Introduction: Decompressive craniectomy with duraplasty is an life-saving procedure for the treatment of persistent elevated intracranial pressure, when optimized medical therapies have failed. Ultimately the skin edges are easily reapproximated. We describe four cases of a huge intraoperative brain swelling that was refractory to standard measures and the temporary augmentation of the scalp with a sterile plastic sheet.
Methods: The authors present four cases of decompressive hemicraniectomy with durotomy, two for the treatment of traumatic brain swelling with midline shift to the right side (a 21 year-old male, and a 7 year-old boy), and two for left-sided malignant middle cerebral artery ischemic stroke (51 year-old, and 44 year-old, both males) with the development of massive intraoperative brain herniation. The duraplasty was performed, but the primary skin closure was precluded. Thus, in order to provide an augmentation of the scalp, a sterile plastic sheet was sewn to the skin edges with running suture, and no brain tissue was surgically removed.
Results: Two patientes died: the 51 year-old within the first week of the craniectomy, from brainstem compression along with sepsis; the 44 year-old, after 112 days from craniectomy, from sepsis, but the skin was reapproximated after 3 weeks. The skin was reapproximated in 10 days for the 21 year-old patient, and the 7 year-old boy eventually needed a skin graft.
Conclusions: The use of a plastic sheet to provide skin augmentation, resembling a Bogota bag, in the face of massive brain herniation during decompressive craniectomy should be considered a viable option, including the preservation of potentially functioning brain tissue.
Patient Care: To accomplish the decompressive craniectomy with duraplasty, as widely described in the literature, with the advantage of preserving potentially functioning brain tissue by not removing it when this extensive herniation is encountered.
Learning Objectives: By the conclusion of this session, participants should be able: 1) Describe this alternative and simple technique for temporary scalp augmentation, 2) Recognize that this technique represents an alternative for a rare situation, and the authors do not recommend as a primary type of closure applied to all cases of decompressive hemicraniectomy.