Bipolar duraplasty: a new technique for reducing transcranial cerebral herniation to allow for definitive cranioplasty

Technical note

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Large, full-thickness calvarial defects cause increased brain tissue compliance, often resulting in transient, transcranial herniation in the setting of normotensive intracranial pressures. Cranioplasty serves to protect the cerebrum from external injury, provide an aesthetic contour, and alleviate neurological symptoms. Traditional options for management include head elevation, osmotic diuresis, mild hyperventilation, durotomy with closure following fluid evacuation, expansile cranioplasty, lobectomy, and procedure abortion with prolonged helmet therapy. Patients treated conservatively with helmet therapy commonly are noncompliant and sustain repeated minor trauma to unprotected cerebral contents. Furthermore, recent literature suggests that early cranioplasty may improve outcomes and reduce costs. The authors present a novel solution, bipolar duraplasty, which allows safe, transient reduction of normotensive parenchymal herniation using bipolar electrocautery. The dura of the herniated sac is cauterized using a low-set, bipolar current in a series of sagittal and coronal lines, resulting in immediate contraction and reduction allowing for definitive cranioplasty. This new method was used in a patient with a 30-cm2 frontal bone defect following resection of a right falcine atypical meningioma. In this scenario, bipolar duraplasty was performed free of complication, and the patient has remained asymptomatic and greatly satisfied for 1 year since the procedure. This technique might facilitate earlier cranioplasty, could be applied to a wide range of patients, and may afford better neurological outcomes at a reduced cost.

Article Information

Address correspondence to: Chad R. Gordon, D.O., Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, JHOC #8152F, Baltimore, Maryland 21287. email: cgordon@jhmi.edu.

Please include this information when citing this paper: published online August 19, 2011; DOI: 10.3171/2011.7.JNS11744.

© AANS, except where prohibited by US copyright law.

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Figures

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    Preoperative CT (left) and MR (right) images demonstrating the cranial defect with herniating cerebral contents in the setting of normal ventricular size, without signs of mass effect or hypertensive intracranial pressure.

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    Intraoperative lateral (A) and bird's eye (B) images of external brain herniation through a longstanding, bifrontal cranial defect, and corresponding photographs (C and D) showing immediate intraoperative reduction of external parenchymal brain herniation following bipolar duraplasty.

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    Titanium mesh (A and B) and methylmethacrylate onlay (C and D) cranioplasty of bifrontal cranial defect made possible following reduction of transcranial cerebral herniation with bipolar duraplasty.

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    Postoperative CT images showing reduction of herniated cerebral parenchyma and titanium mesh cranioplasty in the setting of normal ventricular size.

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    Frontal and lateral photographs obtained 1 year postoperatively, demonstrating correction of the acquired defect and aesthetically pleasing cranial contour.

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