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Preservation of the STA and accidental opening of the mastoid air cells. Representative postoperative CT angiography confirming preservation of the STA on (A) coronal, (B) axial and (C) sagittal plane. (D) shows breach of the bony air cells of the squamous segment of the temporal bone anterior to the mastoid. Arrows indicate the STA and * marks the external auditory canal. The arrowhead marks the opening of the bony air cells.
Source publication
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 in...
Citations
... Following title and abstract screen as well as final application of inclusion/exclusion criteria during full-text review, seven studies remained eligible for final inclusion (Fig. 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. Thus, the majority (n = 4) of studies were rated as moderate risk for bias, while two studies were ranked as having a low risk for bias and one was determined to have a high risk for bias (Table 1). ...
... 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] In addition to providing comparable decompression, the retroauricular incision was found to reduce rates of postoperative infection and cranioplasty failure [10]. These findings can be attributed to the skin flap preserving properties of the retroauricular incision, which does not interfere with the perfusion supplied by the STA (and also partially preserves the occipital artery, another contributor to perfusion of the vascularized skin flap). ...
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 swelling brain and to prevent dangerous and potentially fatal increases in ICP. DHC is indicated for pathologies ranging from MCA stroke to traumatic subarachnoid hemorrhage—essentially 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 significant 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. We 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. We identified seven studies eligible for inclusion in the formal meta-analysis. The traditional RQM technique shortened operative times by 36.56 min, on average. Additionally, mean EBL was significantly lower when the RQM scalp incision was used. Postoperatively, there was no significant association between DHC incision type and mean intensive care unit (ICU) length of stay (LOS), nor was there a significant difference in predisposition to developing wound complications or infections between the RQM and retroauricular/Kempe incision cohorts. Superficial temporal artery (STA) preservation and reoperation rates were collected but could not be analyzed due to insufficient number of studies reporting these outcomes. Our meta-analysis suggests that there is no significant 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 flap is large enough to enable sufficient cerebral expansion and decompression of the temporal lobe, 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 first to meta-analyze the literature on outcomes in DHC by scalp incision type) does not support these findings. As such, further investigations in the form of prospective trials with high statistical power are merited.
... 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. Thus, the majority (n=4) of studies were rated as moderate risk for bias, while two studies were ranked as having a low risk for bias and one was determined to have a high risk for bias (Table 1). ...
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 hemorrhage – essentially 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 significant 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.
Methods
We 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.
Results
We identified 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 significantly lower when the RQM scalp incision was used. Postoperatively, there was no significant association between DHC incision type and mean intensive care unit (ICU) length of stay (LOS), nor was there a significant difference in predisposition to developing wound complications or infections between the RQM and Retroauricular/Kempe incision cohorts. Superficial temporal artery (STA) preservation and reoperation rates were collected but could not be analyzed due to insufficient number of studies reporting these outcomes.
Conclusion
Our meta-analysis suggests that there may not be a significant 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 flap is large enough to enable sufficient 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 first to meta-analyze the literature on outcomes in DHC by scalp incision type) does not support these findings. As such, further investigation in the form of prospective trials with high statistical power are merited.
