Decompressive craniotomy: durotomy instead of duroplasty to reduce prolonged ICP elevation

Usually, decompressive craniectomy (DC) in patients with increased intracranial pressure (ICP) is combined with resection of the dura and large-scale duroplasty. However, duroplasty is cumbersome, lengthens operation time and requires heterologous or autologous material. In addition, the swelling brain could herniate into the duroplasty with kinking of the superficial veins at the sharp cutting edges and subsequent ICP exacerbation. Several longitudinal durotomies avoid these limitations, but it remains a matter of discussion if durotomies reduce ICP sufficiently.

DC was performed in ten patients (mean age 45 years) with increased ICP after head trauma or subarachnoid hemorrhage. After craniectomy, the dura was opened by three to four durotomies from midline to the temporal base. Duration of surgical procedure and ICP during each surgical step and postoperatively were recorded.

Mean duration of surgery was 90 +/- 10 min. ICP prior to skin incision was 39 +/- 12 mmHg and dropped to 22 +/- 9 mmHg after craniectomy. During durotomy ICP decreased stepwise and reached stable values of 12 +/- 6 mmHg at the end of surgery. On days 1-10 after surgery, ICP values ranged between 12-17 mmHg.

This study showed that durotomy is a fast and easy, but likewise effective method to lower ICP further after craniectomy.