Flap Design for Cranial Reconstruction: An Analysis of Craniectomy and Cranioplasty Incisions.

Background: The surgical approach for cranial reconstruction is influenced by the presence of pre-existing scar tissue. Scars that lie within the vicinity of cranial defect require modification. Purpose: The present study was conducted to analyse co-relation between craniectomy scar and cranioplasty incision. Materials and Methods: A retrospective evaluation of 70 patients who were divided into three groups based on location of cranioplasty incision line was done. In group I, incision was located parallel and outside the scar; group II, incision was located over the scar; and group III, mixed and criss-cross incision was present. The primary outcome variable of interest was to analyse co-relation between craniectomy and cranioplasty incisions. Results: There were 45 cases of group I, 15 cases of group II and 10 cases of group III. Thirty-three patients had defect on left side, 26 had on right side, and 10 had bifrontal defect. No significant association was noted between the site and cranioplasty incision (Chi2 = 9.155, p = 0.433 and likelihood ratio = 9.487, p = 0.394). Conclusion: Well-vascularized broad-based scalp flap that provides adequate exposure and located on healthy bone irrespective of pre-existing craniectomy scar forms the mainstay of successful cranial reconstruction.

Letter to editor: Scalp incision technique for decompressive hemicraniectomy: Comparative systematic review and meta­analysis of the reverse question mark versus alternative retroauricular and Kempe incision techniques of published cases.

The "Letter to the Editor" titled "Scalp incision technique for decompressive hemicraniectomy: comparative systematic review and meta-analysis of the reverse question mark versus alternative retroauricular and Kempe incision techniques of published cases" provides a detailed analysis of different scalp incision techniques in decompressive hemicraniectomy procedures. While commendable for its systematic approach and valuable insights, the letter has several limitations, including a lack of transparency in the search strategy, failure to address potential sources of bias, and a narrow focus on technical aspects without considering broader outcome domains and practical considerations. Despite these limitations, the letter underscores the importance of evidence-based decision-making in neurosurgical practice and calls for further research to address these gaps.

Scalp incision technique for decompressive hemicraniectomy: comparative systematic review and meta-analysis of the reverse question mark versus alternative retroauricular and Kempe incision techniques.

Decompressive hemicraniectomy (DHC) is a critical procedure used to alleviate elevated intracranial pressure (ICP) in emergent situations. It is typically performed to create space for the swelling brain and to prevent dangerous and potentially fatal increases in ICP. DHC is indicated for pathologies ranging from MCA stroke to traumatic subarachnoid hemorrhage-essentially any cause of refractory brain swelling and elevated ICPs. Scalp incisions for opening and closing the soft tissues during DHC are crucial to achieve optimal outcomes by promoting proper wound healing and minimizing surgical site infections (SSIs). Though the reverse question mark (RQM) scalp incision has gained significant traction within neurosurgical practice, alternatives-including the retroauricular (RA) and Kempe incisions-have been proposed. As choice of technique can impact postoperative outcomes and complications, we sought to compare outcomes associated with different scalp incision techniques used during DHC. We queried three databases according to PRISMA guidelines in order to identify studies comparing outcomes between the RQM versus "alternative" scalp incision techniques for DHC. Our primary outcome of interest in the present study was postoperative wound infection rates according to scalp incision type. Secondary outcomes included estimated blood loss (EBL) and operative duration. We identified seven studies eligible for inclusion in the formal meta-analysis. The traditional RQM technique shortened operative times by 36.56 min, on average. Additionally, mean EBL was significantly lower when the RQM scalp incision was used. Postoperatively, there was no significant association between DHC incision type and mean intensive care unit (ICU) length of stay (LOS), nor was there a significant difference in predisposition to developing wound complications or infections between the RQM and retroauricular/Kempe incision cohorts. Superficial temporal artery (STA) preservation and reoperation rates were collected but could not be analyzed due to insufficient number of studies reporting these outcomes. Our meta-analysis suggests that there is no significant difference between scalp incision techniques as they relate to surgical site infection and wound complications. At present, it appears that outcomes following DHC can be improved by ensuring that the bone flap is large enough to enable sufficient cerebral expansion and decompression of the temporal lobe, the latter of which is of particular importance. Although previous studies have suggested that there are several advantages to performing alternative scalp incision techniques during DHC, the present study (which is to our knowledge the first to meta-analyze the literature on outcomes in DHC by scalp incision type) does not support these findings. As such, further investigations in the form of prospective trials with high statistical power are merited.

Linear Scalp Incision in Brain Tumor Surgery: Intraoperative and Postoperative Considerations.

BACKGROUND: Although the linear scalp incision is commonly used in neurosurgical practice, a systematic study elucidating its pros and cons in a specific surgical setting is lacking. Herein, we analyzed our experience with linear scalp incision in brain tumor surgery and the impact on intraoperative variables and postoperative complications. METHODS: Patients undergoing brain tumor surgery (January 2014-December 2021) at 2 neurosurgical departments were included and divided into 2 groups: linear or flap scalp incision. Patients' demographics characteristics, surgical variables, and wound-related complications were analyzed. RESULTS: More than a total of 1036 craniotomies, linear incision (mean length 6cm) was adopted in 282 procedures (27.2%). Mean maximum diameter of the craniotomy was 5.25 cm, with no statistical difference between the 2 groups. In emergency surgery (36 cases), the linear and flap incisions were used indifferently. Linear incision was predominant in supratentorial and suboccipital lesions. Flap incision was significantly more frequent among meningiomas (P < 0.01). Neuronavigation, operative microscope, and subgaleal drain were more frequently used in the flap scalp incision group (P = 0.01). Overall complication rate was comparable to flap scalp opening (P = 0.40). CONCLUSIONS: The use of the linear incision was broadly applied for the removal of supratentorial and suboccipital tumors granting adequate surgical exposure with a low rate of postoperative complications. Tumors skull base localization resulted the only factor hindering the use of the linear incision. The choice of 1 incision over another didn't show to have any impact on intraoperative and postoperative variables, and it remains mainly based on surgeon expertise/preference.

The "Three on a Stick" Incision-A Curvilinear Solution for the Occipital and Suboccipital Region.

BACKGROUND: Different conditions of the posterior fossa such as Chiari malformations, tumors, and arachnoid cysts require surgery through a suboccipital approach, for which a typical midline vertical linear incision is used. Curvilinear incisions have been carried in all other scalp regions other than the sub region for better cosmetic outcomes; a vertical curvilinear incision in the occipital and suboccipital region has not been reported. OBJECTIVE: To evaluate the cosmetic value and safety of the "3 on a stick" vertical suboccipital curvilinear incision. METHODS: We compared curvilinear to linear incisions, considering the scar's width, color, how conspicuous, and how well the scar could be covered by hair naturally. RESULTS: Between 2010 and 2016, 68 children with Chiari I malformation were surgically intervened. The curvilinear incision was performed in 56 (82.4%) while a linear incision in 12 (17.6%) children. There were only 2 (2.9%) wound related complications (superficial dehiscences) in the curvilinear group and 1 additional dehiscence in a linear incision case. There were no neural or vascular complications. Scars were very similar among the 2 groups; both were equally conspicuous but curvilinear ones seemed to get covered better by hair. CONCLUSION: The "3 on a stick" curvilinear incision of the suboccipital region is safe and allows for better hair coverage of the scar. It can be used for multiple conditions requiring a midline suboccipital or even occipital approach, such as Chiari malformations, tumors, and cysts.

Subcutaneous Metastasis of Atypical Meningioma: Case Report and Literature Review.

BACKGROUND: Meningioma, a neoplasm of the meninges, is usually a benign localized tumor. Extraneural metastasis is an extremely rare complication of meningiomas, and only a few cases have been reported to date. The present study reports a case of scalp metastasis of an atypical meningioma and discusses the types of atypical meningiomas and their management options. CASE DESCRIPTION: A 69-year-old man presented with scalp metastasis of an atypical meningioma. Six years after the right frontoparietal meningioma lesion was completely resected, an isolated subcutaneous metastasis developed at the right frontal region of the scalp, originating at the scar left by the first surgery. Postoperative histologic examination of the subcutaneous tumor revealed the features of an atypical meningioma. CONCLUSIONS: This study highlights that resection of meningiomas is still associated with a risk of iatrogenic metastasis. Surgeons should carefully wash out the operative field and change surgical tools frequently to avoid the potential risk of metastasis.

Hemodynamic outcomes of adult patients on scalp block using ropivacaine and lidocaine: Retrospective cohort study

Background@#Hemodynamic instability can occur with the pain from scalp incision to brain retraction during cranial neurosurgery. @*Objective@#To determine the hemodynamic outcomes of patients who received ropivacaine plus lidocaine scalp block. @*Design@#Retrospective cohort study. @*Setting@#Southern Philippines Medical Center, Davao City. @*Participants@#44 patients given scalp block for cranial neurosurgery. @*Main outcome measures@#Heart rate (HR), mean arterial pressure (MAP), and frequencies of tachycardia, hypertension, bradycardia, and hypotension from the time of scalp block administration to 15 minutes after scalp incision (observation period).

Clinical Hemostasis Effect of Hemocoagulase for Injection in Scalp Incision in Craniocerebral Surgery / 中国药师

Objective: To investigate the hemostasis effect of hemocoagulase for injection in scalp incision in craniocerebral surgery, and evaluate its effect on coagulation function and drug safety. Methods: Before undergoing craniotomy, 60 patients were randomly divid-ed into the study group and the control group. The study group was injected with hemocoagulase for injection at 1u im at the night before surgery, 1u im 1h before incision and 1u im 15min before incision. The control group was injected with 0. 9% saline at the same time with the same volume. The hemorrhagic volume, hemorrhagic volume per square decimeter, hemostatic time, blood coagulation and ad-verse events were tested and compared between the groups. Results: In the study group, the mean hemorrhagic volume was (37. 18 ± 2. 96)g, the mean hemorrhagic volume per square decimeter was (0. 23 ± 0. 16)g·cm-2and the mean hemostatic time was (125. 53 ± 36. 42)s. In the control group, the corresponding value was (60. 69 ± 2. 30) g, (0. 42 ± 0. 25) g·cm-2and (182. 72 ± 52. 29) s, re-spectively. The hemorrhagic volume, hemorrhagic volume per square decimeter and hemostatic time significantly decreased in the study group when compared with those in the control group (P<0. 05). No significant difference in blood coagulation and safety (P>0. 05). No adverse event was reported. Conclusion: Hemocoagulase for injection shows promising hemostasis effect with high safety, which can ensure craniocerebral surgery going well with shortened operation time.

Hippocampal neuronal degeneration in the traumatic brain injury mouse: non-trivial effect of scalp incision.

OBJECTIVES: In experimental models of traumatic brain injury (TBI), posttraumatic hippocampal neuronal degeneration in the cornu ammonis 1 (CA1), and/or the cornu ammonis 3 (CA3) regions are regarded as the most notable phenotypic appearances relating to the pathophysiology of human post-concussion syndrome. However, these morphological changes are often also seen in subjects without TBI, namely 'sham' groups. The frequencies and reasons of appearance of hippocampal neuronal degeneration in mice with TBI and/or sham are not clear. METHODS: We compared the frequencies of hippocampal neuronal degeneration among three groups: TBI (mice with external force impact performed by Marmarou's weight drop model after scalp incision), sham (mice with scalp incision alone), and control (mice with neither external force impact nor scalp incision), using hematoxylin and eosin stain in day 6 (n = 5 in each group.) Isoflurane was used for anesthesia in all mice. RESULTS: The frequencies were 80, 100, and 20% in CA1, and 20, 40, and 60% in CA3, for TBI, sham, and control, respectively. In CA1, a significant difference of the frequency was observed between sham and control (p = 0.048), but not, between TBI and sham (p = 1.000) in Fisher's exact test. In CA3, no significant difference in the frequency was observed between the three groups. CONCLUSION: Scalp incision, rather than external impact force, might affect the CA1 hippocampal neuronal degeneration in mice with TBI. In addition, factor(s) other than external impact force or scalp incision may also cause hippocampal neuronal degeneration in both CA1 and CA3. Careful interpretation is needed concerning hippocampal neuronal degeneration induced by a weight drop device observed in mice with TBI.

An innovated surgical strategy of coronoid process fracture combined with ipsilateral zygomatic arch fracture / 重庆医学

Objective To explore an effective and safe therapeutic strategy in the treatment of coronoid process fracture com‐bined with ipsilateral zygomatic arch fracture .Methods Through the semi coronoid scalp incision ,`an open reduction and internal fixation of zygomatic arch fracture was done .The operation was modified that the area of zygomatic arch fracture was exposed ade‐quately ,and then the fracture fragments of zygomatic arch were turned up .The coronoid process fracture pieces were isolated and removed along with the direction of muscle fibers in the temporalis muscle .Results All Cases of the surgical incisions were healed by primary intention .After 3 - 24 months following up ,the function of mouth opening and closing ,and the other movements of mandible became normal .Conclusion Through the semi coronoid scalp incision ,zygomatic arch fracture reduction and internal fixa‐tion and the coronoid process fracture pieces removing can be done simultaneously .In this way ,an effective and safe therapeutic strategy for treating coronoid process fracture combined with ipsilateral zygomatic arch fracture .