Further, it has been suggested that there is an increased risk of accidentally opening the mastoid air cells or injuring the transverse and sigmoid sinuses 12, 15. However, it still remains unclear if this incision allows for the exact same size of the bone flap and for a sufficient exploration and decompression of the temporal base compared to the standard reversed question-mark incision. This incision type is supposed to preserve the STA and demonstrated a significantly reduced rate of infections and wound-healing disorders after cranioplasty 11. Therefore, the altered posterior question-mark incision starting behind the ear and posterior of the base of the mastoid process was proposed 13, 14. Injuring the STA during the skin incision predisposes the wound to ischemia and consecutive wound-healing disorders 12. This might happen, since the universally used standard reversed question-mark incision for DHC starts anterior to the tragus, where the STA runs superficially over the temporal root of the zygoma and is jeopardized during incision 8, 11. Wound-healing problems are one of the most frequently encountered complications after DHC and the main reason for the higher rate of wound-healing disorders is supposed to be due to injuring the superficial temporal artery (STA), which constitutes the main blood supply of the large myocutaneous flap 6, 8, 10. Many of the DHC-associated complications are related to the significant skin and bone flap compared to most standard supratentorial craniotomies. However, this straightforward procedure still constitutes a particular challenging and, in some points, controversial surgery that exposes the patients to significant risks for various intraoperative and postoperative complications 6, 7, 8, 9. Previously described reduction in wound-healing complications and cranioplasty failures needs to be confirmed in prospective studies to demonstrate the superiority of the altered posterior question-mark incision.ĭecompressive hemicraniectomy (DHC) is common practice for various life-threatening indications 1, 2, 3, 4, 5. Thus, the altered posterior question-mark incision demonstrated technically equivalent and allows for an equally effective craniectomy size and decompression of the temporal base without increasing risks of intraoperative complications. There was no difference in duration of surgery. Twelve (29%) and 5 (19%) patients underwent revision due to wound-healing disorders after DHC, respectively (p = 0.34). Twenty-four out of 42 patients in the modified standard and 22/27 patients in the altered posterior question-mark group had a postoperative angiography, and the STA was preserved in all cases in both groups. In both groups, no transverse/sigmoid sinus was injured. There was no difference between the craniectomy sizes of 158.8 mm and 158.2 mm, respectively (p = 0.45), and there was no difference in the rate of accidental opening of the mastoid air cells. The distance of the margin of the craniectomy to the temporal base was 6.9 mm in the modified standard reversed and 7.2 mm in the altered posterior question-mark group (p = 0.77). Forty-two patients underwent DHC with the standard reversed and 27 patients with the altered posterior question-mark incision. Decompression and preservation of the STA was assessed on postoperative CT scans and CT or MR angiography. The authors retrospectively identified 69 patients who underwent DHC from 2019 to 2022. Therefore, this study evaluated the efficacy of the altered posterior question-mark incision for craniectomy size and decompression of the temporal base and assessed intraoperative complications compared to a modified standard reversed question-mark incision. However, decompression size during DHC is essential and it remains unclear if the new incision type allows for an equally effective decompression. The altered posterior question-mark incision for decompressive hemicraniectomy (DHC) was proposed to reduce the risk of intraoperative injury of the superficial temporal artery (STA) and demonstrated a reduced rate of wound-healing disorders after cranioplasty.
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