J Korean Neurosurg Soc.  2025 May;68(3):360-368. 10.3340/jkns.2024.0176.

Efficacy of Anti-Adhesive Substitute and Step-by-Step Techniques in Decompressive Craniectomy and Subsequent Cranioplasty

• Kim YS
• Kim JW
• Joo SP
• Kim TS

• KMID: 2567467
• DOI: http://doi.org/10.3340/jkns.2024.0176

Abstract

Objective
: Dural substitutes have been widely used in decompressive craniectomy to prevent adhesion, and have significantly reduced blood loss and operation time. However, there are only limited studies providing information regarding detailed techniques and the specific operation time that is associated with good prognoses. In this study, we evaluate the effectiveness of using a dural substitute as an anti-adhesive material during cranioplasty, focusing on technical details and operation time from incision to bone closure.
Methods
: A retrospectively reviewed total of 66 patients were included who underwent a craniectomy and subsequent cranioplasty caused by either a severe traumatic brain injury (n=35) or malignant infarction (n=31). The patients were divided into two groups depending on whether Neuro-Patch was used or not (31 in the Neuro-Patch group, 35 in the non-Neuro-Patch group). Propensity score matching was used to minimize the differences. Associated morbidities as well as operation time, and blood loss were analyzed and compared between the two groups.
Results
: To prevent adhesion, Neuro-Patch was placed as an onlay, enough to cover the surrounding skull at least 1 cm beyond the bone edges. A small piece was also placed over the temporalis muscle during the craniectomy. A step-by-step dissection was performed to minimize retraction-related injury during the subsequent cranioplasty. The mean estimated blood loss was significantly lower in the Neuro-Patch group (54.6±34.9 vs. 149.0±70.8 mL, p<0.001) and the mean time from incision to bone closure in the Neuro-Patch group was 40.8±14.3 minutes, which was significantly lower than in the non-Neuro-Patch group (91.5±38.2 minutes) as well. For each analysis of complications, the differences were not significant, however, the overall complication rate was significantly lower in the Neuro-Patch group (9.7%) than in the non-Neuro-Patch group (42.9%).
Conclusion
: Neuro-Patch can be used safely and effectively as an anti-adhesive substitute during cranioplasty. To improve clinical outcomes as well as intraoperative parameters including the time from incision to bone closure, planned placement of Neuro-Patch during craniectomy and the step-by-step dissection during cranioplasty is important.

Keyword

Craniectomy; Cranioplasty; Dural substitutes; Adhesion; Complications

Figure

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  Fig. 1. Intraoperative findings during craniectomy. A : The dura is opened in a stellate fashion to achieve maximal decompression. B : A Lyoplant (B. Braun, Melsungen, Germany) is placed to cover the brain surface underneath the dura. C : Finally, a large piece of Neuro-Patch is placed over the dura and the Lyoplant, separating the overlying temporalis muscle and galea at least 1 cm beyond the bone margin. Note that a small piece of Neuro-Patch (asterisk) is applied between the galea and temporalis muscle.

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  Fig. 2. Intraoperative findings during cranioplasty. A : The scalp is carefully elevated maintaining the galea-Neuro-Patch plane. B : After the scalp is fully retracted, a small piece of Neuro-Patch (asterisk) overlying the temporalis muscle is dissected and removed. C : The temporalis muscle is fully dissected from the underlying Neuro-Patch. D : Finally, a large piece of Neuro-Patch is removed by sharply dissecting it from the underlying dura.

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  Fig. 3. A : Schema of step-by-step dissection during cranioplasty. B : First step 1. Scalp elevation between the galea and the underlying Neuro-Patch. C : Second step 2 and 3. Temporalis muscle dissection. D : Final step 4. Dissection and removal of a large piece of Neuro-Patch.

Reference

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