Hinge Craniotomy for Posterior Cranial Vault Expansion: Using the Keel to the Surgeon's Advantage

Cranial vault reconstructions are a common craniofacial procedure utilized to treat chronically elevated intracranial pressure and its sequelae for children with craniosynostosis. These surgeries often involve split-thickness autologous grafts to facilitate intracranial volume expansion. The hinge craniotomy was developed by neurosurgeons in the early 2000s as an alternative to the hemicraniectomy to allow for greater space and simplified re-securing of the bone flap. In our report, we introduce a novel application of hinge craniotomy in total cranial vault reconstruction for a pediatric patient with microcephaly secondary to congenital cytomegalovirus infection. We performed bilateral barrel stave cuts to the occipital bone as well as an undercut along the midline keel to form a hinge craniotomy. Complex reconstruction followed to augment intracranial volume and restructure the cranial vault. This technique maximized intracranial volume expansion while minimizing the need for prolonged reconstruction. It also allowed for retained vascularization of the bone flap by maintaining the connection with the intact cranial base and pericranium to further support bony healing. Our study presents a novel utilization of hinge craniotomy, using the occipital keel as a natural hinge, to create ample space during cranial vault reconstruction. This technique offers potential advantages in terms of intracranial volume expansion and bony healing.