The reverse question mark and L.G. Kempe incisions for decompressive craniectomy: A case series and narrative review of the literature

Background:

Decompressive craniectomy (DC) is a lifesaving procedure, relieving intracranial hypertension. Conventionally, DCs are performed by a reverse question mark (RQM) incision. However, the use of the L. G. Kempe’s (LGK) incision has increased in the last decade. We aim to describe the surgical nuances of the LGK and the standard RQM incisions to treat patients with severe traumatic brain injury (TBI), intracranial hemorrhage (ICH), empyema, and malignant ischemic stroke. Furthermore, to describe, surgical limitations, wound healing, and neurological outcomes related to each technique.

Methods:

To describe a prospective acquired, case series including patients who underwent a DC using either an RQM or an LGK incision in our institution between 2019 and 2020.

Results:

A total of 27 patients underwent DC. Of those, ten patients were enrolled. The mean age was 42.1 years (26–71), and 60% were male. Five patients underwent DC using a large RQM incision; three had severe TBI, one ICH, and one ischemic stroke. The other five patients underwent DC using an LGK incision (one ICH, one subdural empyema, and one ischemic stroke). About 50% of patients presented severe headaches associated with vomiting, and six presented altered mental status (drowsy or stuporous). Motor deficits were present in four cases. In patients with ischemic or hemorrhagic stroke, symptoms were directly related to the stroke location. Hospital stays varied between 13 and 22 days. No readmissions were recorded, and no fatal outcome was documented during the follow-up.

Conclusion:

The utility of the LGK incision is comparable with the classic RQM incision to treat acute brain injuries, where an urgent decompression must be performed. Some of these cases include malignant ischemic strokes, ICH, and empyema. No differences were observed between both techniques in terms of prevention of scalp necrosis and general cosmetic outcomes.

Evaluating the retro-auricular incision versus reversed question mark incision and Kempe's 'T-bar' incision for decompressive hemicraniectomy

Background

The proper decompression for hemicraniectomy depends on intraoperative surgical technique, so the skin incision, on the other hand, is an important variable throughout hemicraniectomy, and there are a variety of cutaneous incisions, including the Kempe T shaped, the reversed question mark and the retro-auricular incisions. We aim to compare those three types of incisions and assess their effects on the surgical outcomes regarding the skull defect size, survived beyond 1 week, post-operative complications and mortality rates.

Results

A retrospective study included 180 patients were separated into three age- and sex-matched groups according to the type of incision used for their hemicraniectomy. Data including age, sex, causes of surgery, comorbidities, the incision type, the defect area of the skull, intraoperative time and estimated blood loss were recruited for all patients. The mortality and morbidity rates at 3 months post-surgery were documented for all patients. There was a significant difference in the operative time, and the intraoperative measures of blood loss, and insignificant differences in the surviving rate after 1-week post-surgery among the three group patients. There were significant differences between the first and third patient groups compared to the second group regarding wound complications, while the first and third groups were comparable.

Conclusions

The retro-auricular incision is a safe preferable substitute for the reversed question mark and Kempe T-shaped incisions in decompressive hemicraniectomy, due to the better blood flow maintaining, lower rate of post-operative wound complications.