A Faster and Wider Skin Incision Technique for Decompressive Craniectomy: n-Shaped Incision for Decompressive Craniectomy

Yang, Hyun Seok; Hyun, Dong-Keun; Oh, Chang Hyun; Shim, Yu Shik; Park, Hyeonseon; Kim, Eun Young

doi:10.13004/kjnt.2016.12.2.72

Cited by 20 publications

(8 citation statements)

References 10 publications

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“…This "n-type" incision is mostly used in patients with SAH previously treated by operative clipping. 28 The incision starts perpendicular to and at the middle of the previous frontotemporal incision and runs posteriorly to reach the inion, after which it curves laterally in the direction of the mastoid base. The "T-type" or "Kempe" incision was abandoned before 2010 due to frequent wound healing problems at the intersection of both linear incisions.…”

Section: Incision Typesmentioning

confidence: 99%

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

Veldeman

Daleiden

Hamou

et al. 2021

Journal of Neurosurgery

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OBJECTIVEPerforming 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.METHODSA 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.RESULTSOne 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).CONCLUSIONSThe 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.

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Section: Incision Typesmentioning

confidence: 99%

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

Veldeman

Daleiden

Hamou

et al. 2021

Journal of Neurosurgery

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“…Meticulously preserving the superficial temporal artery and limiting the posterior extent of the flap to no more than 5 cm behind the ear could reduce chance of ischemic flap breakdown. A retrospective comparison of patients operated using an n-shaped incision with those who were operated using the conventional question mark flap showed that the former technique could accomplish greater bony decompression, allows more brain protrusion and is faster to perform ( 28 ). We have noticed that making a retroauricular incision could also reduce flap necrosis.…”

Section: Early Complicationsmentioning

confidence: 99%

Complications of Decompressive Craniectomy

et al. 2018

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Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.

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“…However, combined orbital and temporal fractures in the setting of multiple ICH called for a large, single question-mark style incision to expose the extent of both fractures and permit exposure and evacuation of ICH. Yang et al recently discussed how a smaller, "n-shape" incision may permit at least equal utility for decompressive craniectomy [14]. Potential benefits of novel approaches for reconstructive craniotomy of the temporal-orbital area, especially in the setting of complex fractures, require future investigation.…”

Section: Discussionmentioning

confidence: 99%

Reconstruction of Complex Cranial and Orbit Fractures with Associated Hemorrhages: Case Report and Review of the Literature

Caras

Alexander

Young

et al. 2020

Cureus

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We present our experience following a unique case of coincident intracranial hemorrhage and comminuted fractures of both the squamous temporal bone and zygomaticofrontal orbit. Surgical techniques and outcome for this presentation have yet to be sufficiently described. A 55-year-old male presented following trauma with Glasgow Coma Scale score of 7. Radiographic evaluation revealed comminuted fractures of the squamous temporal bone with extension into the lateral orbit, along with zygomatic process fracture extending 2.5 cm medially into the orbital roof. Zygomaticofrontal orbital roof fragments reached superiorly into the middle cranial fossa and inferiorly into the orbit. Surgical intervention was deemed necessary to address underlying epidural hematoma, subarachnoid hemorrhage, correction of cranial bone defects, and decompression of the optic nerve and other intraorbital nerves. A frontotemporal approach was employed. Repair of temporal and orbital fractures was accomplished using a combination of wire mesh screws and titanium miniplates. Postoperative imaging demonstrated bony approximation and successful evacuation of traumatic hemorrhage. The patient remains functionally and neurologically intact apart from a sluggishly responsive left eye presumed to result from a left optic nerve or ciliary ganglion lesion. Although rapid reconstruction of complex cranial-orbital trauma and hematoma evacuation can permit acceptable gross functional neurological outcome following massive trauma, orbital fracture and subsequent hemorrhagic processes may be the nidus of neurological sequelae in this complex traumatic constellation. Thus, alterations in surgical approach and reconstruction are appropriate in order to maximize neurological function while supporting restoration of cosmetic space.

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A Faster and Wider Skin Incision Technique for Decompressive Craniectomy: n-Shaped Incision for Decompressive Craniectomy

Cited by 20 publications

References 10 publications

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

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

Complications of Decompressive Craniectomy

Reconstruction of Complex Cranial and Orbit Fractures with Associated Hemorrhages: Case Report and Review of the Literature

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