Approach Considerations

Incision planning

After the patient is positioned, the first step is to plan the incision. Some basic principles that
govern incisions include the following:

Continuous lines and curves that remain behind the hairline are preferable for wound
healing and cosmesis
Intersecting incisions should be avoided, as these are less likely to heal well
Intraoperative navigational software can be used for incision planning and avoiding
large underlying veins and major sinuses
Reoperative craniotomies should make use of prior incisions
If the incision runs over the superficial temporal artery, take care not to damage the
artery or its major branches, as this can risk blood supply to the scalp
Incisions are not carried beyond the zygomatic arch so as to prevent injury to the
facial nerve [6]

The fundamental goal is to tailor the incision to the underlying intracranial lesion with the
aforementioned principles in mind. A wide variety of intracranial processes must be accessed
via craniotomy, with a corresponding variety of incisions. The following are examples of the
incisions made for the more common craniotomy types: [7]

Pterional and frontotemporal craniotomy: Extends from the zygomatic arch 1 cm in

front of the tragus, curves anteriorly, remains behind the hairline, and ends at widows
peak
Frontal craniotomy (unilateral or bilateral): Unilateral approach uses an incision
starting less than 1 cm anterior to the tragus and just above the zygomatic arch, curves
superiorly and posteriorly, and ends at the midline frontally; bilateral approach uses
an ear-to-ear incision (also known as a bicoronal incision) that is also less than 1 cm
anterior to the tragus and terminates on each side just above the zygomatic arches
while remaining behind the hairline
Temporal craniotomy: May be linear or question-mark depending on the target
pathology; linear incisions stay within the temporalis muscle and begin anterior to the
tragus, 1-2 cm above the zygomatic arch, and extend anywhere from 6-8 cm above the
arch; question-mark incisions also run anterior to the tragus, begin just above the
zygomatic arch, and curve posteriorly at the top of the pinna 6-9 cm, then superiorly
to the superior temporal line, then anteriorly toward the forehead, terminating at the
hairline
Suboccipital craniotomy/craniectomy: Involves a few incision types; midline and
paramedian incisions are linear; midline incision extends from 6 cm above the inion
to the C2 spinous process; paramedian incision (also referred to as a retrosigmoid
approach) begins 5 mm medial to the mastoid notch and extends 4-6 cm above and
below the notch; hockey-stick incisions are curved and begin in the midline at the
C2 spinous process, extend superiorly to just above the inion, and then laterally to
mastoid tip with a terminal caudal curve

Craniotomy
Surgical field preparation

After the incision is planned, a minimal shave (2-4 cm on either side of the incision) is
carried out with a disposable razor. Various surgical scrubs and preps are acceptable; the
fundamental 2 steps involve a lengthier scrub with Betadine detergent (povidone-iodine
solution, Purdue Pharma, Stamford, CT) for 5 minutes followed by sterile application of
Betadine paint that is allowed to dry. Draping involves initial placement of sterile towels to
frame the incision, taking care to keep hair out of the field; placement of a 3M Ioban
antimicrobial drape; and then a craniotomy drape with a fluid pouch. The incision is injected
with a local anesthetic formulation, as described above, and the equipment is then arranged
on and around the field.

Incision, burr holes, craniotomy

The skin is incised with a no. 10 blade down through the galea onto bone. In areas where the
temporalis fascia and muscle underlie the incision, the scalpel is carried down to the fascial
layer, and the fascia is then typically incised sharply and split with either scissors or Bovie
cautery. Raney clips are commonly applied to the scalp edges for hemostasis. The scalp flap
is reflected using either periosteal elevators (blunt dissection) or Bovie cautery. Retraction is
accomplished by placing temporary sutures or perforating towel clips through the base of the
scalp flap, attaching them to rubber bands, and wrapping the rubber bands around a Leyla
bar, which is a straight metal attachment situated above the surgical field.

For suboccipital incisions, the incision is carried down to the fascia and muscles, which are
left intact. Raney clips are difficult to place for these incisions, so major scalp vessels are
cauterized, and self-retaining retractors are placed (cerebellar or Weitlaner retractors).The
fascia and muscles are then dissected with Bovie cautery until the bone is reached. [6]

The number, size, and location of the burr holes depend on the craniotomy type, and there are
many acceptable patterns, as follows: [7]

Pterional and frontotemporal craniotomy: Two burr holes are typically drilled, one at
the posterior insertion of the zygomatic arch (the low burr hole) and the second at the
intersection of the zygomatic bone, superior temporal line, and supraorbital ridge; if
only one burr hole is drilled, it is the temporal burr hole
Frontal craniotomy (unilateral or bilateral): For the unilateral approach, 4 burr holes
are drilled, one at the junction of the superior temporal line and orbital rim, a second
posterior to the depression of the sphenoid wing, a third anteriorly behind the hairline,
and a fourth superiorly; for the bilateral approach, two burr holes are made on either
side of the superior sagittal sinus (or two slots), and two burr holes are made laterally
Temporal craniotomy: For the linear incision, one burr hole is made at the inferior
pole of the incision; for the question-mark incision, one burr hole is made at the
posterior insertion of the zygomatic arch, one at the upper anterior portion of the
zygomatic bone, and one or two burr holes at the superior and posterior edges of the
incision
Suboccipital craniotomy/craniectomy: For midline incisions, the craniotomy involves
a horizontal slot inferior to the inion and laterally placed burr holes on either side of
the midline; the midline craniectomy extends down to the foramen magnum; for
paramedian incisions, smaller craniectomies may be 4 cm in diameter at the
transverse-sigmoid sinus junction, while larger craniectomies are bordered by the
 transverse sinus superiorly, foramen magnum inferiorly, sigmoid sinus laterally
(which may violate mastoid air cells and require packing with bone wax), and midline
medially

The burr holes are drilled with either the burr or perforator tip on the pneumatic drill. The
bone is drilled until the dura is carefully and barely exposed, at which point a curette and
Kerrison rongeur (usually 3 or 4 mm) are used to widen the hole. The dura is then separated
from the bone using the footplate attachment, double-ender, nerve hook, or ball-ender (the
latter 3 are standard instruments in the craniotomy tray). If the planned craniotomy coincides
with a major sinus (eg, superior sagittal sinus), slots may be drilled over the sinus as
opposed to burr holes or running the footplate through the overlying bone. These slots are
longer troughs that allow for the sinus to be visualized through the dura and therefore safely
avoided by the craniotome when the flap is being drilled.

The craniotomy is then drawn out with a marker or Bovie. The drill is fitted with the
craniotome attachment, which slides between the bone and dura at the bottom of the burr
hole. The craniotome is carried through the bone with the footplate angled upward (drill
angled back) so as to dissect the underlying dura free from the bone. Each burr hole is
connected by the craniotome, or a solitary burr hole can be used as both the starting and
ending point for the craniotomy.

Once the complete bone flap is drilled out, a flap elevator is placed underneath the bone and
used to lift while a Penfield no. 3 dissector separates the underlying attached dura. The flap is
removed and then plated later with the mini-plate and screw system. The dura is irrigated to
reveal bleeding vessels with the major vessels, such as the middle meningeal artery,
cauterized by the bipolar instrument. Blood coming from bony edges is stopped with bone
wax. Epidural bleeding, which tends to be diffuse, can be stopped by application of a
hemostatic agent such as FloSeal (Baxter, Deerfield, IL), along with overlying Gelfoam and
cottonoids that have been saturated in thrombin solution.

At this point, the craniotomy is complete. Once the bleeding is controlled, the dural opening
is planned, and the intracranial surgery can proceed.

Craniectomy
In the case of the suboccipital approach, a craniectomy is often performed in lieu of a
craniotomy. A craniectomy involves the removal of bone without replacing it. This is
typically preferred because postoperative swelling in the suboccipital region (which includes
the brainstem) is exacerbated by an inelastic bone flap as opposed to absent bone or a pliable
synthetic cranioplasty.

Craniectomies are drilled with the pneumatic drill and burr attachment until the underlying
dura is partially exposed; curettes and Kerrison rongeurs complete the bony removal and
dural exposure. Great care must be taken to avoid injuring the underlying sinuses in this
region (eg, transverse and sigmoid sinuses). Bony landmarks such as the asterion can be used
to help localize the sinuses (along with image-guided intraoperative navigational software),
and, once enough bone is removed with the craniectomy, the sinus may be directly visualized
through the dura.
Stereotactic Craniotomy
Stereotactic neurosurgery refers to the process of using image guidance to localize and aid in
the resection of an intracranial lesion. Preoperatively, the patient must undergo a dedicated
MRI or CT sequence (with a set number of finer cuts than the standard MRI/CT sequences).

In the operating room, this special sequence is displayed on the navigational system, which is
then used to detect either facial bony landmarks on the patient or fiducial markers that were
placed on the patients skull prior to obtaining the imaging. These fiducials can then be
detected in the operating room and interfaced with the displayed imaging (MRI or CT). The
interface between the navigational system and the patients landmarks allows the
neurosurgeon to place a probe on the patient that is displayed on the system monitor in
relation to the underlying brain anatomy (including the lesion of interest).

The incision and craniotomy can be planned at this point. This navigational system can then
be used throughout the case to help actively locate the lesion of interest, as well as any
structures that the neurosurgeon would care to avoid (eg, large draining veins, sinuses).

The use of intraoperative image guidance to plan and execute a craniotomy has grown
considerably in recent years because of the availability of state-of-the-art stereotactic
navigational systems (BrainLab [Heimstetten, Germany] and Stealth [Medtronic, Louisville,
CO]) and the success that these systems have in accurately localizing intracranial lesions. For
the practicing neurosurgeon, such stereotactic systems have become quite easy to implement.