Necessity of dural tenting sutures in modern neurosurgery: protocol for a systematic review

Creating high-resolution 3D cranial implant geometry using deep learning techniques

Creating a personalized implant for cranioplasty can be costly and aesthetically challenging, particularly for comminuted fractures that affect a wide area. Despite significant advances in deep learning techniques for 2D image completion, generating a 3D shape inpainting remains challenging due to the higher dimensionality and computational demands for 3D skull models. Here, we present a practical deep-learning approach to generate implant geometry from defective 3D skull models created from CT scans. Our proposed 3D reconstruction system comprises two neural networks that produce high-quality implant models suitable for clinical use while reducing training time. The first network repairs low-resolution defective models, while the second network enhances the volumetric resolution of the repaired model. We have tested our method in simulations and real-life surgical practices, producing implants that fit naturally and precisely match defect boundaries, particularly for skull defects above the Frankfort horizontal plane.

Remote bifrontal epidural hematoma following hemispheric glioma resection. A rare life-threatening postoperative complication

Background:

Postoperative acute epidural hematoma (EDH) is a well-known serious complication that usually occurs at the operated site after cranial surgery. However, epidural bleeding, distant from the site of the previous craniotomy, is relatively rare and may sometimes cause significant neurological morbidity or even mortality. We report such a case.

Case Description:

A 35-year-old woman, previously healthy, was operated on for a left temporo-parieto-fronto-insular anaplastic astrocytoma. Between 2 and 4 h after the surgery, the patient had trouble waking-up following the general anesthesia. Emergent computed tomography (CT) scan revealed an acute bifrontal EDH away from the initial surgical field. The patient underwent an immediate reoperation, a decompressive bifrontal craniotomy, and the evacuation of the hematoma. Despite the neurologic improvement, she died 24 days after the surgery due to severe sepsis caused by pulmonary infection with pseudomonas aeruginosa.

Conclusion:

The pathophysiology of postoperative remote EDH is poorly understood, although various hypotheses have been suggested including the loss of tamponade effect, the vasomotor mechanisms, and the coagulopathy. As seen in the present case report, we suspected that the intensive use of perioperative mannitol may also promote this complication. In the early postoperative period, every patient with neurological deterioration should have a rapid cranial CT-scan because early detection and removal of postoperative acute EDH can be life-saving.

Is Placing Prophylactic Dural Tenting Sutures a Dogma?

OBJECTIVE

In this study, we investigated if and when dural tenting sutures are necessary during craniotomy.

METHODS

Results from 437 patients 18-91 years of age (average, 43.5 years) who underwent supratentorial craniotomy between 2014 and 2019 were evaluated. The patients were categorized into 1 of 3 groups: patients who had at least 3 prophylactic dural tenting sutures placed before opening of the dura (group 1); patients who had at least 3 dural tenting sutures placed after surgery was completed, during closure (group 2); or patients who had no dural tenting sutures (group 3 [control]). All such sutures in groups 1 and 2 were placed in the circumference of the craniotomy and dural junction. No central dural tenting sutures were placed in any of the patients.

RESULTS

Among the 437 patients, 344 underwent surgery for the first time and 93 were undergoing a second surgery. Cranial computed tomography imaging was performed for each patient 1 hour, 3 days, and 1 month after surgery. In group 1, 3 patients had a cerebral cortex contusion and 2 patients had acute subdural hematoma after the sutures were placed. In groups 2 and 3, none of the patients had a cerebral cortex contusion or acute subdural hematoma. Fewer complications were observed when dural tenting sutures were placed during postsurgical closure.

CONCLUSIONS

Placing dural tenting sutures is an important technique for ensuring hemostasis. However, when not needed, they seem to cause inadvertent complications. As our results suggest, knowing when and where to use them is equally important.

Prophylactic use of dural tenting sutures in elective craniotomies in adults-is it necessary? A study protocol for a multicentre, investigator- and participant-blinded randomised, parallel-group, non-inferiority trial

Background

In the early days of neurosurgery, extradural haemorrhages (EDHs) contributed to a high mortality rate after craniotomies. Almost a century ago, Walter Dandy reported dural tenting sutures as an effective way to prevent postoperative EDH. Over time, his technique gained in popularity and significance to finally become a neurosurgical standard. Yet, several retrospective reports and one prospective report have questioned the ongoing need for dural tenting sutures. Dandy’s explanation that the haemostasis observed under hypotensive conditions is deceiving and eventually causes EDH may be obsolete. Today, proper intra- and postoperative care, including maintenance of normovolemia and normotension and the use of modern haemostatic agents, may be sufficient for effective haemostasis. Thus, there is a fundamental need to evaluate the necessity of dural tenting sutures in a solid, unbiased, evidence-based manner.

Methods

This study is designed as a randomised, multicentre, double-blinded, controlled interventional trial with 1:1 allocation. About one half of the participants will undergo craniotomy without dural tenting sutures and will be considered an intervention group. The other half will undergo craniotomy with these sutures. Both groups will be followed clinically and radiologically. The primary outcome is reoperation due to extradural haematoma. Secondary outcomes aim to evaluate the impact of dural tenting sutures on mortality, readmission risk, postoperative headaches, size of extradural collection, cerebrospinal fluid leak risk and the presence of any new neurological deficit. The study protocol follows the SPIRIT 2013 statement.

Discussion

It is possible that many neurosurgeons around the globe are tenting the dura in elective craniotomies which brings no benefit and only extends the operation. Unfortunately, there is not enough data to support or reject this technique in modern neurosurgery. This is the first study that may produce strong, evidence-based recommendations on using dural tenting sutures.

Trial registration, ethics and dissemination

The Bioethics Committee of the Medical University of Warsaw approved the study protocol (KB/106/2018). The trial is registered at http://www.clinicaltrials.gov (NCT03658941) on September 6, 2018. The findings of this trial will be submitted to a peer-reviewed neurosurgical journal. Abstracts will be submitted to relevant national and international conferences.

Trial status

Protocol version and date: version 1.5, 14.01.2020

First recruitment: September 7, 2018

Estimated recruitment completion: September 1, 2021

Perioperative Practice Patterns of Craniotomies-Results of a National Neurosurgical Survey in Poland

BACKGROUND

Perioperative craniotomy practices depend mainly on neurosurgeon preferences. To investigate the variations in these preferences, we surveyed neurosurgeons in Poland regarding different aspects of their practices.

METHODS

Anonymous questionnaires were circulated in 2019 at the neurosurgery conferences in Poland. We then analyzed the responses, categorized in subgroups by sex, affiliation, and stage of training.

RESULTS

A total of 114 responses to the questionnaire were obtained. For surgical site exposure, regional hair shaving was the most common pattern (64.9%), followed by whole-scalp (19.3%) and strip line shaving (12.3%). Most respondents (65.8%) used clamp-based devices for bone flap fixation, and approximately one third (30.7%) reported using bone suturing. During cranioplasty, respondents most often used artificial bone implants (69.3%), followed by a preserved bone flap from the patient (24.5%). More than three quarters reported that they (77.2%) performed routine radiologic evaluation after uncomplicated brain tumor surgery. Most patients (64.0%) were discharged between the third and sixth postoperative days. Almost half of emergent surgeries (48.2%) and most elective surgeries (89.5%) were performed with the help of an assistant surgeon. No significant differences were found in practice between the sexes or by affiliation or training stage. We inferred an influence of regional economic status on some of the reported choices.

CONCLUSIONS

Perioperative craniotomy practices among Polish neurosurgeons show a significant heterogeneity. Economic factors can explain some choices, but others trace to a conservative mindset. Further studies are needed to identify which factors are most relevant and to identify approaches to a standardized method of care.