Tissue Healing in Hemicraniectomy

Abstract

Introduction Decompressive hemicraniectomy (DHC) is a last-resort treatment for refractory intracranial hypertension. Perioperative morbidity is associated with high risks of wound healing disturbances (WHD). Recently, a retromastoidal frontoparietooccipital (RMF) incision type was performed to avoid healing disturbance due to enhanced tissue flap perfusion compared to the classical reverse “question mark” (“Dandy flap”) incision. The goal of this study was to analyze the details of tissue healing problems in DHC. Materials and methods A total of 60 patients who underwent DHC were retrospectively analyzed. In 30 patients the “Dandy flap” incision (group A) and in 30 patients the RMF incision (group B) was made. Since no evidence-based data for the incision type that favors better wound healing exists, the form of incision was left at the surgeon´s discretion. Documentation of the patients was screened for the incidence of WHD: wound necrosis, dehiscence, and cerebrospinal fluid (CSF) leakage. Patient age, the time interval from surgery until the appearance of WHD, the length of surgeries in minutes, and the indications of the DHC were analyzed. A Chi-square test of independence was performed to examine the relationship between the incision type and the appearance of WHD with the statistical significance level set at p<0.05. The mean age of the patients, the mean time interval from surgery until the occurrence of WHD, and the mean length of the surgery between the two groups were compared using an independent sample t-test with the statistical significance level set at p<0.05. Results The most common indication for DHC in both groups was malignant MCA infarction (n=20, 66.6% for group A and n=16, 53.3% for group B). CSF leakage was 20% of the most frequent WHD in each group. Wound necrosis was observed only in group A. Although group B showed 13.3% fewer WHD than group A, this difference was not statistically significant. There was no statistically significant difference in the time range between surgery and the occurrence of WHD between the two groups. The length of surgery in group B was significantly shorter than in group A (120.2 mins vs. 103.7 mins). Conclusion A noticeable trend for reduced WHD was observed in the patient group using the RMF incision type although the difference was not statistically significant. We praise that the RMF incision allows an optimized skin-flap vascularization and, thereby, facilitates better wound healing. We were able to show a statistically shorter length of surgery with the RMF incision in contrast to the classic “Dandy flap” incision. Larger multicenter studies should be implemented to analyze and address the major advantages and pitfalls of the routinely applied incision techniques.

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

“…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 ]. In summation, each of the studies comparing the RQM and RA reported positive benefits of the RA, and most reported decreased rates of postoperative wound infection (Fig.…”

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

“…Finally, Nertengian's study reported the unique nding that the RA was associated with shorter operative times. 15 In summation, each of the studies comparing the RQM and RA reported positive bene ts of the RA, and most reported decreased rates of postoperative wound infection.…”

“…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.…”

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

“…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.…”