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

Abstract

Introduction:Decompressive hemicraniectomy (DHC) is a critical procedure used to alleviate elevated intracranial pressure (ICP) in emergent situations. It is typically performed to create space for the swollen brain and to prevent dangerous and potentially fatal increases in ICP. DHC is indicated for pathologies ranging from MCA stroke to traumatic subarachnoid hemorrhageessentially any cause of refractory brain swelling and elevated ICPs. Scalp incisions for opening and closing the soft tissues during DHC are crucial to achieve optimal outcomes by promoting proper wound healing and minimizing surgical site infections (SSIs). Though the reverse question mark (RQM) scalp incision has gained signi cant traction within neurosurgical practice, alternatives -including the retroauricular (RA) and Kempe incisions -have been proposed. As choice of technique can impact postoperative outcomes and complications, we sought to compare outcomes associated with different scalp incision techniques used during DHC. MethodsWe queried three databases according to PRISMA guidelines in order to identify studies comparing outcomes between the RQM versus "alternative" scalp incision techniques for DHC. Our primary outcome of interest in the present study was postoperative wound infection rates according to scalp incision type. Secondary outcomes included estimated blood loss (EBL) and operative duration. ResultsWe identi ed seven studies eligible for inclusion in formal meta-analysis. The traditional RQM technique shortened operative times by 36.56 minutes, on average. Additionally, mean EBL was signi cantly lower when the RQM scalp incision was used. Postoperatively, there was no signi cant association between DHC incision type and mean intensive care unit (ICU) length of stay (LOS), nor was there a signi cant difference in predisposition to developing wound complications or infections between the RQM and Retroauricular/Kempe incision cohorts. Super cial temporal artery (STA) preservation and reoperation rates were collected but could not be analyzed due to insu cient number of studies reporting these outcomes. ConclusionOur meta-analysis suggests that there may not be a signi cant difference between scalp incision techniques as they relate to surgical site infection and wound complications. At present, it appears that outcomes following DHC can be improved by ensuring that the bone ap is large enough to enable su cient cerebral expansion and decompression of the temporal fossa, the latter of which is of particular importance. Although previous studies have suggested that there are several advantages to performing alternative scalp incision techniques during DHC, the present study (which is to our knowledge the rst to meta-analyze the literature on outcomes in DHC by scalp incision type) does not support these ndings. As such, further investigation in the form of prospective trials with high statistical power are merited.