Novel Decompressive Hemicraniectomy Technique for Traumatic Brain Injury: Technical Note

Novel hemicraniectomy: Preserving temporal structures in severe traumatic brain injury patients

OBJECTIVE

This study evaluates the efficacy and safety of Novel Hemicraniectomy Technique (NHT) in Severe Traumatic Brain Injury (STBI) patients.

METHODS

A retrospective analysis of 79 STBI patients who underwent decompressive hemicraniectomy was conducted. The study compared 25 patients treated with NHT and 54 patients treated with Classic Decompressive Craniectomy (CDC), focusing on therapeutic effects, complications, intracranial pressure, and prognosis.

RESULTS

NHT resulted in shorter surgery duration (101.4 ± 11.8 min, p = 0.008) and greater decompressive effects (21.4 ± 5.6 mmHg, p = 0.018). It also prevented temporal muscle injury (0.0 %, p = 0.026), superficial temporal artery injury (0.0 %, p = 0.009), and masticatory dysfunction (5.9 %, p = 0.040). However, NHT showed no significant advantages in intracranial pressure normalization time (3.5 ± 0.9 days, p = 0.679), hospital stay length (34.3 ± 10.4 days, p = 0.805), intraoperative blood loss reduction (284.0 ± 82.6 ml, p = 0.190), or Glasgow Outcome Scale (GOS) scores (2.8 ± 0.9, p = 0.814) and prognosis (32.0 %, p = 0.831) compared to CDC.

CONCLUSION

NHT offers shorter surgery duration (101.4 ± 11.8 min vs 107.7 ± 8.2 min), superior decompressive effects (21.4 ± 5.6 mmHg vs 17.7 ± 6.9 mmHg), and better protection of temporal structures, but does not significantly reduce complications or improve prognosis compared to CDC. Prospective studies with larger sample sizes are needed to better understand the potential benefits of NHT in STBI treatment.

Novel retro-auricular myocutaneous hemicraniectomy flap: Technical note and cadaveric dissection

Objective

The hemicraniectomy is a common technique used in a variety of pathologies including some traumatic brain injury and malignant stroke. A novel technique of performing hemicraniectomies using a retro-auricular incision can avoid transgressing the temporalis muscle and superficial temporal artery while providing adequate hemicranial exposure.

Methods

This technique was reproduced in a skull base lab using a cadaveric head. The key steps of this approach were illustrated in step-by-step fashion. A post-approach CT scan of the cadaver was performed to evaluate the decompression exposure.

Results

This approach can provide sufficient middle fossa decompression and area of exposure, while preserving the temporalis along with the superficial temporal artery. A step-by-step technical illustration is demonstrated in the present note.

Conclusions

The modified retro-auricular myocutaneous flap is a novel technique in hemicraniectomy which can provide sufficient middle fossa decompression and exposure while sparing the temporalis muscle and superficial temporal artery during the approach.

Decompressive Craniectomy in Severe Traumatic Brain Injury: The Intensivist's Point of View

INTRODUCTION

Traumatic brain injury (TBI) represents a severe pathology with important social and economic concerns, decompressive craniectomy (DC) represents a life-saving surgical option to treat elevated intracranial hypertension (ICP). The rationale underlying DC is to remove part of the cranial bones and open the dura mater to create space, avoiding secondary parenchymal damage and brain herniations. The scope of this narrative review is to summarize the most relevant literature and to discuss main issues about indication, timing, surgical procedure, outcome, and complications in adult patients involved in severe traumatic brain injury, underwent to the DC. The literature research is made with Medical Subject Headings (MeSH) terms on PubMed/MEDLINE from 2003 to 2022 and we reviewed the most recent and relevant articles using the following keywords alone or matched with each other: decompressive craniectomy; traumatic brain injury; intracranial hypertension; acute subdural hematoma; cranioplasty; cerebral herniation, neuro-critical care, neuro-anesthesiology. The pathogenesis of TBI involves both primary injuries that correlate directly to the external impact of the brain and skull, and secondary injuries due to molecular, chemical, and inflammatory cascade inducing further cerebral damage. The DC can be classified into primary, defined as bone flap removing without its replacement for the treatment of intracerebral mass, and secondary, which indicates for the treatment of elevated intracranial pressure (ICP), refractory to intensive medical management. Briefly, the increased brain compliance following bone removal reflects on CBF and autoregulation inducing an alteration in CSF dynamics and so, eventual complications. The risk of complications is estimated around 40%. The main cause of mortality in DC patients is due to brain swelling. In traumatic brain injury, primary or secondary decompressive craniectomy is a life-saving surgery, and the right indication should be mandatory in multidisciplinary medical-surgical consultation.

Tissue Healing in Hemicraniectomy

Introduction

Decompressive hemicraniectomy (DHC) is a last-resort treatment for refractory intracranial hypertension. Perioperative morbidity is associated with high risks of wound healing disturbances (WHD). Recently, a retromastoidal frontoparietooccipital (RMF) incision type was performed to avoid healing disturbance due to enhanced tissue flap perfusion compared to the classical reverse “question mark” (“Dandy flap”) incision. The goal of this study was to analyze the details of tissue healing problems in DHC. 

Materials and methods

A total of 60 patients who underwent DHC were retrospectively analyzed. In 30 patients the “Dandy flap” incision (group A) and in 30 patients the RMF incision (group B) was made. Since no evidence-based data for the incision type that favors better wound healing exists, the form of incision was left at the surgeon´s discretion. Documentation of the patients was screened for the incidence of WHD: wound necrosis, dehiscence, and cerebrospinal fluid (CSF) leakage. Patient age, the time interval from surgery until the appearance of WHD, the length of surgeries in minutes, and the indications of the DHC were analyzed. A Chi-square test of independence was performed to examine the relationship between the incision type and the appearance of WHD with the statistical significance level set at p<0.05. The mean age of the patients, the mean time interval from surgery until the occurrence of WHD, and the mean length of the surgery between the two groups were compared using an independent sample t-test with the statistical significance level set at p<0.05.

Results

The most common indication for DHC in both groups was malignant MCA infarction (n=20, 66.6% for group A and n=16, 53.3% for group B). CSF leakage was 20% of the most frequent WHD in each group. Wound necrosis was observed only in group A. Although group B showed 13.3% fewer WHD than group A, this difference was not statistically significant. There was no statistically significant difference in the time range between surgery and the occurrence of WHD between the two groups. The length of surgery in group B was significantly shorter than in group A (120.2 mins vs. 103.7 mins).

Conclusion

A noticeable trend for reduced WHD was observed in the patient group using the RMF incision type although the difference was not statistically significant. We praise that the RMF incision allows an optimized skin-flap vascularization and, thereby, facilitates better wound healing. We were able to show a statistically shorter length of surgery with the RMF incision in contrast to the classic “Dandy flap” incision. Larger multicenter studies should be implemented to analyze and address the major advantages and pitfalls of the routinely applied incision techniques.