Craniotomy and resection of brain tumour in adults

Craniotomy means making a window in the skull. During a craniotomy procedure, the neurosurgeon makes an incision in the scalp (skin) before removing a small piece of the skull (bone) to expose the brain. This removal of your bone is referred to as a craniotomy or bone flap. The section of bone is sterilised before being secured back in place at the end of the procedure with small titanium screws and plates (see below section about what happens during the procedure).

The aims of this procedure are:

• To find out what kind of cells are causing the tumour. This is called a histopathology diagnosis.
• To remove as much of the tumour as possible.

Taking out as much tumour as a possible may have the following benefits:

• Better survival outlook
• Fewer symptoms

It means other treatments may be more effective or safer. For example, radiotherapy causes swelling (oedema), so by creating space in the brain, the risk of severe complications is reduced.

Sometimes it is not safe for the neurosurgeon to take out the entire tumour (known as complete resection), for example, the tumour might have invaded vital structures. When the tumour is partially removed, this is referred to as a partial resection or debulking procedure.

This procedure will only be performed by a consultant neurosurgeon or neurosurgery specialist registrar operating under the supervision of a consultant.

Anaesthesia means ‘loss of sensation’. There are three types of anaesthesia: general, regional and local. The type of anaesthesia chosen by your anaesthetist depends on the nature of your surgery as well as your health and fitness. Sometimes different types of anaesthesia are used together.

Before your operation

Before your operation you will meet an anaesthetist who will discuss with you the most appropriate type of anaesthetic for your operation, and pain relief after your surgery.

To inform this decision, he/she will need to know about:

Your anaesthetist may need to listen to your heart and lungs, ask you to open your mouth and move your neck and will review your test results.

Pre-medication

You may be prescribed a ‘pre-medication’ prior to your operation. This is a drug or combination of drugs which may be used to make you sleepy and relaxed before surgery, provide pain relief, reduce the risk of you being sick, or have effects specific for the procedure that you are going to have or for any medical conditions that you may have. Not all patients will be given a pre-medication or will require one and the anaesthetist will often use drugs in the operating theatre to produce the same effects.

Moving to the operating room or theatre

You will usually change into a gown before your operation and we will take you to the operating suite. When you arrive in the theatre or anaesthetic room and before starting your anaesthesia, the medical team will perform a check of your name, personal details and confirm the operation you are expecting.

Once that is complete, monitoring devices may be attached to you, such as a blood pressure cuff, heart monitor (ECG) and a monitor to check your oxygen levels (a pulse oximeter). An intravenous line (drip) may be inserted. If a regional anaesthetic is going to be performed, this may be performed at this stage. If you are to have a general anaesthetic, you may be asked to breathe oxygen through a face mask.

During general anaesthesia you are put into a state of unconsciousness and you will be unaware of anything during the time of your operation. Your anaesthetist achieves this by giving you a combination of drugs.

While you are unconscious and unaware your anaesthetist remains with you at all times. He or she monitors your condition and administers the right amount of anaesthetic drugs to maintain you at the correct level of unconsciousness for the period of the surgery. Your anaesthetist will be monitoring such factors as heart rate, blood pressure, heart rhythm, body temperature and breathing. He or she will also constantly watch your need for fluid or blood replacement.

Regional anaesthesia includes epidurals, spinals, caudals or local anaesthetic blocks of the nerves to the limbs or other areas of the body. Local anaesthetic is injected near to nerves, numbing the relevant area and possibly making the affected part of the body difficult or impossible to move for a period of time. Regional anaesthesia may be performed as the sole anaesthetic for your operation, with or without sedation, or with a general anaesthetic. Regional anaesthesia may also be used to provide pain relief after your surgery for hours or even days. Your anaesthetist will discuss the procedure, benefits and risks with you and, if you are to have a general anaesthetic as well, whether the regional anaesthesia will be performed before you are given the general anaesthetic.

In local anaesthesia the local anaesthetic drug is injected into the skin and tissues at the site of the operation. The area of numbness will be restricted. Some sensation of pressure may be present, but there should be no pain. Local anaesthesia is used for minor operations such as stitching a cut, but may also be injected around the surgical site to help with pain relief. Usually a local anaesthetic will be given by the doctor doing the operation. Some people who have this type of procedure will have it performed as a day case but others will require an overnight stay.

Sedation is the use of small amounts of anaesthetic or similar drugs to produce a ‘sleepy-like’ state. Sedation may be used as well as a local or regional anaesthetic. The anaesthesia prevents you from feeling pain and the sedation makes you drowsy. Sedation also makes you physically and mentally relaxed during an investigation or procedure which may be unpleasant or painful (such as an endoscopy) but where your co-operation is needed. You may remember a little about what happened but often you will remember nothing. Sedation may be used by other professionals as well as anaesthetists.

In modern anaesthesia, serious problems are uncommon. Risks cannot be removed completely, but modern equipment, training and drugs have made it a much safer procedure in recent years. The risk to you as an individual will depend on whether you have any other illness, personal factors (such as smoking or being overweight) or surgery which is complicated, long or performed in an emergency.

Very common (1 in 10 people) and common side effects (1 in 100 people)

• Feeling sick and vomiting after surgery
• Sore throat
• Dizziness, blurred vision
• Headache
• Bladder problems
• Damage to lips or tongue (usually minor)
• Itching
• Aches, pains and backache
• Pain during injection of drugs
• Bruising and soreness
• Confusion or memory loss
• Seizures or partial seizures

Uncommon side effects and complications (1 in 1000 people)

• Chest infection
• Muscle pains
• Slow breathing (depressed respiration)
• Damage to teeth
• An existing medical condition getting worse
• Awareness (becoming conscious during your operation)

Royal College Of Anaesthetists (opens in a new tab)

• Damage to the eyes
• Heart attack or stroke
• Serious allergy to drugs
• Nerve damage
• Death
• Equipment failure

Deaths caused by anaesthesia are very rare. There are probably about five deaths for every million anaesthetics in the UK.

For more information about anaesthesia, please visit the Royal College of Anaesthetists’ website: Royal College Of Anaesthetists (opens in a new tab)

You will be taken to neurosurgery theatres on your hospital bed. The surgeon shaves a small amount of hair and then makes an incision in your scalp. The size and shape of the opening will depend on the size and position of the tumour. The incision will be made behind the hairline whenever possible so the scar is hidden when the hair grows back.

The neurosurgeon then cuts out a window in the skull to expose the brain. This part of the operation is called a craniotomy. The surgeon will then remove as much of the tumour as possible. Sometimes it is not possible to completely remove a tumour. For example, if the tumour is in a vital structure in your brain, then removing all of it may cause severe disability or even death. Sometimes the surgeon can tell you before the operation whether they can remove the entire tumour. Sometimes they don’t know until they are doing the operation itself.

If your tumour is close to a location that controls movement, the surgeons use intraoperative monitoring (IOM) to help minimise complications during surgery when you are fully asleep. They do this by placing small electrodes onto your brain surface. Before removing the tumour, they pass a small electric current through these electrodes. If your muscles start twitching, they know this part controls vital movements. In most instances, they will not remove tumour from this area as it may cause permanent weakness. The surgeons will then leave other treatments, such as radiotherapy to deal with this. If your muscles do not twitch, it is safe for the tumour to be removed.

After the tumour is resected the bone window is closed with small titanium screws and plates (which are MRI/CT safe) and the skin closed with stitches or clips (staples) and covered with a dressing. The time your surgery takes depends upon the complexity of the procedure, but you will be away from the ward for several hours.

How you will feel will depend on the type of anaesthetic and operation you have had, how much pain relieving medicine you need and your general health.

Most people will feel fine after their operation. Some people may feel dizzy, sick or have general aches and pains. Others may experience some blurred vision, drowsiness, a sore throat, headache or breathing difficulties.

You may have fewer of these effects after local or regional anaesthesia although when the effects of the anaesthesia wear off you may need pain relieving medicines.

Once your surgery is completed you will usually be transferred to the recovery area where you will be looked after by specially trained nurses, under the direction of your anaesthetist. The nurses will monitor you closely until the effects of any general anaesthetic have adequately worn off and you are conscious. They will monitor your heart rate, blood pressure and oxygen levels.

You may be given oxygen via a facemask, fluids via your drip and appropriate pain relief until you are comfortable enough to return to your ward. You may (or may not) also have a tube inserted in your wrist called an arterial line, a tube in your neck called a central line and a urinary catheter.

After certain major operations you may be transferred to the intensive care unit (ICU/ITU/NCCU), high dependency unit (HDU), intermediate dependency area (IDA) or fast track/overnight intensive recovery (OIR). These are areas where you will be monitored much more closely because of the nature of your operation or because of certain pre-existing health problems that you may have. If your surgeon or anaesthetist believes you should go to one of these areas after your operation, they will tell you and explain to you what you should expect.

If there is not a bed in the necessary unit on the day of your operation, your operation may be postponed as it is important that you have the correct level of care after major surgery.

There are risks of surgery in general and risks associated specifically with the craniotomy. The risks of surgery in general include problems with the wound (for example infection), problems with breathing (such as a chest infection) and blood clots for example in the legs (also known as deep venous thrombosis or DVT) or less frequently the lungs (also known as pulmonary embolism or PE). Some of the possible problems related to the craniotomy are listed below.

These are very general figures and your surgeon will discuss with you risks pertaining to your specific case.

• Infection in the brain: approximately 1-5 in 100 people
• Leakage of brain fluid (CSF): approximately 1-5 in 100 people
• Bleeding (haemorrhage) into the brain: 4 in 100 people
• Superficial wound infection: 2 in 100 people
• Permanent ‘neurological deficit’ such as speech, visual, arm or leg weakness if the tumour is away from a critical area of the brain: 3 in 100 people
• Permanent ‘neurological deficit’ such as speech, visual, arm or leg weakness if the tumour is in or close to a critical area of the brain: 10 in 100 people
• Death: 1 in 100 people

If you do wake up with a new neurological deficit then remember that most patients with a new neurological deficit following this procedure will improve over a few days and weeks as the swelling subsides. Some will resolve completely.

There are generally two alternative treatment options for brain tumours:

Brain tumour biopsy. During this procedure a very small amount of the tumour is removed and sent for analysis. Once a diagnosis is known, further treatment options can be discussed. This is a less intrusive procedure but the benefits may not be as good.

You may decide not to have surgery at all. This may also prevent you from having other types of treatment such as radiotherapy or chemotherapy as these depend upon having a tissue diagnosis, i.e. histopathological diagnosis. The full implications of deciding not to have surgery will be discussed with you.