After the craniotomy has been performed, and before the dura is opened, one should tack the dura to the periosteum of the skull. Because of the remarkably high degree of vascularization of the skull and the relatively loose adherence between outer layer of the dura and inner table of the skull, it is essential to sew the outer layer of the dura to the periosteum along the craniotomy line before proceeding to open the dura in order to minimize risks of epidural hematoma formation (4–0 sutures suffice to perform this). It is not necessary to perforate the skull to anchor these sutures because the periosteum is strong enough to offer adequate purchase. However, one should place the dural needle through the periosteum along a line parallel to the cut edge of the periosteum (skull), not perpendicular to it, since this avoids fraying or tearing of the periosteum at the time the knot is tied. One need not sew the dura to the periosteum along the region of the anterior or posterior fontanels, across a cranial suture, or at the superior sagittal or transverse sinues, since at these points outer layer of dura, cranial suture, and periosteum are one continuous structure in the newborn and infant.
KeywordsSuperior Sagittal Sinus Dural Opening Transverse Sinus Pineal Region Middle Meningeal Artery
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