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  • Linear Durotomies Instead of Classic Duramater Openning in Severe Stroke Decompressive Craniectomy

    Final Number:

    Almir F. Andrade MD, PhD; Saul Almeida da Silva MD; Ricardo Ferrareto Iglesio MD; Thales Bhering Nepocumecno MD; Gustavo Noleto MD, PhD; Wellingson S. Paiva MD PhD; Eberval G. Figueiredo MD, PhD; Manoel Jacobsen Teixeira

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: Preventing extrusion and the consequent brain injury associated with wide dural opening is a challenge for the neurosurgeon. We proposed a modification in the dural opening consisting of three frontoparietal and two temporal durotomies in decompressive craniectomy for malignant cerebral infarction. Therefore we achieve pressure reduction without allowing extrusion of brain tissue.

    Methods: In this pilot study we aimed to evaluate two concepts: Decompressive Craniotomy with Linear Durotomies (DCLD), and its comparison with the Decompressive Craniotomy with wide durotomy and classic duroplasty (DCCD). Data were collected in the period between 2012 and 2015. Nineteen patients with severe ischemic stroke of the middle cerebral artery were enrolled.

    Results: The mean age of the patients was 52.2 years, 12 men and 7 women, with a mean period from ictus to surgery of 1.2 days. The mean Glasgow Coma Score (GCS) on admission in the Classic Duroplasty group was 12 points, two of them had GCS less than nine, four presented with anisochoric pupils and a 50 % overall mortality rate. In the Linear Durotomies group, mean GCS was 12, one with GCS less than nine, one with anisochoric pupils, overall mortality was 33%. The midline structures deviation was related to the prognosis, 7-12mm with higher mortality.

    Conclusions: We concluded that the two surgical techniques are safe and effective, and the Decompressive Craniotomy with Linear Durotomies avoids the brain extrusion through the craniectomy. If the bone flap will be maintained or not is a neurosurgeon decision.

    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 conclusion of this session, participants should be able to descibre the importance of this new surgical technique for the treatment of ischemic stroke, reducing complications associated with brain extrusion.

    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 9. Michell P et al. Decompressive craniectomy with lattice duraplasty. Acta Neurochir, UK, 2004

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