Rapid closure technique in decompressive craniectomy

Clinical article

Restricted access

Object

The object of this study was to describe the rapid closure technique in decompressive craniectomy without duraplasty and its use in a large cohort of consecutive patients.

Methods

Between 1999 and 2008, supratentorial rapid closure decompressive craniectomy (RCDC) was performed 341 times in 318 patients at the authors' institution. Cases were stratified as 1) traumatic brain injury, 2) subarachnoid hemorrhage, 3) intracerebral hemorrhage, 4) cerebral infarction, and 5) other. A large bone flap was removed and the dura mater was opened in a stellate fashion. Duraplasty was not performed—that is, the dura was not sutured, and a dural substitute was neither sutured in nor layed on. The dura and exposed brain tissue were covered with hemostyptic material (Surgicel). Surgical time and complications of this procedure including follow-up (> 6 months) were recorded. After 3–6 months cranioplasty was performed, and, again, surgical time and any complications were recorded.

Results

Rapid closure decompressive craniectomy was feasible in all cases. Complications included superficial wound healing disturbance (3.5% of procedures), abscess (2.6%) and CSF fistula (0.6%); the mean surgical time (± SD) was 69 ± 20 minutes. Cranioplasty was performed in 196 cases; the mean interval (± SD) from craniectomy to cranioplasty was 118 ± 40 days. Complications of cranioplasty included epidural hematoma (4.1%), abscess (2.6%), wound healing disturbance (6.1%), and CSF fistula (1%).

Compared with the results reported in the literature for decompressive craniectomy with duraplasty followed by cranioplasty, there were no significant differences in the frequency of complications. However, surgical time for RCDC was significantly shorter (69 ± 20 vs 129 ± 43 minutes, p < 0.0001).

Conclusions

The present analysis of the largest series reported to date reveals that the rapid closure technique is feasible and safe in decompressive craniectomy. The surgical time is significantly shorter without increased complication rates or additional complications. Cranioplasty after a RCDC procedure was also feasible, fast, safe and not impaired by the RCDC technique.

Abbreviations used in this paper: DC = decompressive craniectomy; EDH = epidural hematoma; ICH = intracerebral hemorrhage; ICP = intracranial pressure; MCA = middle cerebral artery; OR = odds ratio; RCDC = rapid closure decompressive craniectomy; SAH = subarachnoid hemorrhage; SDH = subdural hematoma; TBI = traumatic brain injury; VP = ventriculoperitoneal.
Article Information

Contributor Notes

Address correspondence to: Erdem Güresir, M.D., Department of Neurosurgery, Johann Wolfgang Goethe University, Frankfurt am Main, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany. email: Gueresir@em.uni-frankfurt.de.Please include this information when citing this paper: published online January 29, 2010; DOI: 10.3171/2009.12.JNS091065.
Headings
References
  • 1

    Aarabi BHesdorffer DCAhn ESAresco CScalea TMEisenberg HM: Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 104:4694792006

    • Search Google Scholar
    • Export Citation
  • 2

    Albanèse JLeone MAlliez JRKaya JMAntonini FAlliez B: Decompressive craniectomy for severe traumatic brain injury: evaluation of the effects at one year. Crit Care Med 31:253525382003

    • Search Google Scholar
    • Export Citation
  • 3

    Barth MTuettenberg JThomé CWeiss CVajkoczy PSchmiedek P: Watertight dural closure: is it necessary? A prospective randomized trial in patients with supratentorial craniotomies. Neurosurgery 63:4 Suppl 23523582008

    • Search Google Scholar
    • Export Citation
  • 4

    Beck JRaabe ALanfermann HBerkefeld JDe Rochemont RDMZanella F: Effects of balloon angioplasty on perfusion- and diffusion-weighted magnetic resonance imaging results and outcome in patients with cerebral vasospasm. J Neurosurg 105:2202272006

    • Search Google Scholar
    • Export Citation
  • 5

    Bullock MRChesnut RGhajar JGordon DHartl RNewell DW: Surgical management of acute subdural hematomas. Neurosurgery 58:3 SupplSiivS16S242006

    • Search Google Scholar
    • Export Citation
  • 6

    Güresir EBeck JVatter HSetzer MGerlach RSeifert V: Subarachnoid hemorrhage and intracerebral hematoma: incidence, prognostic factors, and outcome. Neurosurgery 63:108810942008

    • Search Google Scholar
    • Export Citation
  • 7

    Güresir ERaabe ASetzer MVatter HGerlach RSeifert V: Decompressive hemicraniectomy in subarachnoid haemorrhage: the influence of infarction, haemorrhage and brain swelling. J Neurol Neurosurg Psychiatry 80:7998012009

    • Search Google Scholar
    • Export Citation
  • 8

    Güresir ESchuss PVatter HRaabe ASeifert VBeck J: Decompressive craniectomy in subarachnoid hemorrhage. Neurosurg Focus 26:6E42009

    • Search Google Scholar
    • Export Citation
  • 9

    Horaczek JAZierski JGraewe A: Collagen matrix in decompressive hemicraniectomy. Neurosurgery 63:1 Suppl 1ONS176ONS1812008

  • 10

    Jaeger MSoehle MMeixensberger J: Effects of decompressive craniectomy on brain tissue oxygen in patients with intracranial hypertension. J Neurol Neurosurg Psychiatry 74:5135152003

    • Search Google Scholar
    • Export Citation
  • 11

    Jiang JYXu WLi WPXu WHZhang JBao YH: Efficacy of standard trauma craniectomy for refractory intracranial hypertension with severe traumatic brain injury: a multicenter, prospective, randomized controlled study. J Neurotrauma 22:6236282005

    • Search Google Scholar
    • Export Citation
  • 12

    Jüttler ESchwab SSchmiedek PUnterberg AHennerici MWoitzik J: Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke 38:251825252007

    • Search Google Scholar
    • Export Citation
  • 13

    Ko KSegan S: In situ hinge craniectomy. Neurosurgery 60:4 Suppl 22552592007

  • 14

    Korinek AM: Risk factors for neurosurgical site infections after craniotomy: a prospective multicenter study of 2944 patients. The French Study Group of Neurosurgical Infections, the SEHP, and the C-CLIN Paris-Nord. Neurosurgery 41:107310811997

    • Search Google Scholar
    • Export Citation
  • 15

    Malliti MPage PGury CChomette ENataf FRoux FX: Comparison of deep wound infection rates using a synthetic dural substitute (neuro-patch) or pericranium graft for dural closure: a clinical review of 1 year. Neurosurgery 54:5996042004

    • Search Google Scholar
    • Export Citation
  • 16

    Schwab SSteiner TAschoff ASchwarz SSteiner HHJansen O: Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 29:188818931998

    • Search Google Scholar
    • Export Citation
  • 17

    Vahedi KHofmeijer JJuettler EVicaut EGeorge BAlgra A: Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 6:2152222007

    • Search Google Scholar
    • Export Citation
  • 18

    Vahedi KVicaut EMateo JKurtz AOrabi MGuichard JP: Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 38:250625172007

    • Search Google Scholar
    • Export Citation
  • 19

    Yang XFWen LShen FLi GLou RLiu WG: Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir (Wien) 150:124112482008

    • Search Google Scholar
    • Export Citation
TrendMD
Cited By
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 884 833 85
Full Text Views 515 300 9
PDF Downloads 229 78 1
EPUB Downloads 0 0 0
PubMed
Google Scholar