Abstract
Background
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).
Results
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.
Conclusions
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.
Similar content being viewed by others
Change history
20 December 2018
Incorrect given and family of Miron Yousif.
Abbreviations
- GCS:
-
Glasgow Coma Scale
- CNS:
-
Central nervous system
- CSF:
-
Cerebrospinal fluid
- CT:
-
Computer tomography
- MRI:
-
Magnetic resonance imaging
References
Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM (2006) Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 104:469–479. https://doi.org/10.3171/jns.2006.104.4.469
Albanese J, Leone M, Alliez JR, Kaya JM, Antonini F, Alliez B, Martin C (2003) Decompressive craniectomy for severe traumatic brain injury: evaluation of the effects at one year. Crit Care Med 31:2535–2538. https://doi.org/10.1097/01.CCM.0000089927.67396.F3
Aslakson RA, Curtis JR, Nelson JE (2014) The changing role of palliative care in the ICU. Crit Care Med 42:2418–2428. https://doi.org/10.1097/CCM.0000000000000573
Blomstedt GC (1985) Infections in neurosurgery: a retrospective study of 1143 patients and 1517 operations. Acta Neurochir 78:81–90
Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger J, Surgical Management of Traumatic Brain Injury Author G (2006) Surgical management of traumatic parenchymal lesions. Neurosurgery 58:S25–S46; discussion Si-iv. https://doi.org/10.1227/01.NEU.0000210365.36914.E3
Crudele A, Shah SO, Bar B (2016) Decompressive Hemicraniectomy in acute neurological diseases. J Intensive Care Med 31:587–596. https://doi.org/10.1177/0885066615601607
Fowler RA, Abdelmalik P, Wood G, Foster D, Gibney N, Bandrauk N, Turgeon AF, Lamontagne F, Kumar A, Zarychanski R, Green R, Bagshaw SM, Stelfox HT, Foster R, Dodek P, Shaw S, Granton J, Lawless B, Hill A, Rose L, Adhikari NK, Scales DC, Cook DJ, Marshall JC, Martin C, Jouvet P, Canadian Critical Care Trials G, Canadian ICUCG (2015) Critical care capacity in Canada: results of a national cross-sectional study. Crit Care 19:133. https://doi.org/10.1186/s13054-015-0852-6
Goedemans T, van der Veer O, Verbaan D, Bot M, Lequin MB, Coert BA, van Furth WR, Bouma GJ, Vandertop WP, Buis DR, van den Munckhof P (2018) Skin augmentation as a last-resort operative technique during decompressive Craniectomy. World Neurosurg 119:e417–e428. https://doi.org/10.1016/j.wneu.2018.07.177
Gower DJ, Lee KS, McWhorter JM (1988) Role of subtemporal decompression in severe closed head injury. Neurosurgery 23:417–422
Hamed M, Schuss P, Daher FH, Borger V, Guresir A, Vatter H, Guresir E (2016) Acute traumatic subdural hematoma: surgical Management in the Presence of cerebral herniation-a single-center series and multivariate analysis. World Neurosurg 94:501–506. https://doi.org/10.1016/j.wneu.2016.07.061
Holsgrove DT, Kitchen WJ, Dulhanty L, Holland JP, Patel HC (2014) Intracranial hypertension in subarachnoid hamorrhage: outcome after decompressive craniectomy. Acta Neurochir Suppl 119:53–55. https://doi.org/10.1007/978-3-319-02411-0_9
Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ, Collaborators RET (2016) Trial of decompressive Craniectomy for traumatic intracranial hypertension. N Engl J Med 375:1119–1130. https://doi.org/10.1056/NEJMoa1605215
Jennett B, Bond M (1975) Assessment of outcome after severe brain damage. Lancet 1:480–484
Jiang JY, Xu W, Li WP, Xu WH, Zhang J, Bao YH, Ying YH, Luo QZ (2005) Efficacy of standard trauma craniectomy for refractory intracranial hypertension with severe traumatic brain injury: a multicenter, prospective, randomized controlled study. J Neurotrauma 22:623–628. https://doi.org/10.1089/neu.2005.22.623
Karamanos E, Teixeira PG, Sivrikoz E, Varga S, Chouliaras K, Okoye O, Hammer P (2014) Intracranial pressure versus cerebral perfusion pressure as a marker of outcomes in severe head injury: a prospective evaluation. Am J Surg 208:363–371. https://doi.org/10.1016/j.amjsurg.2013.10.026
Kim KT, Park JK, Kang SG, Cho KS, Yoo DS, Jang DK, Huh PW, Kim DS (2009) Comparison of the effect of decompressive craniectomy on different neurosurgical diseases. Acta Neurochir 151:21–30. https://doi.org/10.1007/s00701-008-0164-6
Kurland DB, Khaladj-Ghom A, Stokum JA, Carusillo B, Karimy JK, Gerzanich V, Sahuquillo J, Simard JM (2015) Complications associated with decompressive Craniectomy: a systematic review. Neurocrit Care 23:292–304. https://doi.org/10.1007/s12028-015-0144-7
Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM, Investigators SI (2013) Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 382:397–408. https://doi.org/10.1016/S0140-6736(13)60986-1
Stone HA, Edelman RD, McGarry JJ (1993) Epigard: a synthetic skin substitute with application to podiatric wound management. J Foot Ankle Surg 32:232–238
Sundseth J, Sundseth A, Jacobsen EA, Pripp AH, Sorteberg W, Altmann M, Lindegaard KF, Berg-Johnsen J, Thommessen B (2017) Predictors of early in-hospital death after decompressive craniectomy in swollen middle cerebral artery infarction. Acta Neurochir 159:301–306. https://doi.org/10.1007/s00701-016-3049-0
Takeuchi S, Takasato Y, Masaoka H, Hayakawa T, Yatsushige H, Shigeta K, Nagatani K, Otani N, Nawashiro H, Shima K (2013) Decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage. Acta Neurochir Suppl 118:277–279. https://doi.org/10.1007/978-3-7091-1434-6_53
Vavilala MS, Kernic MA, Wang J, Kannan N, Mink RB, Wainwright MS, Groner JI, Bell MJ, Giza CC, Zatzick DF, Ellenbogen RG, Boyle LN, Mitchell PH, Rivara FP, Pediatric Guideline A, Outcomes S (2014) Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury. Crit Care Med 42:2258–2266. https://doi.org/10.1097/CCM.0000000000000507
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. After reviewing the study protocol, the ethical committees at both institutions approved the study (2018–076 and 1011/2018).
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Comments
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
The original version of this article was revised. The name of Miron Yousif was interchanged and is now corrected.
This article is part of the Topical Collection on Neurosurgery general
Rights and permissions
About this article
Cite this article
Grassner, L., Marhold, F., Yousif, M. et al. Experiences with a temporary synthetic skin substitute after decompressive craniectomy: a retrospective two-center analysis. Acta Neurochir 161, 493–499 (2019). https://doi.org/10.1007/s00701-018-3748-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00701-018-3748-9