Dural Sandwich Technique for Hemicraniectomy and Benefits During Cranioplasty

Objective: Hemicraniectomy is a commonly performed neurosurgical procedure used in the setting of medically refractory malignant intracranial hypertension. Complications from cranioplasty after hemicraniectomy can be significant, including infection and wound issues. Difficulty with scar tissue during exposure for cranioplasty can be challenging and can lead to prolonged surgical time and increased bleeding. We describe a surgical technique, termed the “dural sandwich,” that could provide a significant benefit during cranioplasty as compared with traditional single-layered dural closure. Methods: A retrospective analysis was conducted that included 14 patients who underwent a hemicraniectomy procedure over a 4-year period. Seven patients were identified who received a cranioplasty after dural sandwich technique during craniectomy. They were compared with a similar patient group of 7 patients who received a cranioplasty after conventional hemicraniectomy with single-layered dural closure. Surgical time, estimated blood loss, and complication rates were compared between the 2 groups. Analysis of variance measures were performed to assess for statistically significant differences in blood loss and operative time between the dural sandwich and control groups. Statistical significance was defined as P < 0.05. Results: The mean estimated blood loss was 82.1 mL in the dural sandwich craniectomy group versus 150 mL in the conventional hemicraniectomy group (P < 0.05). The mean estimated surgical time was 91.7 minutes in the dural sandwich craniectomy group versus 127.5 minutes in the conventional craniectomy group (P < 0.05). There was no evidence of neurologic deterioration, cerebral spinal fluid leak, or postoperative hematoma requiring evacuation in either group. In the conventional craniectomy group, a single report of a wound infection was noted that was treated conservatively with antibiotics. Conclusions: By layering bovine pericardium above and below the dura during initial hemicraniectomy, an artificial plane is created that improves ease of exposure during cranioplasty. This technique could reduce surgical time and blood loss during subsequent cranioplasty, and potentially reduce recovery time and postoperative complications.