Elsevier

World Neurosurgery

Volume 124, April 2019, Pages e431-e435
World Neurosurgery

Original Article
Decompressive Cranioplasty (Osteoplastic Hinged Craniectomy): A Novel Technique for Increased Intracranial Pressure—Initial Experience and Outcome

https://doi.org/10.1016/j.wneu.2018.12.112Get rights and content

Background

We redesigned decompressive craniectomy and cranioplasty procedures to decrease the inherent risk of complications. This novel technique, called decompressive cranioplasty, not only may decrease the complication rate but also may improve the cosmetic result, obviate the need for artificial skull implant, and increase the decompressive volume compared with traditional craniectomy.

Methods

In decompressive cranioplasty, the Agnes Fast craniotomy was adopted without cutting the temporalis muscle from the underlying bone flap. After opening the dura with or without removal of intracranial hematomas, duraplasty was performed with an intracranial pressure monitor inserted. Four miniplates were bent into a “Z” shape, and the vascularized bone flap was elevated approximately 1.2–1.5 cm above the outer cortex of the skull and fixed with the miniplates. Subsequent cranioplasty was done with a mini-incision on the miniplate sites and reshaping of the miniplate to align the outer cortex of the bone flap.

Results

We successfully performed decompressive cranioplasty in 3 emergent cases—2 traumatic subdural hematomas and 1 malignant middle cerebral artery infarction. Postoperative brain computed tomography demonstrated adequate decompression in all cases. Cosmetic outcome was excellent, and there was no temporal hallowing. Mastication function was not affected. At 6-month follow-up, there was no bone flap shrinkage and no hydrocephalus.

Conclusions

Decompressive cranioplasty is a safe and effective method in the management of patients with brain edema and intracranial hypertension. It is simple to perform and may reduce the morbidity associated with traditional decompressive craniectomy and subsequent cranioplasty.

Introduction

Decompressive craniectomy (DC) has been used for decades in management of patients with brain edema and intracranial hypertension. However, the morbidity associated with DC and subsequent cranioplasty is as high as 40%. Potential complications of DC include delayed postoperative seizures in 37% of cases (seizures in 61.1% of patients after malignant middle cerebral artery infarcts submitted to DC in some studies), hydrocephalus in 40% of cases, neurologic deficit (syndrome of the trephined) in 26% of cases, and chronic headache that improves only with replacement of the cranial plate in 17% of cases.1, 2, 3, 4 Ban et al.5 reported the following complications of DC: hematoma contralateral to the craniectomy defect (5.6%), contusion expansion (12.4%), postoperative epilepsy (3.4%), external cerebral herniation (14.6%), cerebrospinal fluid leakage through skin incision (2.2%), postoperative infection (4.5%), subdural effusion (32.6%), posttraumatic hydrocephalus (11.2%), and syndrome of the trephined (9.0%).

Cranioplasty requires a second operation performed under general anesthesia and exposes the patient to additional potential complications, such as infection and resorption of the autologous bone flap. Cranioplasty has a significant infection risk, with 8.2%–26.43% of patients requiring removal of the autologous cranial plate or prosthetic with subsequent revision.6, 7, 8 In addition, resorption of the bone plate can be a problem. In a cohort of 207 patients, the overall complication rate was 39.6%, and the bone flap removal rate was 19.3%.9 Because of the high complication rate, our goal was to redesign the DC and cranioplasty procedures in the hope to decrease the inherent risk of complications associated with these procedures. We designed a decompressive cranioplasty (DCP), which may avoid the inherent complications, improve the cosmetic result, reduce bone flap resorption, and provide larger decompressive volume.

Section snippets

Materials and Methods

In our decompressive cranioplasty, the Agnes Fast craniotomy was also adopted without cutting or separating the temporalis muscle from the underlying bone flap (Figure 1). This method creates a fully vascularized bone flap and obviates the need for interfascial dissection for frontal nerve preservation. This approach is most useful in emergency cases owing to its simplicity and rapid exposure of the dura mater. After opening the dura with or without removal of intracranial hematomas, duraplasty

Illustrative Case

An 81-year-old man was brought to the emergency department with a head injury following a motorcycle accident. Disorientation to people and confused speaking were noted in the emergency department. Glasgow Coma Scale score was 14 (E4V4M6); pupils were right/left, 3 mm/3 mm; light reflex was +/+; and muscle power was right limbs, 4/5 and left limbs, 5/5. CT showed extensive left traumatic subdural hematoma and left temporal contusion hemorrhage with midline shift of 1.2 cm (Figure 2A). We

Discussion

The Agnes Fast craniotomy is a fast and simple method of performing the pterional craniotomy with preservation of the temporalis muscle and its vascular supply, innervation, bony attachment, and fascia.11 Because this craniotomy can be done within 5 minutes, it is very suitable for emergency surgeries. We adopted the Agnes Fast craniotomy to achieve early decompression, and then the hinged craniotomy (HC) concept was adopted. The use of HC for cerebral decompression was introduced in 2007 by

Conclusions

Our initial experience with DCP demonstrates that this procedure is a safe and effective alternative to traditional DC and subsequent cranioplasty in management of patients with brain edema and intracranial hypertension. It is simple to perform and may reduce the morbidity associated with traditional procedures. Potential benefits include better cosmetic outcome (avoid temporalis resection and temporal hallowing), less dysfunction of mastication, less bone flap shrinkage, no need for general

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Cited by (8)

  • New CT measurements to assess decompression after hemicraniectomy: A two-center reliability study

    2020, Clinical Neurology and Neurosurgery
    Citation Excerpt :

    The tissues overlying the craniectomy include skin, muscle and connective tissue, dural patches, various amounts of bloody and non-bloody exudates, and occasionally air. Rarely, the resected skull segment is hinged posteriorly and not removed [6]. Thus, in this study we propose three new simple post-DHC CT measurements and test them for reliability among independent raters.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Yung-Chun Hsu and Abel Po-Hao Huang are co–first authors.

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