A craniectomy is a neurosurgical procedure that involves removing a portion of the skull. It differs from a craniotomy in that the removed bone is not replaced, leaving a defect in the skull. A craniectomy is performed to relieve pressure on the brain, such as from swelling, bleeding, or infection. After the procedure, patients require wound care including cleaning and monitoring the incision, hair washing, and safety measures like fall prevention due to their vulnerability. Complications can include infection, bleeding, seizures, and brain injury.

1. Care of the patient with
Craniectomy
Evaluator: Mr L Anand [Asso professor, CON AIIMS BBSR]
Presenter: Shruti Shirke
M.Sc Neuroscience Nursing

3. CRANIOTOMY
Defines a procedure where the cranial cavity is accessed through
removal of bone to perform a variety of brain surgeries. Once the
surgery is completed, the bone flap is returned to its previous
position.

4. CRANIECTOMY
Differs from craniotomy in that the bone is not
replaced to its previous position; instead it is
stored for future insertion or may be discarded
(depending on pathology – e.g. infection). This
results in a cranial defect. – If the bone flap
needs to be discarded, it is replaced with a
custommade implant.

5. CRANIECTOMY
Is a neurosurgical procedure that
involves removing a portion of
the skull, where the patient's
scalp is closed without re-
implantation of the bone.

6. ROLE OF A CRANIECTOMY
Increases buffering capacity of cranium.
Allows outward herniation of brain tissue: preventing
compression of brainstem structures. – reestablish brain
perfusion.
Intracranial pressure (ICP) reduction 15-85% depending on size
of bone removed.

7. INDICATION
Craniectomy may be used in nonemergent circumstances to
augment the opening of a craniotomy.
Decompressive Craniectomy is used in urgent or emergent
conditions where there is substantial brain swelling from bleeding,
stroke or infection.

8. CRITERIA FOR STROKE(MCA)
Inclusion
<96h from symptoms onset
(recommended <48hrs)
Infarct >1/2 MCA territory on
imaging
Premorbid MRS<_ 2
NIHSS 1a>1
Exclusion
Pupil fixed or dilated
Serious comorbid illness
GCS <6
Life expectancy <3 years
Uncorrected coagulopathy

9. PROCEDURE
The neurosurgeon makes an incision in the scalp, and once the skin
and underlying tissues have been cut and moved out of the way, a
drill is used to make holes in the skull. The holes are connected
with a saw, and a portion of the skull bone is removed.

10. PROCEDURE CONT..
Once the bone is removed, and any underlying clot that is
compressing the brain is evacuated, or any bleeding around the
brain has been controlled, relieving pressure in the brain, the skin
and connective tissue overlying the brain are closed with sutures.

11. Positioning C-head fixator
Marking on scalp
Incision of scalp and retraction of scalp (keeping layer of connective
tissue)
Drilling and cutting skull of area of interest
Cleaning and storing skull
Separating dura mater

14. BONE FLAP STORAGE AFTER
CRANIECTOMY
After a decompressive craniectomy for brain swelling, bone flaps
need to be stored in a sterile fashion until cranioplasty.
Temporary placement in a subcutaneous pocket (SP) and
cryopreservation (CP) are the two commonly used methods for
preserving bone flaps

15. STORAGE OF BONE FLAPS
Bone flap freezer
Bone flaps can be kept there for months – years

17. BONE FLAP APPEARANCE (SITE)
As the swelling begins to decrease, the patient’s head may be
depressed until the skull is re-inserted.
If the bone is being stored in the patient’s abdomen, it will feel
like a hardened area in the abdomen when palpating.

18. BONE FLAP REPLACEMENT
Once the patient’s brain swelling has subsided and his or her
condition is stable, the bone or other form fitting artificial material
is implanted in a procedure called a cranioplasty.
This procedure can occur weeks to even years after the bone flap
removal.

19. CRANIOPLASTY
Cranioplasty is a surgical procedure to correct a deformity or
defect of the skull. Reconstruction of the skull-cranioplasty may be
performed with titanium mesh or other artificial products.
Cranioplasty - Re-implantation of the bone flap. Typically, rigid
fixation is achieved with small compatible titanium fasteners
(plates) that do not activate metal detectors in airports.

20. CRANIOPLASTY

21. COMPLICATIONS
THE MAJOR RISKS OF CRANIECTOMY INCLUDE THE FOLLOWING:
Bleeding Infection Seizures
Abnormalities
in cerebrospinal
fluid (CSF)
absorption
Further damage
to the brain
Stroke Death

22. COMPLICATIONS CONT..
Post Cerebral contusion
expansion: usually occurs
within first two days.

23. Coagulopathy. Preoperative
noncontrast CT scans of an SDH
in a patient on a regimen of
warfarin (A and B). Despite
reversal of the coagulopathy
before surgery, marked
hemorrhagic blossoming
occurred as evidenced by
postoperative noncontrast
images (C and D). Note in panel
C the development of an
extraaxial SDH contralateral to
the decompressed hemisphere.

24. COMPLICATIONS CONT..
Bleeding complications include: •
newly developed subdural or
epidural hematomas potentially
within the first few hours (for
epidurals) or a few days
postoperative.

25. A and B: preoperative
noncontrast CT scans
obtained in a patient with
traumatic subarachnoid
hemorrhage and a small
SDH who underwent
decompressive
craniectomy. C and D:
postoperative noncontrast
CT scans showing
evolution of an occipital
EDH (arrow),

26. COMPLICATIONS CONT..
Post traumatic hydrocephalus can
occur one month post-operative.

27. COMPLICATIONS CONT..
Subdural hygroma due to
alteration in the dynamics of
CSF circulation.

28. SYNDROME OF TREPHINE
Sinking skin flap syndrome.
Caused by changes in the pressure
gradient of intracranial pressure and
atmospheric pressure.
Patients with this syndrome benefit
having the bone flap replaced sooner
rather than later.

29. SURGICAL SITE INFECTION (SSI)
SSI is a serious complication of
cranioplasty.
Dehiscence: Defined as a diastase of
facing flap borders occurring along the
line of suture, with different degrees of
exposure of underlying tissues.

30. Ulcer: Defined as a loss of substance
occurring inside the skin flap,
usually distant from the line of
suture, constantly presenting with
underlying tissues exposure.
SSI CONT..

31. SSI CONT..
Necrosis: Defined as a large,
discolored area of complete loss
of skin viability, both on flap
contour and on the surrounding
skin border.

32. Nursing Interventions

34. WOUND CARE
•Inspect the incision on the head and abdomen (if present) to
ensure edges remain well approximated, and staples/sutures are
intact.
•Monitor for redness around the incision, discharge, and any other
signs of infection.
•Incision is usually left open to the air, dependent on the
physician’s order and preference.

35. WOUND CARE CONT..
•Sutures are usually removed in 2 weeks; however, practice
differs between physicians.
•Topical agents on the incision may or may not be prohibited by the
physician. – Ointments commonly used are topical antibiotic ointments
•Incision should be covered if patient is going outside to prevent
sunburn.

36. HAIR CARE
oPatients who have had a bone flap removed may still have their hair washed.
oDo not submerge the incision until all staple sutures have been removed or as
per direction of your physician.
oBe gentle when handling this area and do not rub too vigorously.
oUse a mild shampoo with no strong perfumes.
oDo not direct shower head directly to site.

37. SAFETY CONSIDERATIONS
•When used, a helmet should be fit to the patient by an orthotics
specialist to minimize pressure on the open cerebrum as well as skin
over the skull.
•Helmets should be removed when patient is in bed and when bathing.
•Each facility and physician have different protocols and varying use of
helmets.

39. SAFETY CONSIDERATIONS CONT..
Positioning may be supported with towels,
pillows, and positioning devices to prevent
pressure onto the cerebrum and attempt to
stay off the site.
Signage above the patients bed allows all
health care providers to recognize that
patient has no bone flap.

40. Post-op craniectomy patients are at an increased risk for falls.
Some falls prevention strategies to consider:
Keep bed at lowest level.
Ensure room is not cluttered.
Ensure patient is supervised at all times during mobilization (may use a
helmet during this time if part of patient’s care).
General supervision as much as possible.
SAFETY CONSIDERATIONS CONT..

41. SOME FALLS PREVENTION STRATEGIES
CONT..
Ensure patient uses non-slip shoes when necessary.
May want to have patient’s room near nursing station so staff can
better monitor.
Purposeful rounding (e.g. assess patient’s need to use bathroom prior
to bedtime).
May consider using bed rail pads on the patient’s bed in case patient
hits head on bed rails (e.g. while asleep, during seizure).

42. Always remember…..
Conduct regular neurological assessments on
patients post-craniectomy

43. SUMMARY
Craniotomy
Craniectomy
Cranioplasty
Procedure
Complications
Nursing consideration

45. CONCLUSION
Successful craniectomy is when patient is hemodynamically
stable while surgery, standard level of sterility is
maintained, no SSI, and prevention of other complications
and adequate management of these complications. Critical
observation by the nurses.
Dedicated team work is essential for better outcome of
patient.

46. REFERENCES
Basheer, N., Gupta, D., Mahapatra, A., & Gurjar, H. (2010). Cranioplasty following
decompressive craniectomy in traumatic brain injury: Experience at level — I apex
trauma centre. The Indian Journal of Neurotrauma, 7(2), 139–144.
doi:10.1016/s0973-0508(10)80029-2
Brain, M., & Spine. (2016). Craniotomy, Craniectomy | Mayfield brain & spine.
Retrieved January 4, 2017, from http://www.mayfieldclinic.com/PE-
Craniotomy.htm
Brain, M., & Spine. (2016). TBI, Traumatic brain injury (TBI), brain injury | Mayfield
brain & spine. Retrieved January 4, 2017, from http://mayfieldclinic.com/PE-
TBI.htm
Brommeland, T., Rydning, P. N., Pripp, A. H., & Helseth, E. (2015). Cranioplasty
complications and risk factors associated with bone flap resorption. Scandinavian
Journal of Trauma, Resuscitation and Emergency Medicine, 23(1), .
doi:10.1186/s13049-015-0155-6

47. THANKYOU

48. Keep the incision clean. Craniotomy incisions are usually closed with
sutures or surgical staples. Follow the physician’s instructions regarding
incision care. Some physicians want patients to keep the incision dry, while
others allow patients to gently wash their hair (and the incision) soon after
surgery. Do not apply any lotions, creams or ointments to the incision, unless
instructed to do so by your healthcare provider. Cover the incision with a
bandana or loose hat when going outside.

49. Watch the incision for signs of infection or complications. An
incision that becomes red and warm to the touch may be infected. Leaking or
oozing fluid (after the bandage has been removed) can indicate a possible
complication, such as increased brain pressure or a cerebrospinal fluid leak.
Any abnormalities should be reported immediately.

50. Control Pain. Most patients go home with a prescription for a small
number of narcotic pain pills. If the pain pills are not adequate to control
pain, or if the patient is still having severe pain when the narcotics have run
out, notify the healthcare provider. Uncontrollable or persistent pain can be a
sign of complications.

51. Gradually return to activity. Friends and family members may want to
pamper the person who’s had surgery, but it’s best to allow someone to do as
much as possible independently. “Simple everyday activities such as getting
dressed, grooming and meal prep are fantastic exercise and probably just as
important as formal physical and occupational therapy,” says Michael O’Dell,
chief of clinical services in the Department of Rehabilitation Medicine and
medical director of the Inpatient Rehabilitation Medicine Center at New
York-Presbyterian Hospital-Weill Cornell Medical Center in New York.