Common Neurosurgical Procedures

Procedure to open narrowed or blocked cerebral or intracranial arteries

PURPOSE

Restore blood flow due to arterial occlusions. May be done in combination with IV tPA. Indicated for patients who present more than 6 hours after onset, or those who have contraindications to or do not improve after IV tPA. Works well for large vessel occlusions.

THERAPEUTIC PRECAUTIONS

• May require bed rest for up to 8 hours following the procedure — confirm activity orders with the team before mobilizing

• The primary post-procedure concern is the arterial access site closure method and the presence of a femoral sheath (if used)

• Monitor the access site for hematoma formation or frank bleeding; if bleeding occurs, hold pressure and cease activity

• Defer mobility until the femoral sheath has been removed and activity orders have been advanced

A small hole drilled into the skull

PURPOSE

Remove a localized fluid collection (e.g., chronic subdural hematoma) or provide access for drain or monitor placement.

THERAPEUTIC PRECAUTIONS

See General Neurosurgical Precautions above. Confirm activity orders with the team — post-op parameters vary depending on reason for burr hole and what was placed.

Surgical removal of plaque buildup from inside the carotid artery

PURPOSE

Treat carotid artery stenosis to reduce risk of stroke from atherosclerotic plaque.

THERAPEUTIC PRECAUTIONS

• Tight BP parameters are typically in place post-op to avoid reperfusion injury (commonly SBP 120–160 mmHg — confirm with team)

• Monitor closely for new neurological deficits, which may indicate perioperative stroke

• Observe the surgical site (neck) for hematoma formation — a rapidly expanding neck hematoma is a surgical emergency; notify the team immediately

• See General Neurosurgical Precautions above

Catheter-based imaging of the cerebral blood vessels

PURPOSE

Investigate or examine blood vessels of the brain, head, or neck. A catheter is inserted into an artery (typically the femoral artery, occasionally the radial artery or neck) and contrast dye is injected, after which X-rays show blood flow to the brain.

THERAPEUTIC PRECAUTIONS

• Following the procedure, patients are typically on bed rest for 6–8 hours with the involved limb (hip/knee or arm) immobilized — confirm duration with the team

• If the neck was used as the access site, monitor for hoarseness, breathing difficulties, pain, or difficulty swallowing

• Defer mobility until the femoral sheath has been removed and activity orders have been advanced

• Monitor the access site for hematoma formation or bleeding

A small metal clip placed around the neck of a cerebral aneurysm via craniotomy

PURPOSE

Isolate the aneurysm from normal blood circulation to prevent rupture or re-rupture.

THERAPEUTIC PRECAUTIONS

See General Neurosurgical Precautions above. Post-clipping vasospasm (typically days 4–14) is a significant risk — monitor for new or worsening neurological deficits and report immediately.

Surgical removal of a portion of the skull that is not immediately replaced

PURPOSE

Relieve intracranial pressure, reduce intracranial hypertension, or allow for unrestricted brain swelling (e.g., after severe TBI or malignant MCA infarction). The removed bone flap may be stored in a subcutaneous abdominal pocket, the subgaleal space, or cryopreserved in a bone bank until it can be replaced (cranioplasty).

THERAPEUTIC PRECAUTIONS

• Helmet use: Helmets are generally recommended whenever the patient is out of bed. However, this is neurosurgeon- and facility-specific — confirm helmet protocol with the team before mobilizing.

  • When ordering a helmet, measure the head circumference approximately 1 inch above the ears

  • Ensure the helmet does not compress the unprotected area

  • If no helmet is in use, be cautious not to apply any pressure to the area without bone

• Positioning: Do not roll the patient onto the side of the craniectomy — this places pressure on the unprotected brain

• Restrict forward trunk bending during ADLs and mobility — particularly important given the absence of bony protection

• Avoid Valsalva maneuvers

• See General Neurosurgical Precautions above

• For further reading: Pandit et al. (2022) — see References

Replacement of the bone flap removed during craniectomy

PURPOSE

Restore bony protection of the brain and correct the cosmetic skull defect. May also improve neurological function by restoring normal CSF dynamics and cerebral blood flow.

THERAPEUTIC PRECAUTIONS

See General Neurosurgical Precautions above. Confirm helmet protocol has been discontinued with the surgical team — patients may still be wearing a helmet at the time of cranioplasty.

Temporary removal of a portion of the skull (bone flap), with replacement at the end of the procedure

PURPOSE

Remove a tumor, relieve pressure, drain blood from a hemorrhagic area, repair a damaged blood vessel, or clip an aneurysm.

THERAPEUTIC PRECAUTIONS

• See General Neurosurgical Precautions above

• If ICP monitoring or an EVD was placed during the same surgery, see the ICP page and ICU Lines, Leads & Drains for additional precautions

Surgical excision of as much of a CNS mass as safely possible

PURPOSE

Reduce tumor burden to decrease neurological deficits, relieve mass effect, and improve quality of life. Complete resection is often not possible given the tumor's location.

THERAPEUTIC PRECAUTIONS

See General Neurosurgical Precautions above. New or changing neurological deficits post-debulking should be documented carefully and reported — they may reflect surgical change, edema, or recurrence.

Catheter-based placement of coils inside an aneurysm or vascular lesion

PURPOSE

Block a cerebral aneurysm from normal blood flow to prevent rupture. Also used to reduce vascularity of a tumor prior to surgical resection (preoperative embolization).

THERAPEUTIC PRECAUTIONS

• Access site precautions apply — typically the femoral artery; monitor for hematoma or bleeding

• Defer mobility until the femoral sheath is removed and activity orders are advanced

• Post-embolization vasospasm is a risk — monitor for new neurological deficits

• See General Neurosurgical Precautions above

Surgical removal of intracerebral blood or a clot

PURPOSE

Reduce ICP caused by bleeding in the brain. Performed via burr hole, craniectomy, or craniotomy depending on the size, location, and acuity of the bleed.

THERAPEUTIC PRECAUTIONS

See General Neurosurgical Precautions above. ICP monitoring is often in place following evacuation — see the ICP page for activity decision guidance.

Insertion of a sensor or catheter to measure intracranial pressure in real time

TYPES

• Intraparenchymal monitor (e.g., Camino bolt, Licox): a small sensor placed directly into brain tissue through a small burr hole. Measures ICP continuously but cannot drain CSF.

• External ventricular drain (EVD): a catheter placed into a lateral ventricle. Can both monitor ICP and drain CSF to reduce pressure. See the ICU Lines, Leads & Drains and ICP pages for detailed EVD management.

PURPOSE

Continuous real-time monitoring of ICP to guide medical management, prevent secondary brain injury, and determine when intervention is needed.

THERAPEUTIC PRECAUTIONS

• Do not dislodge the device — confirm the monitor or EVD is secured before any repositioning or mobility

• Review ICP values and waveform before beginning the session; notify nursing if ICP is elevated or the waveform is dampened

• For EVDs: confirm the clamping/unclamping protocol with nursing before activity; the drain must be leveled to a specific anatomical landmark (typically the tragus of the ear) to ensure accurate readings

• HOB positioning is typically ordered at 30° — confirm with the team before adjusting

• Monitor ICP response during activity; stop and notify nursing if ICP rises with position change or exertion

• See the ICP page for the full Activity Decision Framework when ICP monitoring is in place

A needle is inserted between lumbar vertebrae to access the cerebrospinal fluid

PURPOSE

Diagnose CNS diseases (e.g., infection, subarachnoid hemorrhage, inflammatory conditions) by analyzing CSF. Also used to provide short-term relief of elevated CSF pressure, or for intrathecal medication administration.

THERAPEUTIC PRECAUTIONS

• Bed rest for 2–4 hours following the procedure is typical — confirm with the team or nurse before mobilizing

• Hold or defer OOB activity if the patient has any of the following post-LP: severe headache (especially positional), backache, fever, bleeding at the site, CSF leak, or difficulty voiding

• Post-LP headache (positional — worse upright, better supine) is common; report to the team if present and do not push activity until resolved

Catheter-based retrieval of a clot from a cerebral blood vessel

PURPOSE

Restore blood flow in large vessel occlusions causing acute ischemic stroke. A device is used to retrieve and remove the clot, with or without intra-arterial (IA) thrombolytics to assist. Works best for large vessel occlusions. Indicated for patients who present more than 6 hours after onset, or those with contraindications to or failure of IV tPA.

THERAPEUTIC PRECAUTIONS

• Typically accessed via the femoral artery — monitor the access site for hematoma formation or frank bleeding; if frank bleeding occurs, hold pressure immediately and cease activity

• The arterial closure system can develop a leak — monitor the access site throughout the session

• Defer mobility until the femoral sheath has been removed and activity orders are advanced

• Post-procedure BP parameters are typically strict — confirm before activity

• Monitor closely for new or worsening neurological deficits indicating re-occlusion or hemorrhagic transformation

Removal of a pituitary tumor through a transnasal approach

PURPOSE

Remove a pituitary gland tumor (adenoma) via an endoscopic approach through the nasal passage and sphenoid sinus, avoiding open craniotomy.

THERAPEUTIC PRECAUTIONS

Do not remove nasal packing.

• Keep head of bed at 30°

• Avoid all Valsalva maneuvers

• If clear, thin fluid is draining from the nose, alert staff immediately — this may indicate a CSF leak

Sinus precautions are in place for approximately 4–6 weeks (confirm duration with the surgeon):

• Do not bend or lean forward at the waist

• Do not drink from straws

• Do not sneeze through the nose (sneeze with mouth open if needed)

• Do not sniffle or sniff forcefully

• Do not pick or blow the nose

These sinus precautions apply to ADL and functional mobility — incorporate them into patient and family education from the first session.

A surgically implanted tube that drains excess CSF from the brain's ventricles to the abdomen

PURPOSE

Provide a permanent alternate pathway to redirect excess CSF from the cerebral ventricles to the peritoneal cavity, where it is absorbed. Primary goal is to relieve elevated ICP from chronic hydrocephalus.

THERAPEUTIC PRECAUTIONS

• Unlike an EVD, a VP shunt does not require leveling or clamping — it is a closed, internal system

• Do not press on or manipulate the shunt hardware visible under the scalp

• HOB elevation and activity are typically ordered gradually starting post-op day 1 — confirm with the team

• The patient may complain of headache or stomachache post-op — report to nursing; these are common but can indicate shunt malfunction if persistent or severe

• Signs of shunt malfunction (return of headache, nausea, vomiting, altered mental status, or visual changes) should be reported to the team immediately

• See General Neurosurgical Precautions above