Craniotomy

Craniotomy
• A craniotomy involves opening the skull surgically to gain access to
intracranial structures.
Purpose/indications of
craniotomy
• To remove a tumor

• To relieve elevated ICP (Increased Intracranial Pressure)

• To evacuate a blood clot, and control hemorrhage.

Procedure of craniotomy
• The surgeon cuts the skull to create a bony flap, which can be
repositioned after surgery and held in place by periosteal or wire
sutures.
Surgical approach for
craniotomy
• One of two approaches through the
skull is used:
1. Supratentorial craniotomy – above
the tentorium, into the
supratentorial compartment.

2. Infratentorial craniotomy – below

the tentorium into the
infratentorial (posterior fossa)
compartment.
Burr hole craniotomy
• Circular openings made in the skull.

• Made by either a hand drill or an automatic craniotome (which has a self-

controlled system to stop the drill when the bone is penetrated).
Preoperative Management
• Preoperative diagnostic procedures:
CT scan and MRI to demonstrate the lesion and show the degree of
surrounding brain edema, the ventricular size, and the displacement.

Cerebral angiography to study the tumor’s blood supply or give

information about vascular lesions.

Transcranial Doppler flow studies to evaluate the blood flow of

intracranial blood vessels.
Pre-operative medications:
• Antiseizure medication (e.g. phenytoin) – to reduce the risk of
postoperative seizures.

• Corticosteroids (e.g. dexamethasone) – to reduce cerebral edema.

• IV Hyperosmotic agent (mannitol) and a diuretic (furosemide) – if the

patient tends to retain fluid.

• Antibiotics – if there is a chance of cerebral contamination

• Diazepam –to reduce anxiety.

• Fluids may be restricted.
Preoperative Management
• Preoperative assessment:
Serves as a baseline against which postoperative status and recovery
are compared.

Assessment includes:
Evaluating LOC and responsiveness to stimuli
Identifying any neurologic deficits, such as:
Paralysis
Visual dysfunction
Alterations in personality or speech
Bladder and bowel disorders.

Distal and proximal motor strength in both upper and lower

extremities is recorded.
• Assess the patient’s and family’s understanding of surgical procedure
and provide information as necessary.

• Assess the availability of support systems for the patient and family.

• Provide reassurance and support to reduce anxiety.

• The surgical site is shaved.

• An indwelling urinary catheter is inserted.

• A central and arterial line is placed for fluid administration and

monitoring of pressures after surgery.

• Provide information about what to expect during and after surgery

including:
The large head dressing applied after surgery may impair hearing
temporarily.

Vision may be limited if the eyes are swollen shut.

If a tracheostomy or endotracheal tube is in place, the patient will be

unable to speak until the tube is removed, so an alternative method
of communication should be established.
Postoperative Management
• Ongoing postoperative management is aimed at:
Detecting and reducing cerebral edema

Relieving pain

Preventing seizures

Monitoring ICP
REDUCING CEREBRAL EDEMA
• Administer mannitol to reduce cerebral edema
Increases serum osmolality and draws free fluid from areas of the brain
(with an intact blood–brain barrier).
The fluid is then excreted by osmotic diuresis.

• Administer dexamethasone intravenously every 6 hours for 24 to 72

hours.
The route is switched to oral as soon as possible and dosage is tapered
over 5 to 7 days.
RELIEVING PAIN AND PREVENTING SEIZURES
• Administer acetaminophen for controlling temperature exceeding
99.6°F and for pain.

• Administer codeine parenterally to relieve headache.

• Morphine sulfate may also be used for post-operative pain

management.
• Seizure medication (phenytoin, diazepam) is prescribed for patients
who have undergone supratentorial craniotomy because of the high
risk of seizures after supratentorial neurosurgical procedures.

• Serum levels of medications are monitored to keep the medications

within the therapeutic range.
MONITORING ICP
• A ventricular catheter or other type of drain is frequently inserted and
the catheter is connected to an external drainage system.

• The patency of the catheter is noted by the pulsations of the fluid in

the tubing.

• The ICP can be assessed using a stopcock attached to the pressure

tubing and transducer turning to the appropriate position.
• Care is required to ensure that the system is tight at all connections
and that the stopcock is in the proper position to avoid rapid drainage
of CSF and prevent collapse of the ventricles and brain herniation.

• The catheter is removed when the ventricular pressure is normal and

stable.

• The neurosurgeon must be notified if the catheter appears to be

obstructed.
Nursing management
• Assessing respiratory function is essential because even a small
degree of hypoxia can increase cerebral ischemia.
The respiratory rate and pattern are monitored.

Arterial blood gas values are assessed frequently.

• Fluctuations in vital signs are carefully monitored and documented

because they indicate increased ICP.
• The patient’s temperature is measured at intervals to assess for
hyperthermia secondary to damage to the hypothalamus.

• Neurologic assessment is done frequently to detect increased ICP

resulting from cerebral edema or bleeding.
A change in LOC or response to stimuli may be the first sign of
increasing ICP.
• The surgical dressing is inspected for evidence of bleeding and CSF
drainage.

• The nurse must be alert to the development of complications.

Seizures are a potential complication, and any seizure activity is carefully

recorded and reported.

Restlessness may occur as the patient becomes more responsive or may

be due to pain, confusion, hypoxia, or other stimuli.
NURSING DIAGNOSES
• Ineffective cerebral tissue perfusion related to cerebral edema.

• Potential for ineffective thermoregulation related to damage to the

hypothalamus, dehydration, and infection.

• Potential for impaired gas exchange related to hypoventilation,

aspiration, and immobility.
• Disturbed sensory perception related to periorbital edema, head
dressing, endotracheal tube, and effects of ICP.

• Body image disturbance related to change in appearance or physical

disabilities.
Planning and Goals
• The major goals for the patient include neurologic homeostasis to:
Improve cerebral tissue perfusion
Adequate thermoregulation
Normal ventilation and gas exchange
Ability to cope with sensory deprivation
Adaptation to changes in body image
Nursing Interventions
MAINTAINING CEREBRAL TISSUE PERFUSION
• Maintaining ICP
The head is kept in a neutral (midline) position, maintained with the
use of a cervical collar if necessary, to promote venous drainage.

Elevation of the head is maintained at 60 degrees to aid in venous

drainage or as prescribed.
Extreme hip flexion is also avoided because this position causes an increase
in intra-abdominal and intrathoracic pressures, which can produce a rise in
ICP.

Straining at defecation raises ICP and is avoided by administration of stool

softeners as prescribed or if allowed by encouraging intake of a high fiber
diet.

Emotional stress and frequent arousal from sleep are avoided, a calm
atmosphere is maintained, and a environmental stimuli (noise,
conversation) should be minimal.
• Maintaining oxygen level
The endotracheal tube is left in place until the patient shows signs of
awakening and has adequate spontaneous ventilation, as evaluated
clinically and by arterial blood gas analysis.

Before suctioning, the patient should be preoxygenated and

hyperventilated using 100% oxygen on the ventilator.

Suctioning should not last longer than 15 seconds.

• Vital signs and neurologic status (LOC and responsiveness, pupillary
and motor responses) are assessed every 15 minutes to every 1 hour.
• Maintaining proper positioning
Supratentorial surgery
The patient is placed on his or her back or side (unoperated side if a
large lesion was removed) with one pillow under the head.

The head of the bed may be elevated 30 degrees, depending on the

level of the ICP and the neurosurgeon’s preference.
Infratentorial surgery
The patient is kept flat on one side (off the back) with the head on a small,
firm pillow.

The patient may be turned on either side, keeping the neck in a neutral
position.

When the patient is being turned, the body should be turned as a unit to
prevent placing strain on the incision and possibly tearing the sutures.

The head of the bed may be elevated slowly as tolerated by the patient.
The patient’s position is changed every 2 hours, and skin care is given
frequently.

During position changes, care is taken to prevent disrupting the ICP

monitoring system.

A turning sheet placed under the head to the midthigh makes it

easier to move and turn the patient safely.
REGULATING TEMPERATURE
• Monitor the patient’s temperature.

• High fever is treated vigorously to combat the effect of an elevated

temperature on brain metabolism and function by using following
measures:
Remove blankets, apply ice bags to axilla and groin areas, and use a
hypothermia blanket as prescribed.
Administering prescribed antipyretics.
Rewarming should occur slowly to prevent shivering, which increases
cellular oxygen demands.
IMPROVING GAS EXCHANGE
• Assess the patient for signs of respiratory infection, which include:
Temperature elevation, increased pulse rate, and changes in
respirations.
Auscultates the lungs for decreased breath sounds and adventitious
sounds.

• Repositioning the patient every 2 hourly to mobilize pulmonary

secretions and prevent stasis.
• When the patient regains consciousness, additional measures to
expand collapsed alveoli can be instituted, such as yawning, sighing,
deep breathing, incentive spirometry.

• Increase the humidity in the oxygen delivery system to help loosen

secretions.

• Provide chest physical therapy as needed.

MANAGING SENSORY DEPRIVATION
• Sensory deprivation may be caused by periorbital edema.

• Place the patient in a head-up position (if not contraindicated) and

apply cold compresses over the eyes to reduce edema.

• If periorbital edema increases significantly, the surgeon is notified.

• Health care personnel should announce their presence when entering

the room to avoid startling the patient whose vision is impaired due to
periorbital edema or neurologic deficits.
• Additional factors that can affect sensation include a bulky head dressing, the
presence of an endotracheal tube, and effects of increased ICP.

• In the absence of bleeding or a CSF leak, every effort is made to minimize the
size of the head dressing.

• If the patient requires an endotracheal tube for mechanical ventilation, every

effort is made to extubate the patient as soon as clinical signs indicate it is
possible.

• The patient is monitored closely for the effects of elevated ICP.

ENHANCING SELF-IMAGE
• The patient is encouraged to verbalize feelings and frustrations about
any change in appearance.

• Nursing support is based on the patient’s reactions and feelings.

• Factual information may need to be provided if the patient has

misconceptions about puffiness about the face, periorbital bruising,
and hair loss.
• Attention to grooming, the use of the patient’s own clothing, and covering the
head with a turban (and ultimately a wig until hair growth occurs) are encouraged.

• Social interaction with close friends, family, and hospital personnel may increase
the patient’s sense of self-worth.

• Assist and encourage participation in ADLs as possible to develop a sense of

control and competence.

• The family and social support system can be of assistance while the patient
recovers from surgery.
THANK YOU!!