for arteriovenous malformation (avm: a blood vessel
abnormality which consists of blood vessels which rapidly
shunt blood from arteries to veins) is performed to remove
a vascular malformation within the brain to prevent
it from bleeding. The avm may have already bled, in
which case a subarachnoid hemorrhage (bleeding around the
brain) or intracerebral hemorrhage (bleeding within the brain)
has occurred, or it may have been found incidentally on brain
scans (CT or MRI).
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.
A frameless navigational device to allow the surgeon to navigate,
in "real time" within the brain, may be used.
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 intended brain exposure. Then, an air powered
drill is 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 open the brain. Generally this involves carefully
dissecting between the lobes of the brain, or dissecting within
the fissures of the brain. Dissection will be
performed down to the site of the avm, and the arteries leading
into the avm will be dissected. The goal of surgery
is to divide the arteries wupplying the avm while leaving
the veins draining it intact, until the end of the surgeon,
to prevent the avm from "blowing up" with blood.
Another goal is to dissect on the boundary of the avm, removing
all the abnormal blood vessels, but not injuring the normal
brain. Often the edges of the brain are
gently supported using brain retractors. 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
Risks for craniotomy
for aneurysm 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 supine position
(on their back), possibly turned to one side of the other
with the support of rolls inder one side of the body.
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 going into the deep structures of the brain.
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.
Rehemorrhage (rebleeding) can also occur. If
there is vasospasm, postoperative stroke may occur.
Sometimes the bed of the avm may dilate postoperatively,
resulting in hemorrhage. Sometimes some of the avm
may remain postoperatively, and this may potentially require
additional open surgery, or stereotactic radiosurgery (focused
radiation using either a Gamma Knife or a linear accelerator).
Postoperative cognitive (thinking, mentality and personality)
changes may occur.
Risks: These include such general difficulties,
such as bleeding, infection, stroke, paralysis, coma and
death. Incisions on the low back generally heal well,
but if could be tender, 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 problem for which the surgery was performed
may recur, requiring additional surgery 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
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
- 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
- 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.
- Make sure
to follow up with any other physicians involved in your
care. These may include your family physician, neurologist,
radiation oncologist and oncologist.