Bifrontal Decompressive Craniectomy Technique [Neurosurgery Wiki]

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====== Bifrontal Decompressive Craniectomy Technique ======


1. Patient is under   - general anesthesia and C- spine precaution if appropriate. 

2. Patient is placed in the supine position and 90 to the horizontal plane. 

3. Place head on Horseshoe head holder or Mayfield clamp. The patient's head should be in a supine and neutral position on a donut, horseshoe, or in pins. 

4. Mark the caution area on the surface anatomy: 

4.1. [[Superior Sagittal sinus]]: located on the midline from the nasion to the external occipital protuberance. 

4.2. [[Arachnoid granulation]]s and venous lake: located along the [[sagittal sinus]] up to 2 cm from the midline. 

4.3. Frontal hairline and [[coronal suture]]. 

5. Mark the [[skin incision]] and begin anterior to the tragus on each side and curve cranially 2–3 cm posterior to the coronal suture. Incisions should join in the midline using either V-midline, curvilinear or zig-zag pattern (at the surgeons preference). 

6. Infiltrate the local anesthesia along the incision line. 

6.1. Prep and drape the patient's head in a sterile fashion. 

7. Make the skin incision carefully avoiding the facial nerve and superficial temporal artery as they are located 1 cm anterior to the tragus and apply Rainey clips. 

8. Incise the temporalis muscle. 

9. The scalp and temporalis muscle can be reflected anteriorly and secured using fishhooks. Place a sponge beneath the scalp, which helps maintain the blood supply to the scalp. Also, be cautious of increasing ocular pressure once the scalp is reflected anteriorly. 

10. Expose both supraorbital nerves (V1), which emerge from the supraorbital foramen being careful not to injure these nerves. 11. Once bone is exposed make burr holes in the following areas

11.1. Both keyhole areas 

11.2. Both squamous parts of the temporal bones. 

11.3. Make the other two burr holes just behind the coronal suture, 1 cm apart from the midline on each side. 

12. Perform the craniotomy as indicated with the last cut being across (over) the SSS. 

12.1. Elderly patients – the dura can adhere to the skull. 

12.2. The area of the superior sagittal sinus where the dura can adhere to the skull and injury can result in rapid blood loss. 

13. Connect all of the burr hole sites epidurally and remove the skull cap

13.1. Connect the coronal and temporal areas on both sides. 

13.2. Connect the temporal and keyhole areas on both sides. 

13.3. Connect both keyhole and supraorbital areas on each side just above the floor of the anterior cranial fossa.

13.4. Connect both supraorbital areas carefully in the midline region so as not to enter the frontal paranasal sinus. 13.5. Wax the diploic vein with bone wax. 

14. Remove additional bone at the squamous part of the temporal bone and the lesser wing of the sphenoid bone. Be careful of the middle meningeal artery and diploic veins that traverse it. 

15. Make a tiny hole to tack up the dura 2 cm apart along the craniectomy rim. Tack the dura up to the skull. 

16. Stop the bleeding from the sagittal sinus by placing a strip of surgicel and ⁄or gelfoam on to it and weight with the soaked cottonoid. 

17. Make durotomy in a stellate or semicircular fashion (surgeon preference) and extend durotomy linearly down to the base of the middle cranial fossa to decompress the temporal lobe and the middle cranial fossa

18. Make a small durotomy distal to the superior sagittal sinus and parallel to the anterior cranial fossa. Now extend it horizontally to both keyhole areas and curve it along the craniectomy rim. 

19. Make another durotomy from aside the anterior-most part of the superior sagittal sinus to the coronal area on both sides – parallel to the superior sagittal sinus. 

20. Ligate the anterior-most part of the superior sagittal sinus and stop all bleeding from the dural vessels using a bipolar cautery. 

21. Cut the falx cerebri where the sinus was ligated using caution at the deepest portions to avoid damaging the anterior cerebral arteries. 

22. The brain is exposed bifrontal. Inspect the brain and underlying pathology. The viable brain is pulsatile. 

23. Once the underlying pathology is surgically corrected reflect the dura loosely over the exposed brain using the dural substitute to cover areas of the bony defect. 

24. Place a drain. 

25. Reflect back on the scalp flap and inspect the bleeding. 26. Suture the galea and the scalp. 

27. In the case of entering the frontal paranasal sinuses pericranial graft, fat or muscle can be used to obliterate the sinus
((Quinn TM, Taylor JJ, Magarik JA, Vought E, Kindy MS, Ellegala DB. Decompressive craniectomy: technical note. Acta Neurol Scand. 2011 Apr;123(4):239-44. doi: 10.1111/j.1600-0404.2010.01397.x. PMID: 20637010.))