for astrocytoma is performed to remove as much as possible
of the tumor from within the brain. Astrocytoma
is the most common type of brain tumor which starts growing
from within the brain, and does not spread from other parts
of the body. Generally the tumor is not a discrete mass,
distinguishable from the normal brain surrounding it, but
is usually interspersed with normal brain tissue, blending
with the normal brain surrounding it. The prognosis
postoperatively is largely dependent upon the degree of malignancy
of the tumor. One classification system uses four grades.
Grade I is the least agressive, while Grade IV (glioblastoma
multiforme) is the most agressive.
The patient will
be taken to the operating room and put to sleep under general
anesthesia. The head will be partially shaved, to expose
the area of operation. The head is then placed in three
fixation points (Mayfield head pins). This provides
the ability to keep the head perfectly still during the procedure.
The surgeon may register a navigational device which allows
the use of "real time" intraoperative navigation.
The area where surgery is to be performed is then "prepped
and draped" using an antibiotic solution. Next,
the surgeon will make an incision, and reflect the scalp over
the area of the tumor. An air powered drill is then
used to make a hole in the skull, and a "footplate attachment"
on the drill, or another similar device, is used to cut open
a flap of skull. The dura mater (tough covering of the
brain) is then opened. An operating microscope is generally
brought into the field, and the surgeon will approach the
tumor within the brain. The surgery will vary depending
upon the site of the tumor. Often the edges of
the brain are gently supported using brain retractors.
Generally the surgeon will attempt to remove as much
of the tumor as possible. Any visible bleeding points
will be cauterized. Often, hemostatic promoting material
is gently laid over the surfaces of the brain, and closure
is begun. The surgeon will close the dura, and
approximate the skull using titanium plates to hold the bone
together. Next the scalp will be closed in layers, and
a pressure monitor may be placed into the brain to allow the
postoperative monitoring of pressure within the brain.
Risks for craniotomy
for astrocytoma can be broken down into two categories, 1)
those related to the operative site, and 2) those related
to the risks of anesthesia.
related to the operative site
Exposure: The patient is placed in a position
so as to allow the surgeon good access to the tumor.
Insicions in the scalp may range from small to quite large.
There is risk of non healing of the scalp or bone post operatively.
Although very uncommon, there can be injury to or tearing
of the scalp from the pins on the Mayfield clamp.
The plates used to close the skull could erode through the
skin after the wound has heeled.
The surgery involves opening of the surface of the
brain, and may involve going into the deep structures of
the brain. If the tumor crosses midline, or is located
near the deep structures of the brain, there can be injury
to strength of the upper or lower extremities. If
the tumor is located near the sagittal sinus (a large vein
draining both hemispheres of the brain), there is a risk
to this vein of either injury or thrombosis (clotting off).
If the vein is injured, large amounts of blood could be
lost during the surgery. If the vein clots off, this
could result in brain swelling and death. If the tumor
is near the cranial nerves (nerves leaving the brain stem,
and supplying such functions as sensation to the face, movement
of the eyes, ability to swallow and stick out the tongue),
then there could be damage to these nerves and the functions
they serve. If the tumor is near the nerves leaving
the eyes, damage to vision could occur. There
is the possibility that there may be injury to the brain.
If so, this could result in weakness, seizures, stroke,
paralysis, coma or death. There may be residual fluid
or blood, requiring additional surgery in the future.
It is possible that additional surgery may be needed in
the future, and that radiation or chemotherapy may be necessary.
such general difficulties as bleeding, infection, stroke,
paralysis, coma and death. Incisions on the scalp
generally heal well, but could become tender, numb,
or may heal in an unpleasant manner. There is also
the possibility that the surgery may not relieve the symptoms
for which the procedure was performed. The tumor
may recur, requiring additional surgery or radiation in
the future. In addition, although every attempt is
made to protect all areas of the body from pressure on nerves,
skin and bones, injuries to these areas can occur, particularly
with prolonged cases.
Anesthesia: Blood clots in the legs, heart attacks,
reaction to the anesthetic, reaction to blood transfusion,
if it given
There is surprisingly
relatively little pain associated with craniotomies.
Your surgeon will prescribe pain medications for any pain
associated with the incision.
upon discharge, contact our office and set up an appointment
for staple removal if one has not already been set up.
- Take it easy
until seen by the physician. This does not mean bed
rest, but athletic activities during this period are definitely
not recommended. Please give your incision a chance
to heal. Avoid any type of activity which might risk
a blow to the head.
- You may resume
activity as your body permits, but avoid extremes.
For example, walking is fine, but avoid any strenuous running.
USE GOOD JUDGMENT AND COMMON SENSE. If you have
a question, ask your doctor.
- No driving
until cleared with your surgeon. A driving test may
be required, at the discretion of your surgeon. Even
though you may feel fine, your peripheral vision and reflexes
may have been affected, and we want you to be safe on the
road for yourself as well as for others.
- You may shower
after you go home unless otherwise instructed. Cover
the incision with plastic wrap before the shower and remove
it afterward. Change dressing immediately.
You may shower without covering the incision one week after
the staples are out. Follow instructions concerning
care of tapestrips, stitches or staples. Your surgeon
or his nurse clinician will explain the techniques used
in the closure of your incision.
- Sexual activities
- If you notice
swelling, redness or opening of the incision, or if there
is any clear fluid draining from it, please contact your
surgeon immediately! If you develop a fever, stiff
neck or chills, contact the office immediately. Take
your temperature at 4:00 PM daily until the clips are removed.
Call if greater than 101 degrees Fahrenheit.
- If you have
a seizure, notify our office or come to the emergency room.
- If you develop
any new weakness, notify our office.
- If you have
any paralysis or weakness, post-operative care will need
to be tailored to this. If a brace for an arm of a
leg has been prescribed, use it as recommended by your surgeon.
- If you have
any questions, call our office, and for after hours emergencies,
call the medical society.
- Take your
medications prescribed on discharge, as directed.
- Do not take
any medications which will "thin the blood" such
as coumadin or aspirin, or other non-steroidal antiinflammatory
medications, unless otherwise advised by your physicians.
- Make sure
to follow up with any other physicians involved in your
care. These may include your family physician, neurologist,
radiation oncologist and oncologist.