An altered posterior question-mark incision is associated with a reduced infection rate of cranioplasty after decompressive hemicraniectomy

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  • 1 Department of Neurosurgery, RWTH Aachen University Hospital, Aachen; and
  • 2 Department of Neurosurgery, Military Hospital Koblenz, Germany
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OBJECTIVE

Performing a cranioplasty (CP) after decompressive craniotomy is a straightforward neurosurgical procedure, but it remains associated with a high complication rate. Surgical site infection (SSI), aseptic bone resorption (aBR), and need for a secondary CP are the most common complications. This observational study aimed to identify modifiable risk factors to prevent CP failure.

METHODS

A retrospective analysis was performed of all patients who underwent CP following decompressive hemicraniectomy (DHC) between 2010 and 2018 at a single institution. Predictors of SSI, aBR, and need for allograft CP were evaluated in a univariate analysis and multivariate logistic regression model.

RESULTS

One hundred eighty-six patients treated with CP after DHC were included. The diagnoses leading to a DHC were as follows: stroke (83 patients, 44.6%), traumatic brain injury (55 patients, 29.6%), subarachnoid hemorrhage (33 patients, 17.7%), and intracerebral hemorrhage (15 patients, 8.1%). Post-CP SSI occurred in 25 patients (13.4%), whereas aBR occurred in 32 cases (17.2%). An altered posterior question-mark incision, ending behind the ear, was associated with a significantly lower infection rate and CP failure, compared to the classic question-mark incision (6.3% vs 18.4%; p = 0.021). The only significant predictor of aBR was patient age, in which those developing resorption were on average 16 years younger than those without aBR (p < 0.001).

CONCLUSIONS

The primary goal of this retrospective cohort analysis was to identify adjustable risk factors to prevent post-CP complications. In this analysis, a posterior question-mark incision proved beneficial regarding infection and CP failure. The authors believe that these findings are caused by the better vascularized skin flap due to preservation of the superficial temporal artery and partial preservation of the occipital artery. In this trial, the posterior question-mark incision was identified as an easily and costless adaptable technique to reduce CP failure rates.

ABBREVIATIONS aBR = aseptic bone resorption; CP = cranioplasty; CRP = C-reactive protein; DHC = decompressive hemicraniectomy; DM = diabetes mellitus; EVD = external ventricular drain; GOS-E = Glasgow Outcome Scale–Extended; ICH = intracerebral hemorrhage; ICU = intensive care unit; MMI = malignant middle cerebral artery infarction; PMMA = polymethylmethacrylate; SAH = subarachnoid hemorrhage; SSI = surgical site infection; STA = superficial temporal artery; TBI = traumatic brain injury; WBC = white blood cell.

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Contributor Notes

Correspondence Michael Veldeman: RWTH Aachen University Hospital, Aachen, Germany. mveldeman@ukaachen.de.

INCLUDE WHEN CITING Published online April 24, 2020; DOI: 10.3171/2020.2.JNS193335.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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