Using titanium mesh to replace the bone flap during decompressive craniectomy: A medical hypothesis

Decompressive craniectomy (DC) plays a significant role in treating refractory intracranial hypertension. During this surgical procedure, part of the skull is removed and the underlying dura mater is open, which can effectively release intracranial pressure. However, in some cases, the decision whether or not to remove the bone flap relies on the surgeon's personal experience. Positive decisions are usually made to avoid massive postoperative cerebral edema and infarction, which can lead to overtreatment. The procedure is related to many side-effects, which may affect the recovery of neurological function. Patients who have survived have to be anesthetized and undergo secondary cranioplasty 3 or 6 months later. Despite its technical simplicity, complications associated with cranioplasty are hard to ignore. Therefore, there is a need for a new surgical procedure combining decompressive craniectomy and cranioplasty. Acute expansion of the skin flap is limited, and the compensatory capacity of the skull after DC depends on the volume of the bone flap at the early stage. The titanium mesh is thin and strong, does not take up extra space provided by bone flap. Therefore, we put forward the concept of Decompressive Bone Flap Replacement. During this procedure, neurosurgeons resect the massive bone flap, open the dura mater, remove the hematoma in a similar manner to a standard craniotomy and then use titanium mesh shaped appropriately to replace the bone flap. Compared with traditional DC, it can ensure the integrity of the skull without affecting the effect of decompression. This paper presents 2 cases of DC and reviews the literature sustaining our hypothesis.