INTRACRANIAL SURGERY

A craniotomy involves opening the skull surgically to gain access to intracranial structures. This
procedure is performed to remove a tumor, relieve elevated ICP, evacuate a blood clot, or control
hemorrhage.
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.
One of two approaches through the skull is used:
(1) above the tentorium (supratentorial craniotomy) into the supratentorial compartment, or
(2) below the tentorium into the infratentorial (posterior fossa) compartment.
A third approach, the transsphenoidal approach (through the mouth and nasal sinuses) is often
used to gain access to the pituitary gland (Musleh, Sonabend & Lesniak, 2006).

Supratentorial

Site of
Surgery

Incision
Location

Selected Nursing
Interventions

Above the
tentorium

Incision is
made above
the area to be
operated on;
usually
located
behind the
hairline.

Maintain head of bed

elevated 3045
degrees, with neck in
neutral alignment.
Position patient on
either side or back.
(Avoid positioning
patient on operative
side if a large tumor
has been removed.)

Infratentorial

Below the
tentorium,
brain stem

Incision is
made at the
nape of the
neck, around
the occipital
lobe.

Maintain neck in
straight alignment.
Avoid flexion of the
neck to prevent
possible tearing of the
suture line.
Position the patient
on either side. (Check
surgeons preference
for positioning of
patient.)

Transsphenoidal

Sella
turcica and
pituitary
region

Incision is
made
beneath the
upper lip to
gain access
into the nasal
cavity.

Maintain nasal
packing in place and
reinforce as
needed.Instruct
patient to avoid
blowing the nose.
Provide frequent oral
care. Keep head of
bed elevated to
promote venous
drainage and drainage
from the surgical site.

Alternatively, intracranial structures may be approached through burr holes, which are circular
openings made in the skull by either a hand drill or an automatic craniotome (which has a selfcontrolled system to stop the drill when the bone is penetrated). Burr holes may be used to
determine the presence of cerebral swelling and injury and the size and position of the ventricles.
They are also a means of evacuating an intracranial hematoma or abscess and for making a bone
flap in the skull that allows access to the ventricles for decompression, ventriculography, or
shunting procedures. Other cranial procedures include craniectomy (excision of a portion of the
skull) and cranioplasty (repair of a cranial defect using a plastic or metal plate).

SUPRATENTORIAL AND INFRATENTORIAL APPROACHES

PREOPERATIVE MANAGEMENT
Medical Management
Preoperative diagnostic procedures:

CT scan - to demonstrate the lesion and show the degree of surrounding brain edema, the
ventricular size, and the displacement.
MRI scan - provides information similar to that of a CT scan with improved tissue
contrast, resolution, and anatomic definition.
Cerebral angiography - may be used to study a tumors blood supply or obtain
information about vascular lesions.
Transcranial Doppler flow studies - are used to evaluate the blood flow within
intracranial blood vessels.

Medications
Before surgery:
a. Antiseizure medication to reduce the risk of postoperative seizures (paroxysmal transient
disturbances of the brain resulting from a discharge of abnormal electrical activity)
(Karch, 2008)
phenytoin (Dilantin)
phenytoin metabolite (Cerebyx)
b. Corticosteroids may be administered to reduce cerebral edema if the patient has a brain
tumor

 dexamethasone (Decadron)
c. Hyperosmotic agent (mannitol) and a diuretic agent such as furosemide (Lasix) may be
administered IV immediately before and sometimes during surgery if the patient tends to
retain fluid, as do many who have intracranial dysfunction.
d. Antibiotics may be administered if there is a chance of cerebral contamination;
e. Diazepam (Valium) or lorazepam (Ativan) may be prescribed to allay anxiety.
Nursing Management
a. Preoperative assessment serves as a baseline against which postoperative status and
recovery are compared.
Evaluating the level of consciousness and responsiveness to stimuli
Identifying neurologic deficits such as paralysis, visual dysfunction, alterations in
personality or speech and bowel and bladder disorder.
Hair is removed with the use of clippers and the surgical site prepared immediately
before surgery (usually in the operating room), to decrease the chance of infection.
b. Adequate preparation for surgery, with attention to the patients physical and emotional
status can reduce the risk of anxiety, fear, and postoperative complications.
c. An indwelling urinary catheter is inserted in the operating room to drain the bladder
during the administration of diuretics and to permit urinary output to be monitored.
d. Post-operative assessment
Neurologic deficits and potential impact after surgery.
For motor deficits or weakness or paralysis of the arms or legs, trochanter rolls
are applied to the extremities and the feet are positioned against a footboard or the
ankles are supported in a neural position with orthotic boots.
A patient who can ambulate is encouraged to do so.
If the patient is aphasic, writing materials or pictures and word cards showing the
bedpan, glass of water, blanket and other frequently used items may help improve
communication.
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 must be established.
e. Preparation of the patient and family includes providing information about what to expect
during and after surgery.
f. An altered cognitive state may make the patient unaware of the impending surgery. Even
so, encouragement and attention to the patients needs are necessary. Whatever the state
of awareness of the patient, the family needs reassurance and support, because they
usually recognize the seriousness of brain surgery.
POSTOPERATIVE MANAGEMENT
a. Reducing cerebral edema
Medications

b.

c.
d.
e.

Mannitol which increases the serum osmolality and draws free water from
areas of the brain (with an intact blood-brain barrier)
- Osmotic dieresis like dexamethasone (Decadron) may be administered IV
every 6 hours for 24 to 72 hours; the route is changed to oral as soon as
possible, and the dosage is tapered over 5 to 7 days. (Karch, 2008)
Relieving pain and preventing seizure
- Acethamnophen for temperature exceeding 37.5C and for pain.
- Codeine is administered IV is often sufficient to relieve headache.
- Morphine sulfate may also be used in the management of post operative pain.
Anitseizure medication is often prescribed prophylactically for patients who have
undergone supratentorial craniotomy because of high risk of seizures after these
procedures.
Monitoring Intracranial Pressure
Intracranial pressure or cerebral oxygenation monitor is inserted during surgery.
Arterial line and a central venous pressure line may be in place to monitor and manage
blood pressure and central venous pressure.
The patient may be intubated and may receive supplemental oxygen therapy.

TRANSSPHENOIDAL APPROACH
Tumors within the sella turcica and small adenomas of the pituitary can be removed through a
transsphenoidal approach.
An incision is made beneath the upper lip, and entry is then gained successively into the nasal
cavity, sphenoidal sinus, and sella turcica. Although an otorhinolaryngologist may make the
initial opening, the neurosurgeon completes the opening into the sphenoidal sinus and exposes
the floor of the sella. Microsurgical techniques provide improved illumination, magnification,
and visualization so that nearby vital structures can be avoided.
The transsphenoidal approach offers direct access to the sella turcica with minimal risk of trauma
and hemorrhage (Musleh, et al., 2006). It avoids many of the risks of craniotomy, and the
postoperative discomfort is similar to that of other transnasal surgical procedures. It may also be
used for pituitary ablation (destruction) in patients with disseminated breast or prostatic cancer.
Complications
Manipulation of the posterior pituitary gland during surgery may produce transient diabetes
insipidus of several days duration (Hickey, 2009). It is treated with vasopressin but occasionally
persists. Other complications include CSF leakage, visual disturbances, postoperative meningitis,
pneumocephalus (air in the intracranial cavity), and SIADH
PREOPERATIVE MANAGEMENT

Medical Management
a. Preoperative workup
Endocrine tests
Rhinologic evaluation to assess the status of the sinuses and nasal cavity.
Neuroradiologic studies
Fundoscopic examination and visual field determinations are performed because
the most serious effect of pituitary tumor is localized pressure on the optic nerve
or chiasm.
Nasopharyngeal secretions are cultured because a sinus infection is a
contraindication to an intracranial procedure using this approach.
b. Medications
- Corticosteroids may be administered before and after surgery, because the
surgery involves removal of the pituitary, the source of adrenocorticotropic
hormone (ACTH).
- Antibiotics may or may not be administered prophylactically.
POSTOPERATIVE MANAGEMENT
Medical Management
a. Deep breathing is taught before surgery.
b. The patient is instructed that after the surgery he or she will need to avoid vigorous
coughing, blowing the nose, sucking through a straw, or sneezing, because these actions
may place increased pressure at the surgical site and cause a CSF leak (Hickey, 2009).
Nursing Management
a. Vital signs are measured to monitor hemodynamic, cardiac, and ventilator status.
b. Visual acuity and visual fields are assessed at regular intervals because of the anatomic
proximity of the pituitary gland to optic chiasm.
c. Head of the bed is raised to decrease pressure on the sella turcica and to promote nomal
drainage.
d. Intake and output is measured as a guide to fluid and electrolyte replacement and to
assess for diabetes insipidus.
e. Urine specific gravity is measured after each voiding.
f. Daily weight is monitored.
g. Fluids are usually given after nausea ceases and the patient then progresses to a regular
diet.
h. Nasal packing inserted during surgery is checked frequently for blood or CSF drainage.
Oral care is provided every 4 hours or more frequently.
Petrolatum is soothing when applied to the lips.
A roomhumidifier assists in keeping the mucus membrane moist.
i. Home care considerations
Advising the patient to use a room humidifier to keep the mucous membranes mosit
and to soothe irritation.

The head of the bed is elevated for at least 2 weeks after surgery.