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04.12.2018 | Original Article - Neurosurgery general | Ausgabe 3/2019

Acta Neurochirurgica 3/2019

Experiences with a temporary synthetic skin substitute after decompressive craniectomy: a retrospective two-center analysis

Acta Neurochirurgica > Ausgabe 3/2019
Lukas Grassner, Franz Marhold, Miron Yousif, Andreas Grillhösl, Karl Ungersboeck, Joachim Schulz, Martin Strowitzki
Wichtige Hinweise
The original version of this article was revised. The name of Miron Yousif was interchanged and is now corrected.
Lukas Grassner and Franz Marhold contributed equally to this work.
This article is part of the Topical Collection on Neurosurgery general
A correction to this article is available online at https://​doi.​org/​10.​1007/​s00701-018-03776-2.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


substitute called Epiquard in patients where a decompressive craniectomy was done and primary skin closure wasn’t possible (or not safe to be done) because of brain swelling or due to its contribution to refractory intracranial hypertension. As expected, outcome was frequently unfavorable, morbidity was high and many complications existed. Although some patients eventually survived, the use of these substitutes should be reserved only for limited cases following careful consideration and after every possible effort (both conservative and surgical) has been made to avoid reaching this extreme condition.
Parmenion P. Tsitsopoulos
Thessaloniki, Greece



Decompressive craniectomy is a commonly performed procedure. It reduces intracranial pressure, improves survival, and thus might have a positive impact on several neurosurgical diseases and emergencies. Sometimes primary skin closure is not possible due to cerebral herniation or extensive skin defects. In order to prevent further restriction of the underlying tissue, a temporary skin expansion might be necessary.

Methods and material

We retrospectively reviewed patients in need for a temporary skin substitute because skin closure was not possible after craniectomy without violating brain tissue underneath in a time period of 6 years (2011–2016). With this study, we present initial experiences of Epigard (Biovision, Germany) as an artificial temporary skin replacement. We performed this analysis at two level-1 trauma centers (Trauma Center Murnau, Germany; University Hospital of St. Poelten, Austria). Demographic data, injury and surgical characteristics, and complication rates were analyzed via chart review. We identified nine patients within our study period. Six patients suffered from severe traumatic brain injury and developed pronounced cerebral herniation in the acute or subacute phase. Three patients presented with non-traumatic conditions (one atypical intracerebral hemorrhage and two patients with extensive destructive tumors invading the skull and scalp).


A total of 20 Epigard exchanges (range 1–4) were necessary before skin closure was possible. A CSF fistula due to a leaky Epigard at the interface to the skin was observed in two patients (22%). Additional complications were four wound infections, three CNS infections, and three patients developed a shunt dependency. Three patients died within the first month after injury.


Temporary skin closure with Epigard as a substitute is feasible for a variety of neurosurgical conditions. The high complication and mortality rate reflect the complexity of the encountered pathologies and need to be considered when counseling the patient and their families.

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