Exploration of the Most Effective Dural Incision Design in A Decompressive Craniectomy

• Published in: World neurosurgery 2017-04, Vol.100, p.224-229
• Main Authors: Nagai, Mutsumi, M.D., Ph.D, Ishikawa, Mami, M.D., Ph.D
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Brain Edema - diagnostic imaging; Brain Edema - etiology; Brain Edema - surgery; Cerebral Infarction - complications; Cerebral Infarction - diagnostic imaging; Cerebral Infarction - surgery; Decompressive craniectomy; Decompressive Craniectomy - methods; Design; Dura Mater - diagnostic imaging; Dura Mater - pathology; Dura Mater - surgery; Dural incision; Female; Geometric analysis; Humans; Male; Middle Aged; Minimally Invasive Surgical Procedures - methods; Neurosurgery; Operative Time; Treatment Outcome
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2016.12.134

Abstract Objective During a decompressive craniectomy performed for a severe cerebral infarction, sufficient coverage of the underlying bulging brain by converting the flat dura mater to a more dome-like shape is essential. In this procedure, suturing to patch dural substitutes on the dural rifts occupies most of the operative time and is cumbersome. We present a new dural incision design that provides an appropriate volume of subdural space with minimal incisions. Methods The ideal incision design was geometrically analyzed and verified by simulations using a physics engine. Results Assuming a quadrilateral area on the dura mater surface termed S , expanding the entire area of S requires 2d (where d is the skull thickness) + a 30-mm extension of the shortest set of line segments connecting each vertex (LSCV) of S to cover the necessary volume of bulging brain. The shortest LSCV comprises 5 line segments connected with two 3-pronged intersections. The ideal incision design consists of a pair of curved line segments that maintain plane continuity along the LSCV, which automatically limits the maximum expansion. Finally, the ideal incision design of S consists of 5 uncinate line segments. Four of the line segments originate from each vertex of S and end by crossing over the LSCV, and one of the line segments crosses over two separate LSCV. A representative case is shown. Conclusion This technique minimizes the complexity of the operation and shortens the operation time.