The Central Nervous System - Rush–Copley Medical CenterThe entire central nervous system is bathed in a clear fluid called cerebrospinal fluid (CSF). The pathway for this fluid production

The Central Nervous SystemThe central nervous

system is divided into

two parts: the brain

and the spinal cord.

The brain is composed

of three parts: the

cerebrum (80%), the

cerebellum, and the

brainstem. The

cerebrum is divided

into two hemispheres,

which divide the right

and left side of the

brain. Within each

hemisphere, there are

four lobes. The four lobes are the frontal, parietal, temporal and occipital. The cerebellum is located in the back

of the brain. The brainstem is located at the back of the brain and extends down from the brain. It is the bridge

between the brain and the spinal cord. It is made up of the pons, midbrain and medulla.

Each hemisphere of the brain is specialized to control movement and feeling in the opposite half of the body. The

hemispheres must communicate with one another to coordinate movements and feelings. The corpus callosum is

the main connector that allows communication.

The brain lies within a bony structure or skull. Between the skull and the brain, there are layers of tissue that

further protect the brain. The layer closest to the skull is called the dura mater, which is thick and helps stabilize

the brain. The middle layer is called the arachnoid and the innermost layer that lies within the brain is called the

pia mater.

The entire central nervous system is bathed in a clear fluid called cerebrospinal fluid (CSF). The pathway for this

fluid production and movement is called the ventricular system. CSF protects the brain, excretes waste, and

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G u i d e t o Y o u r C r a n i o t o m y


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transports hormones in the brain. Normally, the

brain continuously produces new spinal fluid and

re-absorbs old spinal fluid.

There are twelve pairs of cranial nerves that innervate

certain areas of the brain. The cranial nerves bring

information to the brain and control muscles. Other

cranial nerves are connected to glands or internal

organs such as the heart and lungs.

Blood vessels that supply the brain with oxygen and

nutrients are called cerebral arteries. The arteries flow

through a central location called the Circle of Willis.

If there is a blockage or bleeding of the blood vessel a

person may experience difficulty with certain

functions of the brain.


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Frontal Lobe

• Controls voluntary movement

• Motor control of speech; expressive

speech (ability of talk)

• Conscious thought

• Reasoning, judgment, and ability to

problem solve

• Social and sexual behavior

• Emotion and personality

• Memory for habits and motor activities

Temporal Lobe

• Primary auditory area

• Primary area of speech comprehension

• Intellect and understanding

• Forming and retrieving memories

• Ability to perceive stored auditory and

visual information

Parietal Lobe

• Primary sensory area – ability to perceive touch,

pain, pressure, temperature, and taste

• Recognition of objects through touch

• Awareness of one’s own body

Occipital

• Primary visual perception area

• Discrimination of movement and color

• Stores visual images in memory

Cerebellum

• Movement

• Balance

• Posture

• Coordination

Brain stem

• Breathing

• Blood pressure

• Heart rate

Towards the middle of the brain, there are other

structures that assist in receiving and processing

information.

Thalamus receives sensory information and relays this

information to the cerebral cortex. It also receives

information from the cerebral cortex to relay information

to other areas of the brain and spinal cord.

Areas of the Brain and Function


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Hypothalamus controls the body’s temperature,

circadian rhythm (sleep cycle), emotions, and

certain hormonal function.

Basal Ganglia is the primitive motor area that

controls autonomic associated movements.

The limbic system is a set of brain structures,

two of which are the hippocampus and

amygdala. This system functions emotions,

memory, learning, and behavior.

Lesions of the BrainLesions of the brain can cause problems or deficits in the normal functioning of the nerves, vessels, or particular

areas of the brain. Certain deficits or symptoms a patient may present with can assist in identifying where the

lesion is located in the brain. The terms “lesion” may refer to tumors, abscesses, or bleeding in or on the brain

tissue.

Brain Tumors

Cells are building blocks that make up tissue. Organs are

composed of tissues. When cells are functioning normally they

grow and divide, and eventually die. As old cells die, new cells

are formed. However, the body may make extra new cells, and

old cells at times do not die as they should. This altered process

is what leads to the formation of a growth or tumor. If this

excess of cells occurs in the brain, it is called a brain tumor.

Primary brain tumors are tumors that start in the brain. It is uncommon for a primary brain tumor to spread to

another area of the body. However, tumors that spread to the brain from another area of the body, which has a

growing tumor, are called secondary brain tumors or metastatic tumors.

Brain tumors can be malignant or benign. Benign brain tumors do not have cancer cells and once removed, often


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do not grow back. Often these tumors can be easily removed

because of the distinct borders of the tumor. Benign tumors do

not invade surrounding tissue or spread to other areas of the

body. However, these tumors can still be life threatening as the

tumor can compress certain areas of the brain that are essential

for life. Malignant brain tumors are usually more serious and

do contain cancer cells. These tumors tend to invade nearby

tissue and tend to grow quickly. Malignant tumors are often

life threatening due to compressing vital areas of the brain as well as the rate at which they grow. These types of

brain tumors may or may not be curable depending on the subtype, cellular characteristics and location.

Aneurysms

A cerebral aneurysm is a weakening in the wall of a blood vessel within

the brain that pouches out and fills with blood. The weakened wall of

the vessel can leak or rupture. If this occurs, blood from within the

arteries leaks out to the surrounding brain tissue. When this occurs it

can cause impairments in function of that particular area of the brain.

Aneurysms vary in size, location, and shape. These as well as your risk

factors and medical/surgical history will play a role in what Dr. Sani’s

team will address when treating your aneurysm. This will be discussed in detail at your clinic visit.

TreatmentCraniotomy is a general term that means an “opening of the skull.”

This surgical procedure involves removing a piece of the skull, in

which Dr. Sani’s team, can then access the brain or surrounding areas

of the brain. Craniotomy is used for removal of lesions within the

brain including tumors, blood clots or aneurysms. After the team

has reached the lesion, resected the lesion, or fixed the lesion, as

appropriate, the piece of skull that was removed is placed back over

its original site and held in place with small screws and plates.


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There are two surgical approaches to

treating cerebral aneurysms: microvascular

clipping or endovascular embolization.

Clipping aneurysms has been a

long-standing treatment for cerebral

aneurysms. Research shows that generally

when clipped, aneurysms do not return.

This is a surgical procedure in which you

would receive general anesthesia. A craniotomy is performed by opening the skull and

microvascularly isolating the affected blood vessel that lies in the brain or on the brain.

Dr. Sani will then place a small, titanium clip (looks similar to that of a clothespin)

on the neck of the aneurysm. The “neck” is the point where the weakened wall begins

to balloon out from the normal blood vessel. Generally, aneurysms tend to be found

on the surface of the brain near the skull base and surgery does not involve invading

the brain.

Endovascular embolization does not require opening of the skull. The physician will place a catheter into your

groin to access an artery. The catheter is threaded up the artery to your neck and brain. Under angiography the

neurointerventional team will be able to assess the vessels that supply blood to your brain. When the aneurysm is

reached, detachable coils or a small balloon is released from the catheter. It is released onto the aneurysm. The

purpose is that it fills the weakened vessel wall to form a “plug” so that the wall is no longer weak or at risk for

rupturing. This procedure is very successful with certain types of aneurysms, however, aneurysms treated with

coiling can refill with blood that may require additional procedures.

Preparation for SurgeryTests/Diagnostics

After meeting with us in the office to discuss surgery, a date will be set for the procedure. You will need to see

your primary care physician or healthcare provider prior to surgery. Your provider will perform certain labs and

tests that are necessary prior to surgery. These include blood work and possibly additional radiological exams that

will assist in your care throughout your hospital stay.


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Medications

You will need to discuss your current medications with your primary provider to discuss what may need to be

discontinued prior to surgery (i.e. Prednisone, steroids, Heparin, Coumadin, blood thinners).

Two weeks prior to surgery, there are certain medications that must be discontinued. Non-Steroidal Anti-

inflammatory medications (i.e. Ibuprofen, Motrin, Advil, Naprosyn, Relafen) and Aspirin-containing medications

(i.e. Aspirin, Percodan, Darvon, Excedrin) must be discontinued. We recommend that other medications that thin

your blood be discontinued two weeks prior to surgery. Please discuss this with your primary care provider as

failure to discontinue all the above medications may cancel or postpone your surgery.

If you have a fever, cold, cough or sore throat a few days before your surgery, you should contact your primary care

provider to obtain clearance to proceed with anesthesia and surgery.

Day Before SurgeryBe sure to eat dinner the night before surgery. Do not eat or drink anything after

midnight the night before your surgery. In addition, no chewing gum, hard

candies or smoking. These are measures to prevent complications with the

anesthesia you will receive during surgery. Any routine medications you may be

taking for your heart, lungs or diabetes may be necessary to take the morning of

surgery. Please discuss these medications with your primary care provider.

You will be given Hibiclens (chlorhexedine gluconate), an antiseptic, antimicrobial

skin cleanser to use the evening before or morning of your surgery. This will be

used when you shower. Avoiding eyes, ears and mouth. When you shower, wet your body and hair. Turn the

water off in the shower or move away from the water spray to avoid rinsing the soap solution off. Shampoo with

25 ml (one packet) of Hibiclens for three minutes, then rinse thoroughly. Use another 25ml of Hibiclens for the

rest of the body, then rinse thoroughly. Pat yourself dry with a clean towel.

• Do not wash with regular soap after you have washed with Hibiclens.

• Do not apply any powders, deodorants or lotions. Dress in freshly washed clothes after you wash with

Hibiclens.


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Day of SurgeryPlease arrive to the hospital at the pre-arranged time, which is at least two hours before surgery. Wear comfortable,

loose-fitting clothes.

Do not bring any valuables or medication from home to the hospital. Bring a complete list of medications that

you are taking and any allergies you have. If you wear glasses or dentures, do not forget to bring them along with

their appropriate cases.

When you arrive to the pre-operative area, the nurse

will place an intravenous (IV) line through which

medications and fluids can be given. The medication

to relax you before you are put to sleep will be given

in this line. You will change into a hospital gown and

your family can hold all of your belongings. In the

pre-operative area, you will meet with the

anesthesiologist or nurse anesthetist. Dr. Sani will

meet with you as well before you go into the operating

room. Your family will be asked to wait in the surgical waiting area at this point.

In most cases, computer-assisted neuronavigation will be used. This means that prior to

going to the operating room you will have special markers, called fiducials, placed on your

head around the area of your tumor. Then you are taken to MRI for images to be done

that help the surgeon specifically map out the course for surgery and the most precise way

to remove the tumor and protect important structures and blood vessels. From MRI, you

will go directly to the operating room.

Once you are in the operating room, anesthesia will meet with you again. At this time,

they will put you to sleep with medication and a breathing tube (endotracheal tube) will be

placed to assist with your breathing. When you are asleep, the Mayfield frame will be

placed on your head. This is to ensure that your head is stable during the procedure as

well as assistive in mapping the entry point for surgery with the use of pictures of your


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MRI from that morning. When you wake up, you will have three small pin sites noted on your head away from

the surgical site. These pin sites often heal on their own and do not need sutures or staples.

Additional intraoperative monitoring will be used during the surgery. You will have small needles placed in your

arms, legs, and head once you are put to sleep, which connect to a computer to closely monitor functions

associated with the brain, spinal cord and peripheral nerves. Neural monitoring is a technique that provides

neuroprotection for patients by watching neural structures that may be at risk during surgery. By measuring the

brain's responses, neural monitoring often can detect effects such as lack of oxygen, a stretched nerve, or a

mechanical disturbance during surgery. If an anomaly develops during surgery, a surgical intervention can reduce

or eliminate nerve damage. Neural monitoring includes somatosensory evoked potentials (SSEP), Auditory

Evoked Potentials (AEP), Cortical Mapping, Electromyography (EMG), Transcranial Dopplers, and

Electroencephalogram (EEG). You may recognize small areas of tenderness or needle marks when you wake which

may be a result of these small needles.

Post-Operative CareWhen surgery is complete, neuro-monitoring, Mayfield pins, and neuronavigation equipment is removed. Most

often you are awakened in the operating room. However, the medication that was used during surgery to keep you

asleep may cause you not to remember this. You may hear particular sounds, beeping, and unfamiliar voices. You

will then be taken to the Intensive Care Unit (ICU). This is located on the first floor of the hospital.

The nurses will get you settled in and a monitor will be placed on you so that we can closely monitor your heart

rate, breathing and blood pressure. Initially, there will be a few nurses and support staff in the room making sure

you are settled in. Then your family will be permitted to come and see you. The doctors and nurses will be

performing frequent neurological exams. The neurological exam will consist of many questions and certain

commands you are asked to do. The purpose is to ensure that you do not have any neurological changes after

your surgery.

Dr. Sani may need to place a drain from the area around your incision. It may be used to collect additional blood

that may form in the area where surgery was done or to decrease extra pressure within your skull. You will also be

placed on an antibiotic temporarily that will be given through your IV line to prevent any infection associated with

the drain.


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The endotracheal tube (ET) is often removed before you are completely awake after surgery. However, at times an

endotracheal tube is necessary to assist with breathing after surgery. The ET tube is used temporarily until you are

breathing on your own, when the medications have worn off and the swelling in your brain has gone down. The

tube is in your throat and can be irritating. You will be given medication to help you relax and assist with the

discomfort from the tube. You may also experience a sore throat once the tube is removed. Drinking fluids and

throat lozenges can assist with this discomfort.

Pain may occur after surgery. Within the first few hours after surgery, you will be given pain medication through

your IV line. However, when you start feeling that you are ready to eat, the pain medication will be given orally.

Be sure to ask your nurse for pain medication if you are having pain. Pain is normal to have post-operatively.

Controlling your pain will help you progress throughout your recovery.

You will have a dressing that will be placed on your incision in the operating room. The incision will depend on

the size of the area in the brain that needs to be operated on. Sutures (stitches) or staples are used to close the

incision. They will be left in for seven to ten days and then removed when you return to our office. The incision

will stay covered for three days. On the third day, the dressing will be removed and the incision will be left open

to the air.

After your surgery, you will also have a CT scan and an MRI performed within the first 48 hours.

When you are awake and alert without nausea, you will be started on a clear liquid diet. As tolerated, your diet will be

advanced to a regular diet. At times, the tumor, bleeding or swelling in the brain can affect the way that you swallow.

If this occurs, nutrition may be given through a tube or intravenously. This will be discussed with you.

As mentioned above, there are risks and complications associated with a craniotomy. These may include, but are

not limited to, infection, swelling, bleeding, seizures, stroke, and brain damage.

Medication After Surgery

Certain medications may be given after surgery.

• Low-dose steroids may be used to help with swelling of the brain tissue. Steroids can cause an elevation in

blood sugar. The nurses will be checking your blood sugar while you are the steroids, and if it is high, you

may need insulin at times while you are taking the steroids.


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• Antibitoics will be used to prevent infection during your post-operative course. However, concerns of

resistance for antibiotics do exist therefore we carefully prescribe such medications. You often receive three

doses in the initial post-operative period.

• Nausea can occur with the medications from surgery as well as from pain medication. Anti-nausea medications

and anti-acid medication may be ordered to prevent any breakdown in the lining of your stomach as well as to

decrease the acid in your stomach, which may contribute to nausea.

• After surgery we want your blood pressure to be maintained within certain parameters. You may require blood

pressure medications to keep your blood pressure within this range.

• Seizures can occur from the irritation of the brain tissue. If necessary, you may be placed on medication to

prevent seizures.

• Constipation may occur from the medications, anesthesia, lack of normal physical activity, or alterations in

your diet. Stool softeners are given during your post-op course. After brain surgery it is important to avoid

things that increase the pressure in your head, straining should be avoided and stool softeners should help

with this.

• Special anticoagulant medications are used post-operatively. These are injections placed in your abdomen.

This is used to thin your blood and helps prevent blood clots. Surgical patients are at increased risk for blood

clots, therefore the injection along with stockings and/or pumps on your legs that help prevent blood clots.

Therapy

You will be seen by physical and occupational therapy to evaluate your safety, gait (walking), and ability to perform

activities of daily living. They may recommend assistive walking devices (cane, walker) as well as home therapy or

rehabilitation if the medical team feels you would benefit from this. Depending on where the tumor or blood is

located in the brain, speech therapy may also work with you post-operatively to evaluate your speech, swallowing,

and/or cognitive function.

When you are stable and improving from surgery, you will be transferred out of the ICU. Many of the same

orders/activities will be carried out.


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Discharge PlanningIn most cases, you will meet with a discharge planner from the hospital. They will make an assessment as to what needs

you may have and where you will be going once discharged from the hospital. If extensive rehabilitation is required, you

may go to a sub-acute care rehab facility for further treatment. If you are returning home, it is important to have

support available for the first few weeks. It may be beneficial to have outpatient rehabilitation, including physical,

occupational and possibly speech therapy, all depending on the extent of your surgery and tumor location.

What to Expect

Fatigue — This is very common following any surgery, and especially after brain surgery. It can last anywhere

from a few weeks to a few months.

Pain/Headaches — Some patients report having headaches around the incision site. This can usually be relieved

with over-the-counter Tylenol. We have also given you narcotics to help with increased pain. If you have a

headache that is not relieved with Tylenol or the prescribed pain medication or a headache that seems more severe

than normal, it is important to call our office. You must avoid aspirin, NSAIDs, Ibuprofen and Aleve for two

weeks. After brain surgery pain is relatively minimal. There are no pain receptors within the brain, so much of the

pain you will experience is due to the incision.

Seizures — Seizures can occur due to swelling and irritation of the brain. A seizure is an abnormal excitability of

the brain. If you suffer from seizures post-operatively, you will be managed by a neurologist who will monitor your

medication once discharged from the hospital. The seizures typically will subside once the irritation from surgery

dissipates. If you do experience any seizure-like activities, you must call your neurosurgical team and notify them

or go to the emergency room.

Nausea — This may be due to anesthesia used during surgery or pain medication. Depending on the location of

the lesion within the brain, you may experience nausea and/or vomiting. In addition, after surgery, swelling

(edema) can cause similar symptoms. Anti-nausea (or anti-emetics) will be ordered if you do have nausea.

Constipation — Anesthesia, pain medications, and inactivity can all contribute to constipation. Straining can

cause an increase in the pressure in your brain and may disrupt the healing of your surgical process. You will be

placed on stool softeners post-operatively until you are having regular bowel movements. If you go more than

three to four days without a bowel movement, additional laxatives may be ordered. It is important to drink lots of

fluids and eat high-fiber foods.


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Muscle Spasms — Depending on the surgical site, muscle will be cut during your surgery. When you wake up

you may have muscle spasms in addition to the surgical pain. Hot and cold packs will be used as needed, and at

times, muscle relaxants are used.

Complications

As with any type of surgical procedure, there are risks for complications. The neurosurgical team will discuss these

with you in more detail prior to your operation. Some of these include:

• Infection

• Blood clots

• Falls

• Stroke

• Shortness of breath

When you are discharged home, you will be given special instructions from the nursing staff. It is important that

if you have any questions or concerns when you get home, you call our office to make us aware or go directly to

the emergency room.

The following are some complications to monitor for. These are not entirely inclusive, so be sure to call if you are

at all unsure.

• Numbness or tingling or changes in sensation

• Weakness on one side

• Difficulty speaking

Follow-up

You will need to follow up usually

about one week after surgery.

However, depending on the time that

you will stay in the hospital post-

operatively, this may be adjusted.

Upon discharge, instructions will be

given on when to follow up in clinic

with the neurosurgery team as well as any additional providers that may be necessary.

• Pain not relieved with pain medication

• Fever/chills

• Persistent nausea and vomiting

• Drainage, redness, or increased swelling at your incision site

• Confusion

• Visual changes

• Difficulty walking


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Additional MRIs, CT Scans, or Angiograms (for aneurysms) may be ordered within

designated time frames after surgery. You may have follow-up imaging done at 3

months, 6 months, and 1 year. This is determined specifically for your type of lesion.

Tumor Resection or Biopsy

On your follow-up visit, the team will review your pathology results. At this time, any further care or treatment

that is necessary will be discussed.

Clopidogrel (Plavix), Warfarin (Coumadin), Non-Steroidal Anti-inflammatory medications (i.e. Ibuprofen, Motrin,

Advil, Naprosyn, Relafen) and Aspirin-containing medications (i.e. Aspirin, Percodan, Darvon, Excedrin) should

be avoided for at least two weeks post-operatively.

Though you may be recommended to take Heparin or Lovenox injections immediately following surgery as well as

upon discharge depending on your medical history.

Driving

You will be restricted from driving a car or motorized vehicle for at least two to four weeks post-operatively. If you

are still taking pain medication at that time, you will not be released to drive until you are completely off of pain

medication. If you suffer any seizures during your surgical course, driving will be restricted for an extended period

of time, in which you would be released to drive as discussed with the team or your neurologist.

Shower/Wound Care

The wound is to remain clean and dry for seven to ten days post-operatively. Your initial surgery dressing will

remain in place for the first three days. After the third day it will be removed, and the wound will be left open to

air (unless otherwise instructed). However, during this time, you must cover your incision when you are showering.

No pools, baths, or hot tubs for six weeks. Do not soak the wound. After your sutures or staples have been

removed by the neurosurgical team, you may shower the following day.

Please be sure to avoid any rubbing, scratching, or irritation to the surgical site. When you are in the sun, your

incision should be covered with clothing as well as sunscreen (SPF 15 or higher).


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Sexual Activity/Intimacy

You may resume sexual activity after two weeks post-operatively. However, you will remain on strenuous activity

restrictions up to six weeks post-operatively. If you feel that sexual activity is too strenuous, we recommend you

abstain from this activity or stop at any point you may feel you are overly exerting yourself.

Activity

After surgery, you will be restricted from lifting more than 10 pounds for six weeks. This is to avoid any increased

pressure within your head as well as any injury that may occur with lifting heavy objects. We suggest lifting no

more than the weight of a gallon of milk.

You may take walks usually starting at one to two weeks post-operatively depending on how you are feeling. You

must have someone with you when you go on your walks. If at any point, you feel overly fatigued, short of breath,

or increased pain, you should stop and rest.

As previously discussed, physical therapy may be necessary when you are discharged home to increase your

conditioning and strength. However, we often do not start intensive physical therapy until you are at least four

weeks post-operative.

You will not be released to run or do more strenuous activities until about three months post-operatively.

Work

Depending on the type of work you do, your restrictions may vary. The neurosurgical team will discuss this with

you on your follow-up visit. Please plan on being off of work for at least four to six weeks post-operatively.

We Are Here for You

It is our goal to provide our patients with exceptional care with your safety and best interests always as our

number one priority.

If you have any concerns at any point in time, we encourage you to let us know. Please contact us with any

questions you have with regards to your care. We will do our best to help you in anyway in order to make this

time less stressful for you.


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Important Phone Numbers / Contact Information

Rush-Copley Neurosurgery 630-978-6770

Outpatient Center 630-499-2300Hours: Monday - Friday 7 a.m. to 9 p.m., Saturday 7 a.m. to 3 p.m.

Billing 630-978-4990

Outpatient Rehabilitation Services 630-978-4878

Pre-Admissions 630-978-4888

Central Scheduling 630-978-6750

Emergency Room 630-978-4815

Day Surgery 630-978-4840

Medical Records 630-978-6786

Web Site ReferencesAmerican Brain Tumor Association ABTA.org

Brain Aneurysm Resource Brainaneurysm.com

Brain Aneurysm Foundation Bafound.org

Epilepsy Foundation Epilepsyfoundation.org


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Notes

Documents

The Central Nervous System - Rush–Copley Medical CenterThe entire central nervous system is bathed in a clear fluid called cerebrospinal fluid (CSF). The pathway for this fluid production