Craniotomy and Excision of Tumour

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What is a craniotomy?

A craniotomy is an operation performed by neurosurgeons in order to treat various conditions affecting the brain.

In simple terms, craniotomy means a ‘hole in the head’ (Crani- = head; -otomy = hole).

A craniotomy involves making an incision in the scalp and removing a window of bone from the skull (this bone is secured back in position at the end of the operation). This allows access to the inside of the skull and brain, and the tumour is either biopsied (a small piece taken to be sent to the pathologist), or excised (removed).

Brain surgery has undergone major developments over the past 15 years or so. The result is that neurosurgeons can operate on parts of the brain previously thought to be unreachable. Furthermore, brain surgery has become much safer and is more likely to be successful than it was previously.

What is a stereotactic craniotomy?

Almost all tumour craniotomies are performed with the assistance of computerized navigation techniques, also known as ‘stereotaxy’. This is done order to improve the accuracy of the surgery, reduce the size of the incision, and increase the safety of surgery by avoiding important structures in the brain.

Stereotaxy works like a satellite navigation or GPS system in your car. It allows the surgeon to use a wand or a pointer to see exactly where he or she is in the brain or on the skull, as depicted on a CT or MRI scan within the operating theatre. This ‘real-time’ navigation facilitates location and removal of the tumour.

There are two types of stereotaxy. The original type is frame-based, where a special frame (for example the CRW frame) is fixed to the skull, relevant brain scans are performed, and surgery is carried out with the frame remaining on. This is a very accurate system, but has the disadvantages of inconvenience, additional time requirements to fit the frame and perform the scans, restricted surgical access to some regions of the head, and patient discomfort (if the patient is awake when the frame is put on). Despite these disadvantages, frame-based systems continue to be used in some situations, and are slightly more accurate than frameless systems. For some tumour biopsies, a frame-based system remains the safest and most appropriate method of stereotaxy.

The second (and more popular) type of stereotaxy is frameless stereotaxy. These systems, such as the Stealth and BrainLab, rely on the application of small markers (‘fiducials’) which are stuck to the patient’s head before the brain scan is performed. Anatomical landmarks such as the nose, eyes and ears may be used instead of fiducials. More recently, surface tracing techniques have done away with the need for fiducials and anatomical landmarks in some situations.

Frameless stereotaxy is slightly less accurate than the frame-based systems, however its numerous advantages have meant that it is used by the vast majority of contemporary neurosurgeons performing brain surgery.

Whilst sterotaxy represents a tremendous advance in the field of neurosurgery, it is not infallible. All stereotactic techniques suffer from the limitations imposed by ‘brain shift’, the phenomenon whereby the brain moves after part of a tumour or some brain (cerebrospinal) fluid (CSF) is drained. Its utility therefore declines as the operation progresses. A potential solution to brain shift is intraoperative MRI, which allows the surgeon to see exactly where he or she is once some of the tumour has been removed.

What are goals of surgery for brain tumours?

There are several potential goals of a tumour craniotomy. These may include one or more of the following:

  • To establish a diagnosis. This is called a biopsy. This is usually done through a small hole (burr hole), rather than a craniotomy, but in some situations a craniotomy is the best option. Biopsies are often done at the same time as removal of the tumour.
  • To reduce pressure on the brain (intracranial pressure). There are several types of surgery to achieve this:
    • Tumour debulking. The goal here is to remove enough of the tumour to reduce the amount of pressure on the brain (partial resection).
      o Tumour removal (excision).
    • Drainage of a cyst (fluid filled structure) associated with the tumour.

    The primary goal of brain tumour surgery usually is to remove as much of the tumour as possible without injury to the surrounding brain. This may be particularly complicated if the boundaries of the tumour cannot easily be identified at surgery, or if the tumour is invading critical structures such as blood vessels or cranial nerves

  • Preventing future problems or deterioration from tumour growth or haemorrhage.
  • Alleviating seizures (epilepsy) or determining precisely which area of the brain is causing seizures.
  • Curing the condition (benign tumours).
  • Increasing the length and quality of survival time (malignant tumours).

What are the alternatives to craniotomy?

The alternatives to surgery depend upon the type, size, location, and number of tumours being treated, as well as the patients overall condition:

  1. Stereotactic biopsy through a small hole (burr hole) in the skull. This can be used to obtain a diagnosis and may enable the drainage of some fluid from a tumour cyst to relieve raised intracranial pressure.
  2. Radiotherapy. This may be delivered to the entire brain (whole brain radiotherapy) or to the area of and surrounding the tumour. Not all tumours are amenable to radiotherapy.
  3. Stereotactic radiosurgery. This involves blasting the tumour with a single treatment session of concentrated radiotherapy. It may be useful for small tumours, as well as deep tumours which may not be amenable to surgery. The Gamma Knife is the best-known system.
  4. Chemotherapy. These may be given in oral (tablet) form, or into the bloodstream (intravenous). Not all tumours are amenable to chemotherapy.

What tests will be required before surgery?

A number of diagnostic tests are often performed before surgery is recommended or carried out. In some cases the diagnosis will be fairly certain before the operation, but in many cases the exact problem will not be clear until surgery is carried out.

A brain CT scan is the usual initial investigation that most patients will have had before being referred to a neurosurgeon.

The following investigations may then be ordered:

1. MRI Brain
This gives much more detail than a CT scan, and is important for surgical planning. It may also detect smaller tumours and vascular malformations which may be missed with CT.

2. Magnetic resonance spectroscopy (MRS)
MRS gives information about the likely chemical composition of the tumour, and therefore its probable diagnosis. It can be done at the same time as the MRI in some institutions.

3. Positron Emission Tomography (PET) and Single Photon Emission CT (SPECT) scans 
These give information about the blood flow and metabolic activity of a mass within the brain. They are frequently useful in differentiating between a recurrent tumour and the effects of radiotherapy, both of which may look identical on MRI.

4. Cerebral angiography/CT angiogram (CTA)/Magnetic resonance angiogram (MRA)
These tests provide detailed information about the appearance of blood vessels in the brain. Angiography may be helpful where a tumour appears very vascular, or where a diagnosis of a vascular malformation or aneurysm is being considered.

5. CT Chest, Abdomen and Pelvis/Nuclear Medicine Bone Scans/Breast Ultrasound or Mammogram
These scans help to pick up tumours elsewhere in the body. This process of "staging" is frequently important in deciding the best way to manage brain metastases.

6. Plain X-rays of the skull are rarely needed nowadays.

What do you need to tell your neurosurgeon before surgery?

Modern neurosurgery is generally fairly safe, but serious complications can always occur. In order to reduce the risks associated with your surgery, it is important for your surgeon and anaesthetist to be aware of certain health problems and medications.

It is important that you tell your surgeon if you have:

  • Blood clotting or bleeding problems
  • Ever had blood clots in your legs (DVT or deep venous thrombosis) or lungs (pulmonary emboli), or if anyone else in your family has
  • Been taking aspirin, warfarin, or anything else (even some herbal supplements) that might thin your blood
  • High blood pressure
  • Any allergies or reactions to medications or tapes
  • Excessive scarring (keloid) or poor healing after surgery
  • Any other health problems

You should tell your anaesthetist if you have:

  • Heart problems or chest pain
  • Respiratory (breathing) problems
  • Diabetes
  • High blood pressure
  • Previous problems with anaesthesia

Your surgeon and/or anaesthetist may order several additional tests before surgery, including:

  • Blood tests (for anaemia, blood clotting problems etc.)
  • ECG (to examine your heart electrical activity)
  • Chest X-ray

Special precautions

If you are a smoker it is imperative that you stop 3 or 4 weeks before surgery, and should not resume smoking for at least a few months afterwards (but preferably never!).

It is important that you stop certain drugs before surgery, especially ones that thin your blood. If you are taking aspirin, warfarin, or other blood-thinning agents (including herbal products) it is very important that you contact us two weeks before your admission so that we can discuss stopping them with you. If you are taking warfarin we may need to admit you earlier but each case varies, so it is important that you phone and we can discuss the plan for you.

Obviously, in situations where your surgery is urgent, we will take other precautions to avoid or minimize bleeding that may arise from any medications you have been taking.

What are the specific risks of this type of surgery?

As with all types of surgery, there is a risk of complications, and the likelihood of these complications will depend upon your condition and exactly what procedure is being undertaken. You should discuss your specific circumstances with your neurosurgeon.
Whilst the majority of patients will not have any complications, there is a small risk of problems. In general the risks of craniotomy include, but are not limited to:
  • Stroke or haemorrhage
  • Infection
  • Seizures
  • Impaired speech (dysphasia), with problems either understanding speech or actually speaking
  • Blindness
  • Deafness
  • Memory loss
  • Cognitive impairment (problems with your thinking)
  • Swallowing impairment
  • Balance problems
  • Hydrocephalus (fluid build-up within the head necessitating a ventricular drain or shunt)
  • Numbness of the skin around the scalp incision
  • Headaches (these usually settle after a couple of weeks following surgery, but may last longer)
  • Cosmetic issues, with a small dimple in the skull where the holes were drilled.
  • Death

What are the risks of anaesthesia and the general risks of surgery?

  • Significant scarring (‘keloid’)
  • Wound breakdown
  • Drug allergies
  • DVT (‘economy class syndrome’)
  • Pulmonary embolism (blood clot in lungs)
  • Chest and urinary tract infections
  • Pressure injuries to nerves in arms and legs
  • Eye or teeth injuries
  • Myocardial infarction (‘heart attack’)
  • Stroke
  • Loss of life
  • Other rare complications

What does the operation involve?

Anaesthetic and Preparation
A general anesthetic is given and a breathing (‘endotracheal’) tube is inserted. Intravenous antibiotics, and frequently dexamethasone (steroids which reduce some types of brain swelling) and anticonvulsants (medications to prevent seizures) are administered. A catheter is often placed in the bladder (this will be removed the next day). A dehydrating agent, such as Mannitol, is often given in an attempt to control brain swelling.

The patient is then positioned according to the area of the brain that must be operated upon. The hair over the incision area is then clipped and shaved, and the frameless stereotactic navigation system is set up. Local anaesthetic and adrenaline are then injected into the proposed incision site.

Incision 
A curved or straight incision is made in the scalp over the appropriate location. The scalp flap is then pulled back to expose the skull.

Craniotomy (bone removal) 
One or more small holes (burr holes) are drilled in the skull with a high speed drill. This sounds dangerous but is actually quite safe in skilled hands. A surgical saw (craniotome) is then used to connect the burr holes and create a "window" in the skull through which brain surgery will take place. The removed piece of bone (bone flap) is kept sterile, and is usually secured back in position at the end of the operation.

Removal of the Tumour
When the dura (lining over the brain) is exposed, an assessment of the likely location of the underlying tumour is performed. The dura is then incised with a scalpel and scissors, and the underlying brain is exposed.
A small incision is made in the surface of the brain and the neurosurgeon proceeds along the appropriate path until the tumour is reached. After the tumour is identified, it is carefully dissected from the normal surrounding brain.

A biopsy (small piece of the tumour) is sent to the pathologist for analysis. A ‘frozen section’ analysis usually takes around 20-30 minutes and should tell the surgeon whether the tissue taken is likely to be a tumour, and roughly what type of tumour it is. The frozen section is not, however, 100% accurate, and the tissue is then prepared and stained for a more thorough and accurate pathological evaluation, a process which usually takes 2-3 days.

Special microsurgical and other instruments are used by the neurosurgeon to locate, incise, and remove the tumour. These may include a microscope or special magnification glasses (‘loupes’), lasers, and an ultrasonic tissue aspirator (abbreviated to ‘CUSA’) that breaks up and then aspirates (sucks away) the abnormal tissue.

With meningiomas and metastatic tumours, it usually easy to distinguish the tumour from the normal brain tissue around them, and a fairly complete excision is usually possible (also known as a ‘gross macroscopic excision’). This is in contrast to surgery for gliomas, where the tumour boundaries are usually unclear and difficult to identify. Furthermore, the tumour cells in glioma usually spread well beyond the visible edges of the tumour, deep into the brain and sometimes into the other side of the brain.

Once the tumour has been removed, the surgeon ensures that there is no significant bleeding (this process is known as obtaining haemostasis).
In situations where there is a large cystic component to the tumour, a drain and reservoir may be inserted into the cystic cavity. This allows easy drainage of fluid if it accumulates in the cyst after surgery, by simply passing a small needle through the scalp and into the reservoir.
An intracranial pressure monitoring device is occasionally implanted, and a drain is sometimes placed within the fluid channels in the middle of the brain (the ventricles).

Bone Replacement 
After the dura has been stitched back together, the piece of bone that was removed is replaced and secured using small plates and screws, or several small clamps which hold the bone flap fairly firmly.

If there are significant defects in the skull from the drilled holes (which may cause cosmetic issues or feel may uncomfortable when combing your hair) these will be filled and the skull recontoured using acrylic or titanium. This is known as a reconstructive cranioplasty.

Incision closure 
The operation is completed when the incision is closed, usually in two or three layers. Unless dissolving suture material is used, the skin staples will have to be removed after the incision has partially healed (usually around 7 days after surgery).

What happens next?

Neurological Observation
You will be transferred to the recovery room immediately after surgery, where you will wake up. The recovery room nurses will monitor you closely, particularly in relation to your level of consciousness, arm and leg strength, as well as breathing, blood pressure and heart rate.

Once you are more awake and relatively stable, you will be moved to the neurosurgical high dependency unit or a closely monitored bed on the neurosurgery ward, where your condition can be closely monitored for around 24-48hrs. These highly specialised areas provide ongoing close observation with highly-trained nursing care.

The first 24 hours after surgery represents the period of highest risk for post-operative bleeding. Your blood pressure will be kept under control and your level of consciousness will be watched closely. In some cases a monitor may be used to measure the pressure inside your skull. A CT or MRI scan is often performed the day after surgery to make sure things are satisfactory. When fully conscious and completely stable, you will be returned to your regular room.

Postoperative Pain and Nausea
A dull headache is common, but is usually all the post-operative pain that is expected. Pain medication will be ordered for this. Nausea and vomiting may also occur, and these will be treated with medications.

Incision care 
The incision will be covered with a dressing, and sometimes a crepe bandage. The wound is usually checked, cleaned and redressed 3 or 4 days after surgery. The staples are usually removed 7 or 8 days after surgery. The wound must be kept dry for the first 2 weeks following g your operation.

Fluid Replacement and Nutrition 
Intravenous fluids will be ordered during the early recovery period and continued until you are fully awake and tolerating a reasonable amount of liquid by mouth. For the first few days, all fluids intake and output will be carefully monitored, due to the danger of brain swelling lessens.

Emotional changes 
Brain surgery is generally fairly stressful, both physically and psychologically. It is common to feel discouraged and tired for several days after surgery. This emotional let-down must not be permitted to obstruct the positive attitude essential to recovery and a return to fairly normal activity.

Discharge
The amount of time spent in the hospital may be different for each patient, and will depend upon the condition for which you underwent a craniotomy, as well as your post-operative recovery. Discharge is planned in consultation with the patient, their family, as well as the physiotherapist, occupational therapist, nursing staff, and neurosurgeon. Some patients are able to be discharged home, but others require a period of inpatient rehabilitation to optimize their outcome and make it as safe as possible for them to return home..

What happens after I am discharged from hospital after brain surgery?

If a significant neurologic deficit remains after surgery, a period of rehabilitation is often necessary to maximise your improvement. Otherwise you are likely to be discharged home.

Your GP should check your wounds 4 days after discharge. We will advise you when to have your staples removed at your GP's surgery or by the Precision Neurosurgery Practice Nurse (this is usually 7-8 days after surgery). You should not sign or witness any legal documents until you have been seen by your GP. You will need to take it easy for 6-8 weeks.

In summary, you should try to do around an hour of gentle exercise, such as walking, every day. You will be reviewed after 6-8 weeks by your neurosurgeon. You should not drive a motor vehicle, operate heavy machinery, or return to work until your neurosurgeon gives you the go ahead.

What follow-up is required?

Your neurosurgeon will review you 6-8 weeks after discharge, but will see you sooner if there are any problems. You will need to see your GP frequently during that time, so that your wound can be monitored for signs of infection, and your medications can be adjusted.

Before returning to see your neurosurgeon, a CT scan or MRI may be arranged. This will depend upon your specific circumstances.

You should keep in contact with the Precision Neurosurgery Registered Nurse, and relay any concerns to her.

Radiation therapy and/or chemotherapy after surgery may be recommended for malignant tumours. You will usually be referred to a neuro-oncologist and a radiation oncologist for their opinion and treatment.

Successful recovery from brain tumour surgery requires that the patient and their family approach the hospitalisation and recovery period with some degree of confidence based on a thorough understanding of the process. This will be complemented by the availability of your neurosurgeon, practice nurse, GP, and other treating specialists to give you advice, information and guidance. Support groups can be very useful in helping you to get through this difficult time, and the input of a psychologist can also be invaluable.

What are my discharge instructions after craniotomy?

These discharge instructions will vary according to the nature of your condition, exactly what type of craniotomy was performed, and your post-operative course. Your Neurosurgeon and/or the Precision Neurosurgery Registered Nurse will give you specific advice which should be followed.

The following instructions are a guide for the ‘average’ craniotomy patient:

Whilst most patients will be discharged home after their surgery, some may benefit from a period of inpatient rehabilitation, whilst others may be transferred to another type of medical or nursing facility. Some patients will benefit from ongoing treatment (either as an outpatient or inpatient) by a physiotherapist, occupational therapist, or speech therapist.
You are encouraged to set a flexible plan for your recovery, and should work slowly and steadily to increase your physical and mental tolerance.

During the first week at home, you should relax and just move around at will. Lifting anything over 2-3kg is discouraged for the first two or three months. Over the first few months after surgery, it is common to feel tired and you should rest frequently.

Your dressing will be changed a few days after surgery, and can be removed a week or so later. Once the dressing is no longer required, you can wear a clean hat or scarf until your hair has re-grown. The staples are generally removed at 7-8 days post-op.

You can shower and gently wash your hair with shampoo, but you should keep your wound dry for the first 2 weeks after surgery. The best way to do this is to wear a shower cap. Avoid hair products such as mousse or gels, as well as hair colourants and perms for at least 2 months after surgery.

Walking is the best exercise to undertake after brain surgery. Commence a walking program your second week home and increase the time and distance as each week passes. Aim for 1-2 hours per day on flat ground after two months.

You should avoid riding bicycles or running for at least two months. Other activities should be discussed with your neurosurgeon or the Precision Neurosurgery Registered Nurse.

You can resume sexual activity when you feel comfortable, but this should not be too vigorous for the first month or so after surgery.

Driving should be discussed with your neurosurgeon, as these guidelines vary from State to State, as well as from patient to patient.

The window of bone that was created to perform your operation has been secured in place with either small clamps or some plates and screws. These clamps or plates hold the bone fairly securely, but it usually takes up to 12 months for the bone window to fuse to the surrounding skull via growth of new bone across the narrow gap.

It is likely that you will be prescribed medications on discharge, and specific instructions will be given to you relating to how long you need to take them for, and how to reduce and stop (‘wean’) them. Such medications may be for:

  • Pain
  • Nausea
  • Brain swelling reduction
  • Seizure prevention
  • Stomach ulcer prevention

What is “normal” after a tumour craniotomy?

The following are common problems encountered by many patients, and usually do not mean anything serious is wrong:
  • Headaches: these are usually present daily to some degree, and may persist for a number of weeks. They will change in their location, character and severity as the bone heals and the scalp nerves regenerate.
  • Numbness: this is common, and arises because the skin nerves have been cut. The area of numbness usually decreases over weeks to months, but sometimes does not disappear completely.
  • Concentration: this is usually impaired for weeks to months after craniotomy. It is common to find difficulty focusing on certain tasks; you may need to re-read information in order to retain it. These symptoms tend to get better with time.
  • Emotional instability (lability): you may experience depression, crying spells, anxiety, and sensitivity to noise or people in crowded places. Try to relax and take it easy. Spend more quiet time. If you have major problems with these symptoms and cannot relax, call us and we will arrange for you to see a Clinical Psychologist to receive some strategies to do so.
  • Tiredness and fatigue: these are very common, and gradually improve.Once you commence a regular walking program, you will start to feel more energy.

It is common for it to take up to 3 months before you feel “well” again. Have plenty of rest during the day and eat healthy foods. Do not drink more than a small amount of alcohol during this time. Get up at your regular time and get plenty of sleep. Your internal clock would have been severely deranged during your hospitalisation, and it takes some time to return to normal.

What should you notify your neurosurgeon or the Precision Neurosurgery Registered Nurse of after surgery?

  • Increasing headache which is unrelieved by pain medication
  • Fever (high temperature) or chills
  • Swelling or infection of the wound (redness, increasing pain or tenderness)
  • Leakage of fluid from the wound, or any opening in the wound after the staples have been removed
  • Fitting (seizures) or fainting spells
  • Abnormal sensations or movements in your face, arms or legs
  • Weakness or numbness
  • Drowsiness
  • Problems with balance or walking
  • Nausea or vomiting
  • Pain in the calf muscles or chest
  • Shortness of breath
  • Any other concerns

What are the costs of surgery?

Private patients undergoing surgery will generally have some out-of-pocket expenses.

A quotation for surgery will be issued, however this is an estimate only. The final amount charged may vary with the eventual procedure undertaken, operative findings, technical issues etc. Patients are advised to consult with their Private Health Insurance provider and Medicare to determine the extent of out-of-pocket expenses.

Separate accounts will be rendered by the anaesthetist and sometimes the assistant, and hospital bed excess charges may apply. Medical expenses may be tax deductible (you should ask your accountant).

You should fully understand the costs involved with surgery before going ahead, and should discuss any queries with your surgeon.

What is the consent process?

You will be asked to sign a consent form before surgery. This form confirms that you understand all of the treatment options, as well as the risks and potential benefits of surgery. If you are unsure, you should ask for further information and only sign the form when you are completely satisfied.

Most frequently asked questions about brain tumour surgery

What happens at the time of your admission?
Patients are usually admitted to hospital either the day before, or on the morning of surgery. In situations where a number of investigations (scans etc) or consultations are needed you may be admitted a couple of days before surgery. On admission you will be assessed by a physician and a nurse. Blood tests and sometimes an ECG are done to make sure you are fit for surgery. You will also meet the anaesthetist at some stage before your operation.

I’ve been told I’ll need a Stealth or BrainLab Scan. What is this? 
A stealth scan is frequently used by neurosurgeons to help them pinpoint the exact location of a tumour. This makes your surgery safer.

Either the day before or on the morning of surgery you will undergo a brain scan, either a CT or an MRI. This information is loaded into a computer in the operating theatre in order to generate an exact three-dimensional image of your head and brain which can be closely correlated with your real brain during surgery.

Small round surface markers called ‘fiducials’ are stuck to the forehead and scalp. It will be necessary to shave a small amount of hair to ensure that the fiducials make proper contact with the skin and don’t fall off. The markers stay in place until surgery where they are ‘seen’ by the computer. It is important you do not pick the fiducials off or wash your hair before surgery, as they are likely to fall off.

A biopsy has been recommended. What is this? 
A biopsy is the removal of a small piece of tumour tissue. This material is then examined under a microscope by an expert pathologist, and an accurate diagnosis is usually made.

During a closed biopsy operation, a small hole (‘burr hole’) is made in the skull using a high sped drill. A sample of tissue is obtained by passing a needle through this hole and into the tumour.

Closed biopsies may be done under a general anaesthetic or local anaesthetic. The procedure usually takes up to an hour. The skin over the wound is stapled together and the bone grows back over the small hole in the skull in a few months.

Am open biopsy refers to a craniotomy. A craniotomy is performed (see below) before samples of the tumour are taken. In some situations this is safer than a closed biopsy.

What is the difference between a tumour excision and a debulking operation?
During a tumour excision procedure, the surgeon performs a craniotomy and then removes all (or almost all) of the tumour before replacing the skull and fixing the skin back in place. There are no problems caused by the gap left after the excision. 

Tumour debulking (partial removal) is undertaken when it is unsafe to remove the entire tumour. Several features of the tumour may make it appropriate for debulking. For example, the tumour might be very close to, or even invading, critical structures, such as major blood vessels.

The decision to perform either a radical excision or a partial removal is not always black and white. It may depend upon a number of factors, including the neurosurgeon’s jugement and patient preferences.

How long will surgery take?
Surgery can take as little as an hour, but may take a number of hours. This depends upon the size and position of the tumour, as well as a number of other technical factors. You will usually be in the recovery room for an hour or so immediately after you wake up, and in total you will be away from the ward for at least a few hours.

What can I expect after surgery?
You will wake up in the recovery room of the operating theatre shortly after surgery is over. You be transferred back to the neurosurgery ward or high dependency unit once you are awake.

When you wake up form surgery you may experience a headache and nausea, both of which are treated with medications.

The incision will usually be closed with clips (staples), which will be removed around a week after surgery. You will be given a staple remover so that these can be removed by GP, however in some situations they can be removed by the Precision Neurosurgery Registered Nurse.

Your wound may feel uncomfortable for several weeks after surgery, and it is usual for the skin around the incision to feel unusual as the wound heals and the nerves re-grow. These sensations typically resolve over a couple of monthsbut occasionally persist in the long term.

Headaches are very common following brain surgery, and often take a few months to settle. Mild pain medications (such as paracetamol) usually suffice, and you should contact your GP or the Precision Neurosurgery Registered Nurse if the headaches persist despite such medications.

The scar and surrounding skin may appear bruised for several days. Your eye may be bruised and swollen, but this settles over a week or so. The hair which was shaved begins to re-grow fairly soon after surgery, and the scar (which is ordinarily behind the hairline) fades to a less-noticeable pale thin line over 6-12 months.

How to I get my life back to ‘normal’ after surgery?
You can gently wash your hair around two weeks after surgery. It is recommended that you use a gentle shampoo for this. It is advised that you avoid hair dyes and perms for a couple of months as these may irritate the incision.

You are advised to avoid flying for around one month after your operation, due to the possibility that changes in cabin pressure may cause problems if you have some air left in your head after surgery.

You can resume light work around the house and a gentle exercise program as soon as you feel fit. How quickly you can return to work will depend upon the nature of your job, and it is best to discuss this with your neurosurgeon.

You are advised to avoid contact sports such as boxing or rugby for at least 12 months. It is safe to resume sexual activities once you feel capable.

Drinking a small amount of alcohol is safe, but you may be more susceptible to the mind-altering effects of alcohol after brain surgery, and there is also an increased risk of you having a fit or seizure if you drink larger amounts.