Decompressive craniotomy is a commonly performed surgery to relieve raised intracranial pressure. At the end of the procedure, it is the convention to cover the exposed brain by performing a lax duraplasty which allows for both brain expansion and provides protection to the underlying parenchyma. Various commercially available dural substitutes are used for this purpose. These have the drawback of being both expensive and nonvascularized. We propose a technique of using pericranium along with everted temporalis fascia (both being locally harvested vascularized pedicle flaps) that can suffice in a vast majority of cases for covering the brain.

Background Cranioplasty following decompressive craniotomy is considered to be a “routine procedure” but several large series have documented a significant amount of both delayed and immediate complications and also a mortality rate of up to 3.6%. Materials and Methods We went through some of the salient complications (excluding seizures) needing resurgery following interval cranioplasty over the past 18 years at our institution in over 300 cases and analyzed the literature that mention these complications and their treatment. Results In addition to the commonly mentioned complications, we found some that had been rarely described or not mentioned hitherto in the literature which we have presented as a pictorial narrative. Based on our experience, we recommend some measures that may decrease the incidence or prevent the occurrence of the same. Conclusions Attention to small but basic surgical techniques will go a long way in preventing unwanted postoperative events.

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The spinal subdural space is an avascular, potential space and is a rare location for intraspinal hematomas. Compared to spinal epidural hematomas, spinal subdural hematomas are uncommonly described complications of lumbar puncture for spinal or epidural anesthesia, particularly in patients who have no pre-existing bleeding disorders or history of antiplatelet or anticoagulant intake. We describe a 19-year-old girl who had a large thoracolumbar spinal subdural hematoma following epidural anesthesia for elective cholecystectomy with no pre-existing bleeding diathesis that caused rapidly developing paraplegia that evolved over the next 2 days following surgery. Nine days after the initial surgery she underwent multilevel laminectomy and surgical evacuation with eventual satisfactory recovery. Even epidural anesthesia without thecal sac violation can result in bleeding in the spinal subdural space. The possible sources of bleed in this space may be from injury to an interdural vein or extravasation of subarachnoid bleed into the subdural space. When neurological deficits occur, prompt imaging is mandatory and early evacuation yields gratifying results.

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