap has
been removed, can cause irreversible damage in the first
72 hours.
(6) Maintain head of bed at 30ºelevation.
(7) Perform passive range of motion exercises to all
extremities every 2-4 hours.
(8) Maintain body temperature.
(a) Increases of body temperature in the
neurosurgical patient may be due to cerebral
edema around the hypothalamus.
(b) Monitor rectal temperature frequently.
(c) Place patient on hypothermia blanket, as
ordered.
(9) Institute seizure precautions at patient's bedside.
(Tongue blade, airway.)
(10) Maintain accurate record of intake and output.
(11) Prevent pulmonary complications associated with
bedrest.
(a) Cough and deep breath every 2 hours.
(b) Perform gentle chest percussion, with the
patient in the lateral decubitus position, if
tolerated.

(12) Continuously talk to the patient while providing care,


reorienting him to person, place, and time.

INSTRUMENTATION

Craniotomy Surgical Set


• 2Jansen Retractor
• 2Weitlaner Retractor
• 1Scalpel Handle #3
• 1Scalpel Handle #4
• 1Scalpel Handle #7
• 4Solid Bar Handle For Gigli Saw
• 2Adson (Ewald) Dressing Forceps
• 2Adson Tissue Forceps
• 12Backhaus Towel Clamp
• 2Cushing Brain Forceps
• 2Cushing Brain Forceps
• 1Echlin Rongeur
• 6Foerster Sponge Forceps
• 6Foerster Sponge Forceps
• 18Halsted Mosquito Forceps
• 18Halsted Mosquito Forceps
• 1Luer Bone Rongeur
• 1Stille-Liston Rongeur
• 2Mayo-Hegar Needle Holder
• 1Gigli Saw Wire
• 1Gigli Saw Wire
• 1Operating Scissors
• 1Mayo-Stille Dissecting Scissors
• 1Mayo-Stille Dissecting Scissors
• 1Metzenbaum Dissecting Scissors
• 1Taylor Dural Scissors

Jansen Retractor

Scalpel

Weitlaner retractor

Adson (Ewald) Dressing Forceps


Echlin Rongeur

Adson Tissue Forceps

Foerster Sponge Forceps

Backhaus Towel Clamp

Halsted Mosquito Forceps

Cushing Brain Forceps (Delicate


Serrated)

Halsted Mosquito Forceps


Gigli Saw Wire

Luer Bone Rongeur

stille-Liston Rongeur

Operating Scissors

Mayo-Hegar Needle Holder

Mayo-Stille Dissecting Scissors


Taylor Dural Scissors

Mayo-Stille Dissecting Scissors


curved