Decompressive craniectomy using gelatin film and future bone flap replacement

Technical note

Restricted access


Decompressive craniectomy plays an important role in the management of patients with traumatic brain injury (TBI) and stroke. Risks of decompressive craniectomy include those associated with cranioplasty, and may be related to adhesions that develop between the brain surface and overlying scalp and temporalis muscle. The authors report their institutional experience using a multilayered technique (collagen and gelatin film barriers) to facilitate safe and rapid cranioplasty following decompressive craniectomy.


The authors conducted a retrospective chart review of 62 consecutive adult and pediatric patients who underwent decompressive craniectomy and subsequent cranioplasty between December 2007 and January 2011. Diagnoses included TBI, ischemic stroke, intraparenchymal hemorrhage, or subarachnoid hemorrhage. A detailed review of clinical charts was performed, including anesthesia records and radiographic study results.


The majority of patients underwent unilateral hemicraniectomy (n = 56), with indications for surgery including midline shift (n = 37) or elevated intracranial pressure (n = 25). Multilayered decompressive craniectomy was safe and easy to perform, and was associated with a low complication rate, minimal operative time, and limited blood loss.


Decompressive craniectomy repair using an absorbable gelatin film barrier facilitates subsequent cranioplasty by preventing adhesions between intracranial contents and the overlying galea aponeurotica and temporalis muscle fascia. This technique makes cranioplasty dissection faster and potentially safer, which may improve clinical outcomes. The indications for gelatin film should be expanded to include placement in the epidural space after craniectomy.

Abbreviations used in this paper:ICP = intracranial pressure; IPH = intraparenchymal hemorrhage; MCA = middle cerebral artery; SAH = subarachnoid hemorrhage; TBI = traumatic brain injury; VP = ventriculoperitoneal.

Article Information

Address correspondence to: Kiarash Shahlaie, M.D., Ph.D., Department of Neurological Surgery, University of California Davis School of Medicine, 4860 Y Street, Suite 3740, Sacramento, California 95817. email:

Please include this information when citing this paper: published online February 8, 2013; DOI: 10.3171/2013.1.JNS121475.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Multilayered repair technique using gelatin film barrier (left) facilitates subsequent cranioplasty by preventing adhesions between the musculocutaneous scalp flap and underlying tissue layers (right).

  • View in gallery

    Representative axial (upper) and 3D reconstructed (lower) CT scans after decompressive craniectomy (left) and following subsequent cranioplasty with native bone flap replacement (right).



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


Bullock MRChesnut RGhajar JGordon DHartl RNewell DW: Surgical management of acute subdural hematomas. Neurosurgery 58:3 SupplS16S242006


Bulters DBelli A: Placement of silicone sheeting at decompressive craniectomy to prevent adhesions at cranioplasty. Br J Neurosurg 24:75762010


Chang VHartzfeld PLanglois MMahmood ASeyfried D: Outcomes of cranial repair after craniectomy. Clinical article. J Neurosurg 112:112011242010


Chibbaro STacconi L: Role of decompressive craniectomy in the management of severe head injury with refractory cerebral edema and intractable intracranial pressure. Our experience with 48 cases. Surg Neurol 68:6326382007


Chun HJYi HJ: Efficacy and safety of early cranioplasty, at least within 1 month. J Craniofac Surg 22:2032072011


Cooper DJRosenfeld JVMurray LArabi YMDavies ARD'Urso P: Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364:149315022011


Danish SFSamdani AHanna AStorm PSutton L: Experience with acellular human dura and bovine collagen matrix for duraplasty after posterior fossa decompression for Chiari malformations. J Neurosurg 104:1 Suppl16202006


Gooch MRGin GEKenning TJGerman JW: Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases. Neurosurg Focus 26:6E92009


Guerra WKGaab MRDietz HMueller JUPiek JFritsch MJ: Surgical decompression for traumatic brain swelling: indications and results. J Neurosurg 90:1871961999


Guresir ESchuss PSeifert VVatter H: Decompressive craniectomy in children: single center series and systematic review. Neurosurgery 70:8818892012


Guresir EVatter HSchuss POszvald ARaabe ASeifert V: Rapid closure technique in decompressive craniectomy. Clinical article. J Neurosurg 114:9549602011


Hofmeijer JKappelle LJAlgra AAmelink GJvan Gijn Jvan der Worp HB: Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 8:3263332009


Honeybul SHo KM: Long-term complications of decompressive craniectomy for head injury. J Neurotrauma 28:9299352011


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


Huang APTu YKTsai YHChen YSHong WCYang CC: Decompressive craniectomy as the primary surgical intervention for hemorrhagic contusion. J Neurotrauma 25:134713542008


Huang XWen L: Technical considerations in decompressive craniectomy in the treatment of traumatic brain injury. Int J Med Sci 7:3853902010


Hutchinson PJCorteen ECzosnyka MMendelow ADMenon DKMitchell P: Decompressive craniectomy in traumatic brain injury: the randomized multicenter RESCUEicp study ( Acta Neurochir Suppl 96:17202006


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


Lee CHCho DSJin SCKim SHPark DB: Usefulness of silicone elastomer sheet as another option of adhesion preventive material during craniectomies. Clin Neurol Neurosurg 109:6676712007


Matsumura GShin'oka TIkada YSakamoto TKurosawa H: Novel anti-adhesive pericardial substitute for multistage cardiac surgery. Asian Cardiovasc Thorac Ann 16:3093122008


McCall TDFults DWSchmidt RH: Use of resorbable collagen dural substitutes in the presence of cranial and spinal infections—report of 3 cases. Surg Neurol 70:92972008


McGhee MADornhoffer JL: The effect of gelfilm in the prevention of fibrosis in the middle ear of the animal model. Am J Otol 20:7127161999


Missori PPolli FMPeschillo SD'Avella EPaolini SMiscusi M: Double dural patch in decompressive craniectomy to preserve the temporal muscle: technical note. Surg Neurol 70:4374392008


Miyake SFujita AAihara HKohmura E: New technique for decompressive duraplasty using expanded polytetrafluoroethylene dura substitute—technical note. Neurol Med Chir (Tokyo) 46:1041062006


Münch EHorn PSchürer LPiepgras APaul TSchmiedek P: Management of severe traumatic brain injury by decompressive craniectomy. Neurosurgery 47:3153232000


Nakagawa SHayashi TAnegawa SNakashima SShimokawa SFurukawa Y: Postoperative infection after duraplasty with expanded polytetrafluoroethylene sheet. Neurol Med Chir (Tokyo) 43:1201242003


Narotam PKJose SNathoo NTaylon CVora Y: Collagen matrix (DuraGen) in dural repair: analysis of a new modified technique. Spine (Phila Pa 1976) 29:286128692004


Nishizawa SRyu HYokoyama TKitamura SUemura K: Intentionally staged operation for large and high-flow cerebral arteriovenous malformation. J Clin Neurosci 5:Suppl78831998


Polin RSShaffrey MEBogaev CATisdale NGermanson TBocchicchio B: Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema. Neurosurgery 41:84941997


Quinn TMTaylor JJMagarik JAVought EKindy MSEllegala DB: Decompressive craniectomy: technical note. Acta Neurol Scand 123:2392442011


Ragel BTKlimo P JrMartin JETeff RJBakken HEArmonda RA: Wartime decompressive craniectomy: technique and lessons learned. Neurosurg Focus 28:5E22010


Sade BOya SLee JH: Non-watertight dural reconstruction in meningioma surgery: results in 439 consecutive patients and a review of the literature. Clinical article. J Neurosurg 114:7147182011


Skoglund TSEriksson-Ritzén CJensen CRydenhag B: Aspects on decompressive craniectomy in patients with traumatic head injuries. J Neurotrauma 23:150215092006


Stephens FLMossop CMBell RSTigno T JrRosner MKKumar A: Cranioplasty complications following wartime decompressive craniectomy. Neurosurg Focus 28:5E32010


Stiver SI: Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus 26:6E72009


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


Vakis AKoutentakis DKarabetsos DKalostos G: Use of polytetrafluoroethylene dural substitute as adhesion preventive material during craniectomies. Clin Neurol Neurosurg 108:7988022006


Wirtz CRSteiner TAschoff ASchwab SSchnippering HSteiner HH: Hemicraniectomy with dural augmentation in medically uncontrollable hemispheric infarction. Neurosurg Focus 2:5E31997


Yamagata SGoto KOda YKikuchi H: Clinical experience with expanded polytetrafluoroethylene sheet used as an artificial dura mater. Neurol Med Chir (Tokyo) 33:5825851993


Yang XJHong GLSu SBYang SY: Complications induced by decompressive craniectomies after traumatic brain injury. Chin J Traumatol 6:991032003




All Time Past Year Past 30 Days
Abstract Views 106 106 36
Full Text Views 381 381 41
PDF Downloads 209 209 15
EPUB Downloads 0 0 0


Google Scholar