Description Of Surgical Technique For Hemicraniectomy And Duraplasty

First performed as a treatment for acute subdural hematoma (14) , hemicraniectomy and durotomy entail a neurosurgical decompressive approach to hemispheric masses and swelling.

Gaze deviation, hemiplegia, and neglect (NIHSS >15 right hemisphere) Hemiplegia and global aphasia (NIHSS >20 left hemisphere) consistent with a total

  1. Early CT > 50% MCA territory hypodensity + ACA or PCA territory hypodensity
  2. Carotid *T" occlusion by MRA, CTA, or conventional angiography Consider the following algorithm with early repeat CT or MRI imaging.

Proposed Hem ¡craniectomy Management Algorithm

1. If high-risk group, repeat CT scan within 6-12 hr of initial evaluation.

If follow-up CT evidence of complete MCA or MCA+ACA/PCA infarction or DWI >145 mL,consider hemicraniectomy with durotomy/duroplasty.

2. If not, repeat CT scan again In 6-12 hr; if new anisocoria or any decreasing level If CT scan reveals midline shift (anteroseptal shift > 5 mm), consider

Figure 1 Algorithm for management of high-risk patients with large hemispheric infarctions.

Hemicraniectomy involves removal of bone on one side of the skull and simultaneously performing a generous dural opening. The minimal adequate decompression is defined by the following bony boundaries (Fig. 2):

  1. anterior, frontal to midpupillary line
  2. posterior, approximately 4 cm to the external auditory canal
  3. superior, to the superior sagittal sinus
  4. inferior, to the floor of the middle cranial fossa

Bone removed during a hemicraniectomy can be saved in the peritoneum or in a bone bank in antibiotic solution at - 80°C. Bone is replaced after the swelling has subsided in one to three months. Cruciate or circumferential durotomy must be performed over the entire region of bony decompression to insure that nothing resists the expanding brain from being able to herniate outward. Dural grafting is recommended. No brain amputation or ventriculostomy is required or necessary. This complete procedure achieves a new pathway of least resistance for the swelling brain ipsilateral to the lesion and causes less compression of the vital brain structures not otherwise involved in the primary disease process (such as the brain stem). The brain acts as a sphere rather than a cylinder when herniating through the decompression opening (Fig. 3). The size of the bone flap determines the magnitude of decompression achieved and significantly increases when the diameter exceeds 12 cm. Small bone flaps do not achieve the desired decompression needed.

Figure 2 Surgical sketch of the bony boundaries recommended in an ongoing prospective, randomized, controlled trial for hemicraniectomy in massive hemispheric stroke. Source: Courtesy of Douglas Chyette, MD, Cleveland Clinic Foundation, Cleveland, Ohio.
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