The following is a photo progression of craniotomy for a dominant (left) frontal lobe AA in Broca’s area in a 6-year-old boy with seizures.
Positioning for resection of left-sided AA: The boy is in a supine position, roll under his left shoulder, head turned to the right, scalp prepared and marked for incision.
Scalp and temporalis muscle turned as single flap: A left fronto-temporal myocutaneous flap has been turned anteriorly.
Frontotemporal craniotomy: A frontotemporal bone flap has been removed and the dura tacked to bone.
Exposed cortex: Opening of the dura exposes the brain. Swollen gyrus marks location of tumor.
Exposed left frontal lobe:
Placement of 20 contact electrode grid: Intraoperative electrocorticography is done to evaluate for epileptogenic foci and to identify motor cortex using stimulation through grid and/or by phase reversal of sensory evoked potentials (cortical mapping).
Monitoring personnel: Neurologist evaluating intraoperative electrocorticography (ECoG).
Cortical incision: Shown is a dissector being used to perform a cortical opening to expose the tumor.
Resecting the tumor: Sharp dissection in addition to ultrasonic aspiration, blunt dissection with micro-dissectors, and suction/bipolar cautery are used to accomplish the tumor’s removal.
Resection cavity: After the tumor’s removal the swollen appearance resolves, with the gyral patterns and vascularity assuming a more normal appearance.
Higher magnification of the tumor cavity: Under microscopic magnification the walls of the resection cavity begin to appear as normal white and gray matter at the margins of the tumor.
Dural closure: The dura is closed to avoid CSF leakage and adherence of the cortical surface to any material in the epidural space.
Bone flap reattached: The bone flap is fixed into position so that it can revascularize and undergo the normal reossification process.
Scalp incision closed: The scalp is closed in such a manner that removal of any suture material will be as easy as possible for the young child.