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  • Effect of Dural Substitute and Technique on Cranioplasty Operative Metrics: A Systematic Literature Review

    Final Number:

    Alankrita Raghavan BS; James Wright MD; Christina Huang Wright MD; Martha Sajatovic MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: Decompressive craniectomy is performed to relieve elevated intracranial pressure1. Dural substitutes are often used in these procedures but there is little concensus on which substitutes to use or the utility of these substitutes in improving outcomes and reducing complications.

    Methods: This systematic literature review examined original reports on outcomes with the use of dural substitutes and was intended to compare different techniques. This review used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). PubMed articles were selected using the following search-terms: “duraplasty and craniectomy” or “duraplasty and cranioplasty” or “dural substitute and craniectomy” or “adhesion and craniectomy.” The reference lists of selected articles were screened for additional articles. Articles met inclusion criteria if the abstract was in English and the surgery investigated was supratentorial. Articles were excluded if they did not address outcomes or complications of the procedure.

    Results: A total of 9 publications met criteria. All were retrospective cohort or case series. Outcomes of adhesion preventing dural substitutes (N= 310) were compared to conventional duraplasty (N= 219), and single layer dural substitute (N= 35). A total of 564 patients were included from 1998 to 2017. While study heterogeneity limited ability for cross-study comparison overall, within each report, the use of adhesion-preventing dural substitutes was associated with statistically significant reduction in operative time and blood loss. The majority of studies did not report an increase in complications, defined as post-cranioplasty fluid collections and infection, although Huang et a2l., found increased risk of infection with the non-absorbable dural substitute Neuro-Patch.

    Conclusions: Decompressive craniectomy is a common neurosurgical procedure. Dural substitutes are increasingly used, however, there is little consensus on preferred material or procedure. This review suggests that synthetic substitutes may be associated with improved surgical outcomes. Larger, controlled studies are needed to compare individual dural substitutes and to clarify indications for each substitute.

    Patient Care: This research serves to summarize the reported literature supporting duraplasty. This is the first literature review of its kind on this subject and will serve as the foundation for further clinical trials.

    Learning Objectives: By the conclusion of this session participants should be able to: 1) discuss the different options of duraplasty, 2) discuss the morbidity profile of each dural substitute, 3) discuss the literature supporting duraplasty

    References: 1. Chibbaro S, Tacconi L. Role of decompressive craniectomy in the management of severe head injury with refractory cerebral edema and intractable intracranial pressure. Our experience with 48 cases. Surg Neurol. 2007. doi:10.1016/j.surneu.2006.12.046. 2. Huang YH, Lee TC, Chen WF, Wang YM. Safety of the nonabsorbable dural substitute in decompressive craniectomy for severe traumatic brain injury. J Trauma - Inj Infect Crit Care. 2011;71(3):533-537. doi:10.1097/TA.0b013e318203208a. 3. Pathrose Kamalabai R, Nagar M, Chandran R, et al. Rationale Behind the Use of Double-Layer Polypropylene Patch (G-patch) Dural Substitute During Decompressive Craniectomy as an Adhesion Preventive Material for Subsequent Cranioplasty with Special Reference to Flap Elevation Time. World Neurosurgery. 2018. 4. Khalili H, Omidvar A, Ghaffarpasand F, Yadollahikhales G. Cranioplasty Results after Application of Anti-adhesive Films (OrthoWrapTM) in Traumatic Decompressive Craniectomy. Bull Emerg Trauma. 2016;4(1 JAN):24-28. Papers/K/Khalili et al. 2016 - Cranioplasty Results after App. 5. Wang F, Xue Y, Zhao SS, Yang TJ, Song HQ, Liu H. Suturing-Free Artificial Dura with Dacron Heart Patch in Decompressive Craniectomy and Cranioplasty. Indian J Surg. 2015;77:1008-1011. doi:10.1007/s12262-014-1111-9. 6. Pierson M, Birinyi P V., Bhimireddy S, Coppens JR. Analysis of Decompressive Craniectomies with Subsequent Cranioplasties in the Presence of Collagen Matrix Dural Substitute and Polytetrafluoroethylene as an Adhesion Preventative Material. World Neurosurg. 2016;86:153-160. doi:10.1016/j.wneu.2015.09.078. 7. Lee CH, Cho DS, Jin SC, Kim SH, Park DB. Usefulness of silicone elastomer sheet as another option of adhesion preventive material during craniectomies. Clin Neurol Neurosurg. 2007;109(8):667-671. doi:10.1016/j.clineuro.2007.05.015. 8. Vakis A, Koutentakis D, Karabetsos D, Kalostos G. Use of polytetrafluoroethylene dural substitute as adhesion preventive material during craniectomies. Clin Neurol Neurosurg. 2006;108(8):798-802. doi:10.1016/j.clineuro.2005.11.026. 9. Kawaguchi T, Hosoda K, Shibata Y, Koyama J. Expanded polytetrafluoroethylene membrane for prevention of adhesions in patients undergoing external decompression and subsequent cranioplasty. Neurol Med Chir (Tokyo). 2003;43(6):320-323; discussion 324. doi:10.2176/nmc.43.320. 10. Oladunjoye AO, Schrot RJ, Zwienenberg-Lee M, Muizelaar JP, Shahlaie K. Decompressive craniectomy using gelatin film and future bone flap replacement. J Neurosurg. 2013;118(4):776-782. doi:10.3171/2013.1.JNS121475.

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