Introduction: Decompressive craniectomy (DC) in severe traumatic brain injury (TBI) is associated with acute and late complications. The wide aperture of the duramater is associated with cerebral extrusion and consequent secondary lesion. To avoid these complications, Burguer et al 2008 developed a durotomy instead of duroplasty. We proposed a technical modification in DC with 5 linear durotomies and duroplasty.

Methods: We performed a prospective cohort with 43 TBI patients undergoing DC for treatment of diffuse hemispheric brain swelling with acute subdural hematoma. All patients underwent the modified durotomies "Burger type" (three on the frontal and parietal lobes and two on temporal lobe) with autologous tissue of subgaleal over the durotomies in order to avoid direct contact of the cerebral cortex with bone flap or CSF leakage.

Results: Comparing the CT scans before and after surgery, the midline shift decreases from median of 11 mm to 5.5 mm (p<0,0001). Only one patient had presented uncontrolled intracranial hypertension after surgery. There has been no intraoperative death. Postoperative mortality in the intensive care unit within 14 days was 50%.

Conclusions: In this pilot study, we observed ICP control, avoiding the complications of classical decompression. The modified durotomies should be an option to avoid abrupt extrusion of the brain and to allow the gradual and gentle reduction of ICP.

Patient Care: This new dural opening technique prevents secondary injury associated with brain extrusion, in a simple safe and efficient way.

Learning Objectives: By the end of this section, participants should be able to describe the Linear Durotomies and the role of ths technical modification

References: 1-Burger R. Duncker D.Uzma N.Rohde V. Decompressive craniotomy:durotomy instead of duroplasty to reduce prolonged ICP elevation. Acta Neurochir Suppl (2008) 102:93-97 2-Alves OL, Bullock R "Basal durotomy" to prevent massive intra-operative traumatic brain swelling..Acta Neurochir (Wien). 2003 Jul;145(7):583-6; discussion 586. 3- Goettler CE and Tucci KA .Decreasing the Morbidity of Decompressive Craniectomy: The Tucci Flap. The Journal of TRAUMA Injury , Infection, and Critical Care 4-Kathryn Ko. Segan S. In Situ Hinge Craniectomy. Volume 60 Suppl / Operative Neurosurgery 2 / 255-259, 2007 4. Wagner S. Schnipperring H. Aschoff A. Suboptimum hemicraniectomy as a cause of additional cerebral lesions in patients with malignant infarction of the middle cerebral artery. J Neurosurg 94: 693-696, 2001. 5. Valença MM, Martins C, da Silva JC."In-window" craniotomy and "bridgelike" duraplasty: an alternative to decompressive hemicraniectomy. J Neurosurg. 2010 Nov;113(5):982-9. 6.Guilburd JN, and Gil ES. Role of dural fenestrations in acute subdural hematoma. J. Neurosurg 95:263-267,2001 7.Yoo Do-Sung, Kim Dal-Soo, Cho Kyung-Suck et al.: Ventricular pressure monitoring during bilateral decompression with dural expansion. J Neurosurg 91:953-959,1999 8.Holst H v, Li X, Kleiven S.:Increased strain levels and water content in brain tissue after decompressive craniotomy. Acta Neurochir, (2012) 154:1583-1593