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  • Decompressive Cranioplasty : A Novel Surgical Method

    Final Number:

    Hui-Tzung Luh MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: Decompressive craniectomy (DC) has been used most often in traumatic brain injury and malignant cerebral infarction. Yet, DC has its risks. Besides, following cranioplasty was needed for the iatrogenic skull defect and may carry additional surgical risks. Hinge craniotomy (HC) was introduced for cerebral decompression in 2007 and was later proved to be as good as DC in ICP control and equivalent early clinical outcomes. Yet HC seems to provide less decompression volume compared with DC. Hereby, we designed a novel surgical method – decompressive cranioplasty for larger decompressive colume and less complication.

    Methods: In decompressive cranioplasty, Agnes Fast craniotomy was adopted. Without cutting or separating the temporalis muscle from the underlying boneflap, Agnes Fast craniotomy offers a valid, simple, and fast way with less blood loss. Besides, the need for an interfascial dissection is circumvented. This method benefits more in emergent cases for its simple and rapid exposure of the dura. Z-shaped miniplates were designed and applied for ensuring the fixed height (>1cm) and decompression volume.

    Results: We have performed decompressive cranioplasty on three emergent cases - two traumatic subdural hemorrhages and one malignant cerebral infarction. The post-operative brain computed tomography revealed adequate decompression. Three patients were all in good clinical recovery and received following reverse cranioplasty under intravenous general anesthesia within one week without complications. Sinking skin flap syndrome was not observed. Cosmetic outcome (no temporal hallowing) and mastication functional outcome were satisfied by the patient. Bone flap preservation cost was also saved. Long-term follow-up for bone flap shrinkage and hydrocephalus is underway.

    Conclusions: Decompressive cranioplasty is a promising and effective method in providing good post-operative ICP control and well early clinical outcomes. Furthermore, better cosmetic result, reduced cost, and less complication may surpass the traditional craniectomy. Long-term follow-up and perspective study were needed.

    Patient Care: The novel method was easy to conduct but can greatly save the medical coat, gain better cosmetic and mastication function outcome, have well clinical outcomes and lower the complication rate (eg. sinking skin flap syndrome, hydrocephalus).

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of timely decompression for ICP control, cosmetic outcome after decompression and preventing sinking skin flap syndrome, 2) Discuss, in small groups, how to perform decompressive cranioplasty with Agnes Fast technique, 3) Identify an effective treatment for ICP control via decompressive cranioplasty.

    References: [1] Adeleye AO, Azeez AL. Decompressive craniectomy bone flap hinged on the temporalis muscle: A new inexpensive use for an old neurosurgical technique. Surg Neurol Int. 2011;2:150. [2] Goettler CE, Tucci KA. Decreasing the morbidity of decompressive craniectomy: the Tucci flap. J Trauma. 2007;62:777-8. [3] Kano T, Kurosaki S, Wada H. Retrospective Analysis of Hinge Technique for Head Trauma or Stroke. Neurologia medico-chirurgica. 2012;52:816-21. [4] Kenning TJ, Gandhi RH, German JW. A comparison of hinge craniotomy and decompressive craniectomy for the treatment of malignant intracranial hypertension: early clinical and radiographic analysis. Neurosurgical Focus. 2009;26:E6. [5] Khanna R, Ferrara L. Dynamic telescopic craniotomy: a cadaveric study of a novel device and technique. J Neurosurg. 2016;125:674-82. [6] Kim YS, Yi HS, Kim HK, Han YS. Effectiveness of Temporal Augmentation Using a Calvarial Onlay Graft during Pterional Craniotomy. Arch Plast Surg. 2016;43:204-9. [7] Kurland DB, Khaladj-Ghom A, Stokum JA, Carusillo B, Karimy JK, Gerzanich V, et al. Complications Associated with Decompressive Craniectomy: A Systematic Review. Neurocrit Care. 2015;23:292-304. [8] Schmidt JH, Reyes BJ, Fischer R, Flaherty SK. Use of hinge craniotomy for cerebral decompression. Journal of Neurosurgery. 2007;107:678-82.

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