Craniectomy size and decompression of the temporal base using the altered posterior question-mark incision for decompressive hemicraniectomy

Abstract

The altered posterior question-mark incision for decompressive hemicraniectomy (DHC) was proposed to reduce the risk of intraoperative injury of the superficial temporal artery (STA) and demonstrated a reduced rate of wound-healing disorders after cranioplasty. However, decompression size during DHC is essential and it remains unclear if the new incision type allows for an equally effective decompression. Therefore, this study evaluated the efficacy of the altered posterior question-mark incision for craniectomy size and decompression of the temporal base and assessed intraoperative complications compared to a modified standard reversed question-mark incision. The authors retrospectively identified 69 patients who underwent DHC from 2019 to 2022. Decompression and preservation of the STA was assessed on postoperative CT scans and CT or MR angiography. Forty-two patients underwent DHC with the standard reversed and 27 patients with the altered posterior question-mark incision. The distance of the margin of the craniectomy to the temporal base was 6.9 mm in the modified standard reversed and 7.2 mm in the altered posterior question-mark group (p = 0.77). There was no difference between the craniectomy sizes of 158.8 mm and 158.2 mm, respectively (p = 0.45), and there was no difference in the rate of accidental opening of the mastoid air cells. In both groups, no transverse/sigmoid sinus was injured. Twenty-four out of 42 patients in the modified standard and 22/27 patients in the altered posterior question-mark group had a postoperative angiography, and the STA was preserved in all cases in both groups. Twelve (29%) and 5 (19%) patients underwent revision due to wound-healing disorders after DHC, respectively (p = 0.34). There was no difference in duration of surgery. Thus, the altered posterior question-mark incision demonstrated technically equivalent and allows for an equally effective craniectomy size and decompression of the temporal base without increasing risks of intraoperative complications. Previously described reduction in wound-healing complications and cranioplasty failures needs to be confirmed in prospective studies to demonstrate the superiority of the altered posterior question-mark incision.

Scalp incision technique for decompressive hemicraniectomy: comparative systematic review and meta-analysis of the reverse question mark versus alternative retroauricular and Kempe incision techniques

“…Both Dowlati [ 12 ] and Veldeman [ 10 ] offered similar conclusions in their respective studies, while Dowlati also added that the RA can enable increased calvarial exposure as compared to the classic RQM. As noted by Fruh and colleagues, [ 13 ] this effect can secondarily enable performance of an anatomically appropriate DHC that allows for maximal decompression of the temporal base. Finally, Nertengian’s study reported the unique finding that the RA was associated with shorter operative times [ 15 ].…”

“…Moreover, it enables comparable temporal lobe decompression as demonstrated by lack of signs of herniation on postoperative CT scans in prior studies. [ 13 ]…”

Scalp Incision Technique for Decompressive Hemicraniectomy: Comparing the Reverse Question Mark to the Alternative Retroauricular and Kempe Incision Techniques

“…16 Both Dowlati 12 and Veldeman 10 offered similar conclusions in their respective studies, while Dowlati also added that the RA can enable increased calvarial exposure as compared to the classic RQM. As noted by Fruh and colleagues, 13 this effect can secondarily enable performance of an anatomically appropriate DHC that allows for maximal decompression of the temporal base. Finally, Nertengian's study reported the unique nding that the RA was associated with shorter operative times.…”

“…Following title and abstract screen as well as nal application of inclusion/exclusion criteria during full-text review, seven studies remained eligible for nal inclusion (Figure 1). Overall, there were six studies 10,[12][13][14][15][16][17] comprising Level III and one study that was Level IV evidence. On NOS risk of bias assessment, scores ranged from 3 to 8.…”