Introduction
Methods
Protocol and registration
Eligibility criteria
PICOS criteria
-
Population: Diagnosis of TBI or stroke and exposure to HC
-
Intervention: Hinge craniotomy; in situ hinge craniectomy; the Tucci flap; in situ resin floating cranioplasty; in situ free floating craniectomy; osteoplastic decompression; hinge decompressive craniotomy temporalis; riding craniotomy; modified temporal muscle hinge decompressive craniotomy; floating anchored craniotomy
-
Comparison: Studies with and without controls were included due to nature of scoping review
-
Outcomes and other data collected: Demographics, description of indications and surgical techniques, intracranial pressure monitoring, mean length of stay, functional outcome, mortality
-
Study design: All prospective and retrospective case series, cohort studies, case-control and randomised controlled trials with n > 1 written in English were included
Selection of sources of evidence
Data charting process
Data items
Synthesis of results
Results
Indication and patient demographics
Reference | Total patients | Pathology | Mean Age (years) | Gender (M:F) | |||||
---|---|---|---|---|---|---|---|---|---|
TBI | Stroke | ||||||||
Subdural haematoma | Epidural haematoma | Intracerebral heamatoma | Diffuse injury | Infarct | Haemorrhage | ||||
Schmidt 2007 [11] | 25 | 25 | 38.2 | 22:3 | |||||
Ko 2007 [10] | 16 | 5 | 1 | 3 | 7 | 51 | 5:11 | ||
Goettler 2007 [12] | 3 | 2 | 1 | – | – | ||||
Ahn 2009 [18] | 7 | 2 | 1 | 3 | 1 | 52.7 | 5:2 | ||
Kenning 2009 [19] | 20 | 11 | 1 | 4 | 4 | 50.5 | 14:6 | ||
Valenca 2010 [20] | 4 | 2 | 1 | 1 | 44.8 | 1:3 | |||
Mracek 2011 [21] | 20 | 13 | 1 | 3 | 2 | 1 | 42 | 17:3 | |
Adeleye 2011 [22] | 4 | 3 | 1 | 36.5 | 3:1 | ||||
Kenning 2012 [24] | 9 | 9 | 58.3 | 5:4 | |||||
Kano 2012 [23] | 21 | 7 | 14 | 57.4 | 16:5 | ||||
Mezue 2013 [27] | 30 | 5 | 2 | 17 | 6 | 36.0 | – | ||
Peethambaran 2015 [28] | 10 | 7 | 3 | 42.7 | 8:2 | ||||
Tsermoulas 2016 [25] | 17 | 17 | 46 | 15:2 | |||||
Adeleye 2016 [26] | 40 | 28 | 12 | 38.4 | 38:2 | ||||
Gutman 2017 [13] | 57 | 57 | 37.2 | 51:5 | |||||
Total | 283 | 182 | 6 | 33 | 9 | 13 | 40 | 45.1 | 199:46 |
Surgical technique and nomenclature
Reference | Technique | Craniotomy size | Dura | Stabilisation of flap | Wound drain | |
---|---|---|---|---|---|---|
Duraplasty | Material | |||||
Schmidt 2007 [11] | Hinge craniotomy | > 12 cm | Simple onlay | Gelfoam or Duragen | 3 miniplates were fastened: a Y-shaped plate just posterior to the coronal suture, and two 2-hole plates, 1 at the sphenoid wing and a second in the posterior temporal region both below the temporalis muscle and fascia. The Y-shaped plate was secured to the surrounding skull whilst the 2-hole plates acted as buttress plates to prevent future settling. | No |
Ko 2007 [10] | In situ hinge craniectomy | “Standard craniotomy” | Simple onlay | Duragen | Four miniplates. Superior plates left unfastened and inferior plates act as hinge. Hinge was refastened in 8 patients 1–2 months later. Ventriculostomy in 7 patients | No |
Goettler 2007 [12] | Tucci flap | “Very large” | “Duroplasty” | Not stated | Anterior plate screwed, posterior plate not screwed | No |
Ahn 2009 [18] | In situ floating resin cranioplasty | “Large” | Not stated | Not stated | Resin implant modelled intraoperatively with diameter > 5 cm larger than bone flap larger and loosely fixed with silk suture | No |
Kenning 2009 [19] | Hinge craniotomy | > 12 cm | Simple onlay | Duragen | 3 miniplates were fastened: a Y-shaped plate just posterior to the coronal suture, and two 2-hole plates, 1 at the sphenoid wing and a second in the posterior temporal region both below the temporalis muscle and fascia. The Y-shaped plate was secured to the surrounding skull whilst the 2-hole plates acted as buttress plates to prevent future settling | No |
Valenca 2010 [20] | In-window craniotomy | 12–15 cm, rectangular | Duraplasty “anteroposterior bridge between the dural edges” | Synthetic graft; homologous pericranium, fascia lata or temporal fascia | Rectangular craniotomy and subtemporal decompression. Bone flap vertically cut in two creating ‘window’. Outer frontal and parieto-occipital sides of the flap are tied to the skull at 2 points using a synthetic nonabsorbable suture to function as hinge joint, allowing opening of the window but prevents downward movement | Yes |
Mracek 2011 [21] | Osteoplastic decompression | “Large hemispheral fronto-temporo-parieto-occipital flap” | Yes | Flap of pericranium or temporalis fascia | Far-near-near-far suture of the temporal muscle and depression prevented by oblique bone incision via Gigli saw | No |
Adeleye 2011 [22] | Hinge DC temporalis | “Trauma bone flap” | Simple onlay— “loose expansile” | Not stated | Bone flap in situ with ipsilateral temporalis muscle; anterior and posterior vertical cuts in muscle sutured allowing mobility | Yes |
Kenning 2012 [24] | Hinge craniotomy | As Kenning 2009 | ||||
Kano 2012 [23] | Hinge craniotomy | “Large” | “Duroplasty” | GORE-TEX | Additional craniectomy in the temporal squama was performed in many cases to decompress the midbrain. Miniplate to prevent flap resorption. Refastening of bone flap in 16/21 cases under local anaethesia | No |
Mezue 2013 [27] | Decompressive craniotomy | “Large temporo-parietal trauma flap” | “Loosely repaired” | Autologous material, temporalis muscle or pericranium | In situ free floating or loosely sutured craniotomy | No |
Peethambaran 2015 [28] | Four-quadrant osteoplastic decompressive craniectomy | “Traditional craniectomy” | Duroplasty | Synthetic patch | Bone flap divided into four-quadrants then the periosteum on each bone piece was sutured loosely to other pieces, as well as to the periosteum on one side of the calvarium with prolene/silk sutures | No |
Tsermoulas 2016 [25] | Riding craniotomy | “Trauma craniotomy and wide exposure” | “Dura left open” | Not stated | Miniplates to prevent flap resorption | No |
Adeleye 2016 [26] | Modified temporal muscle hDC | At least 14 cm | Duraplasty | Composite subgaleal fascia-pericranium flap | Bone flap in situ with ipsilateral temporalis muscle; anterior and posterior vertical cuts in muscle sutured allowing mobility | Yes |
Gutman 2017 [13] | Floating anchored craniotomy | > 12 × 15 cm | Simple onlay | Geloforam or dural substitute | Loose vicryl sutures (1–2 cm slack) and plates (unscrewed) to prevent flap resorption and skin flap 10 cm clearance to facilitate expansion | Subgaleal |
Perioperative parameters
Reference | Pre-operative | Post-operative | |||||
---|---|---|---|---|---|---|---|
ICP (mmHg) | GCS | MLS (mm) | Rotterdam score | ICP (mmHg) | MLS (mm) | Rotterdam score | |
Schmidt 2007 [11] | GCS < 9 (24/25 pt) | 10.6 (13/25 pt) | 5.1 (13/25 pt) | ||||
Ko 2007 [10] | Avg GCS 6 to 7 | Range 2–22 (7/16 pt) | |||||
Goettler 2007 [12] | |||||||
Ahn 2009 [18] | 8 | 9 | 6.7 | ||||
Kenning 2009 [19] | 4.1 (mean motor GCS) | 11.0 ± 4.70 | 4.8 ± 1.1 | 12.0 ± 5.6 | 6.4 ± 4.4 | 3.2 ± 1.0 | |
Valenca 2010 [20] | Range 15–35 (1/4 pt) | ||||||
Mracek 2011 [21] | 3–8 (20/20 pt) | 10 | 14.5 | 3 | |||
Adeleye 2011 [22] | 8–9 (range) (4/4 pt) | ||||||
Kenning 2012 [24] | 4.7 (mean motor GCS) | 8.5 ± 6.1 | 3.4 ± 1.3 | 10.8 ± 3.4 | 6.0 ± 3.9 | 2.9 ± 0.8 | |
Kano 2012 [23] | 3–6 (9/21 pt); 7–12 (11/21 pt); 13–15 (1/21 pt) | 25.5 ± 17.0 (17/21 pt) | |||||
Mezue 2013 [27] | 3–8 (24/30 pt); 9–12 (6/30 pt) | > 10 (12/30 pt) | |||||
Peethambaran 2015 [28] | 7 | 13.1 ± 4.78 | 6.6 ± 3.9 | ||||
Tsermoulas 2016 [25] | 3–8 (9/17 pt); 9–12 (5/17 pt); 13–15 (3/17 pt) | 4 | Intracranial HTN index (13.8) | ||||
Adeleye 2016 [26] | 3–8 (15/40 pt); 9–12 (17/140 pt); 13–15 (8/40 pt) | > 5 (36/40 pt) | ≥ 4 (36/40 pt) | ||||
Gutman 2017 [13] | 32.7 ± 8.1 | ≤ 8 (32/57 pt) | 7.3 ± 5.57 | 3.6 ± 1.2 | 16.0 ± 12.1 | 2.6 ± 3.8 |
Clinical outcomes
Reference | Survival | Functional outcome at discharge unless otherwise stated | Length of follow-up (months) | ||
---|---|---|---|---|---|
n, % of total pt | GOS | mRS | |||
Schmidt 2007 [11] | 13, 52% | NR | NR | NR | |
Ko 2007 [10] | 14, 87.5% | NR | NR | 10 | |
Goettler 2007 [12] | 2, 66.6% | NR | NR | NR | |
Ahn 2009 [18] | 6, 85.7% | Good: 2 (28.6%); Poor: 5 (71.4%) | NR | NR | |
Kenning 2009 [19] | 15, 75% | NR | NR | NR | |
Valenca 2010 [20] | 4, 100% | NR | NR | 2–14 | |
Mracek 2011 [21] | 16, 80% | Good: 8 (40%); Poor: 12 (60%) | NR | Up to 6 | |
Adeleye 2011 [22] | 4, 100% | GOSE ‘near normal’ | NR | 3–18 | |
Kenning 2012 [24] | 5, 56% | 3.6 ± 0.6 (at 1–3 months) | 2.8 ± 1.1 (at 1–3 months) | 12 | |
Kano 2012 [23] | 19, 90.4% | Good: 3 (43%); Poor: 4 (57%) | Good: 1 (7%); Moderate: 9 (64%); Poor: 4 (29%) | 13.7 ± 11.2 (18 cases) | |
Mezue 2013 [27] | 24, 80% | Good: 16 (53%); Poor: 14 (47%) | NR | NR | |
Peethambaran 2015 [28] | 3, 30% | NR | NR | 6 | |
Tsermoulas 2016 [25] | 14, 82.0% | Good: 11 (64.7%); Poor: 6 (35.3%) | NR | 6 | |
Adeleye 2016 [26] | 28, 70% | Good: 27 (67.5%); Poor: 13 (32.5%) | NR | 11 | |
Gutman 2017 [13] | 44, 77.2% | NR | Pre-discharge: Good: 31 (54.3%); Moderate: 10 (17.5%); Poor: 14 (24.6%); NA: 2 (3.5%) | Post-discharge: Good: 22 (38.6%); Moderate: 3 (5.3%); Poor: 13 (22.8%); NA: 10 (17.5%) | NR |
Complications
Reference | Hinge craniotomy | Decompressive craniectomy | ||||||
---|---|---|---|---|---|---|---|---|
Number of patients | Progression to DC | Infection | Cranioplasty | Other | Number of patients | Complications excluding infection | Infection | |
Schmidt 2007 [11] | 25 | 0 | 1 | 1 (due to wound infection) | Other infection (6); seizure (1) | NA: No craniectomy group | ||
Ko 2007 [10] | 16 | 0 | 0 | 0 | Subgaleal collection—resolved (3) | |||
Goettler 2007 [12] | 3 | 0 | 0 | 0 | ||||
Ahn 2009 [18] | 7 | 0 | 0 | 1 (patient requested; cosmetic) | ||||
Kenning 2009 [19] | 20 | 0 | 0 | 0 | Reoperation—indication not stated (3) | 30 | Reoperation—indication not stated (3) | |
Valenca 2010 [20] | 4 | 0 | 0 | 0 | NA: No craniectomy group | |||
Mracek 2011 [21] | 20 | 2 | 0 | 0 | Removal of bone flap—malfunction of technique (2) | |||
Adeleye 2011 [22] | 4 | 0 | 0 | 0 | ||||
Kenning 2012 [24] | 9 | 0 | 1 | 1 | Reoperation to secure mobile bone plate (1); haematoma progression (1); subdural effusion (1); barbiturate-induced coma (1) | 19 | Subdural effusion (11); evolution of contralateral mass lesions (1); hydrocephalus (2); reoperation—cranioplasty (17); reoperation—not cranioplasty (7); contusion progression (11) | Infection (5) |
Kano 2012 [23] | 21 | 4 | 0 | 0 | 37 | Bone flap infection (6) | ||
Mezue 2013 [27] | 30 | 0 | 2 | 0 | 8 | Infection—meningitis (1) | ||
Peethambaran 2015 [28] | 10 | 1 | 2 | 0 | 10 | Hydrocephalus (4) | Infection (3); | |
Tsermoulas 2016 [25] | 17 | 0 | 0 | 0 | Reoperation – indication not stated (4) | 69 | Reoperation (41: excluding cranioplasty, including CSF diversion, evacuation of post-operative heamatoma, burr holes for subdural collection, surgical debridement for infection, lobectomy)* | Infection* |
Adeleye 2016 [26] | 40 | 0 | 4 | 0 | Bone flap sinking (2); hydrocephalus (1); other infection (4) | NA: No craniectomy group | ||
Gutman 2017 [13] | 57 | 2 | 2 | 0 | EVD insertion (2); subgaleal haematoma (1) | |||
Total | 283 | 9 | 12 | 3 | 30 | 173 | 97 | 15 |
Level of evidence
Discussion
Nomenclature and technique
Efficacy of hinge craniotomy
Intracranial pressure
Reference | Pt (n) | Indication | Outcomes | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
TBI | Stroke | ICP (mmHg) | Mean MLS (mm) | GOS | mRS | Survival n (%) | |||||||||
HC | DC | HC | DC | HC | DC | HC | DC | HC | DC | HC | DC | HC | DC | ||
Kenning 2009 [19] | 50 | 12 | 18 | 8 | 12 | 12.1 ± 2.6 | 15.0 ± 6.3 | 6.4 ± 4.4 | 5.5 ± 4.6 | Not stated | 15 (75) | 21 (70) | |||
Kenning 2012 [24] | 28 | – | 9 | 19 | 10.8 ± 3.4 | 11.9 ± 3.5 | 6.0 ± 3.9 | 5.3 ± 5.4 | NA | 2.8 ± 1.1 at 30–90 days post-op | 4.4 ± 0.9 at 30–90 days post-op | 5 (56) | 17 (89) | ||
Kano 2012 [23] | 58 | 7 | 19 | 14 | 18 | 25.5 ± 17.0 | Not reported | Good: 3 (50%); Poor: 3 (50%) | Good: 4 (21%); Poor: 15 (79%) | Good: 1 (7%); Moderate: 9 (64%); Poor: 4 (29%) | Good: 1 (6%); Moderate: 6 (33%); Poor: 11 (61%) | 19 (94) | * | ||
Mezue 2013 [27] | 38 | 30 | 8 | – | Not reported | Good: 16 (53%); Poor: 14 (47%) | Good: 2 (25%); Poor: 6 (75%) | 24 (80) | 6 (75) | ||||||
Peethambaran 2015 [28] | 20 | 10 | 9 | 1 | Not reported | 6.6 ± 3.9 | 6.0 ± 2.1 | Not stated | 3 (30) | 5 (50) | |||||
Tsermoulas 2016 [25] | 86 | 17 | 69 | – | 13.8^ | 16.6^ | Not reported | Good: 11 (64.7%); Poor: 6 (35.3%) | Good: 28 (40.1%); Poor: 41 (59.9%) | NA | 14 (82) | 43 (62) |
Clinical and functional outcomes
Complications
Hinge craniotomy in low-to-middle-income settings
Novel devices
Cost-effectiveness
Limitations of the present study
Developing the evidence base
Reference | Journal | Institution | Economic status | Type of study | Level of evidence | Summary |
---|---|---|---|---|---|---|
Schmidt 2007 [11] | Journal of Neurosurgery | West Virginia University Health Sciences Center Charleston Division, USA | HIC | Retrospective case series | IV | Technical description of HC; HC provided adequate cerebral decompression I small sample; no complications usually associated with DC. |
Ko 2007 [10] | Operative Neurosurgery | Weill Cornell Medical College, USA | HIC | Retrospective case series | IV | Technical description of HC; HC provided adequate cerebral decompression in small sample; no complications usually associated with DC. |
Goettler 2007 [12] | Journal of Trauma-Injury Infection & Critical Care. | Brody School of Medicine, USA | HIC | Small case series | V | Technical description of TF; provides less decompression volume than DC but was adequate; suggested reduced morbidity vs DC. |
Ahn 2009 [18] | Journal of Korean Neurosurgical Society | Wonkwang University School of Medicine, Korea | HIC | Retrospective case series | IV | Technical description; perhaps ISRFC better able to accommodate cerebral odema than HC; obviates need for cranioplasty; particularly useful in elderly population. |
Kenning 2009 [19] | Neurosurgical Focus | Albany Medical Centre, USA | HIC | Retrospective case control | IIIb | Compared ICP outcomes between HC and DC: HC appears to be at least as good as DC in providing post-operative ICP control and results in equivalent early clinical outcomes. |
Valenca 2010 [20] | Journal of Neurosurgery | Federal University of Pernambuco, Brazil | UMIC | Retrospective case series | IV | ‘In-window’ craniotomy is an alternative solution for deploying autologous material and obviates need for secondary surgery. |
Mracek 2011 [21] | Acta Neurochirurgica | Charles University Hospital and Faculty of Medicine in Pilsen, Czech Republic | HIC | Retrospective case series | IV | ODC is effective at reducing ICP in a subgroup of patients where DC would be too radical; obviates need for reoperation and associated complications of DC. |
Adeleye 2011 [22] | Surgical Neurology International | University College Hospital, Ibadan, Nigeria | LMIC | Retrospective case series | IV | Effective cerebral decompression using autologous tissue in LMIC setting |
Kenning 2012 [24] | Journal of Neurosurgery | Thomas Jefferson University Hospital, USA | HIC | Retrospective case control | IIIa | HC appears to be at least as good as DC in providing post-operative ICP control at a similar therapeutic index; in-hospital mortality was higher in HC patients but superior long-term functional outcomes; HC may help limit post-operative complications. |
Kano 2012 [23] | Neurologia Medico-Chirurgic | Fukaya Red Cross Hospital, Japan | HIC | Prospective cohort study | IIIa | HC with ICP monitoring was effective and safe for head trauma or stroke; not associated with bone flap infection; follow up of 13–40 months. |
Mezue 2013 [27] | Nigerian Journal of Clinical Practice | University of Nigeria Teaching Hospital, Nigeria | LMIC | Retrospective cohort study | IIIa | HC sufficient and able to control ICP in selected TBI cases. Severe head injury still requires DC but associated with increased mortality. |
Peethambaran 2015 [28] | Neurology India | Government Medical College, India | LMIC | Prospective observational case control | IIIb | Technique provides adequate and comparable decompression to DC |
Tsermoulas 2016 [25] | World Neurosurgery | Queen Elizabeth Hospital, Birmingham, UK | HIC | Retrospective observational cohort study | IIIb | Compared reoperations, functional outcome and ICP in DC, RC and FC; DC was not associated with better outcomes; replace flap if conditions allow |
Adeleye 2016 [26] | Journal of Neurological Surgery Part A | University College Hospital, Ibadan, Nigeria | LMIC | Prospective cohort study | IV | Further development of temporalis hinge DC technique in LMIC setting; good outcomes in mild to moderate TBI |
Gutman 2017 [13] | Surgical Neurology International | Gold Coast University Hospital, Australia | HIC | Retrospective case series | IV | FAC provides symmetrical decompression vs HC; FAC provided adequate cerebral decompression |