Practice Innovations
Decompressive craniectomies (DCs) are commonly complicated with epidural fibrosis post cranial resection, resulting in adherence of the dura to both the brain internally and skin flap externally. The purpose of this pilot study was to evaluate whether DHACM used in the setting of emergent craniectomies decreased rate of dural adhesion formation and subsequent cranioplasty complications.
Seven patients were retrospectively screened based on having undergone emergent DC for a traumatic brain injury (TBI) or malignant edema secondary to a cerebral infarction of the middle cerebral artery (MCA) where both groups received DHACM anti-adhesion protocol with subsequent delayed cranioplasties (CPs). The primary objective was to qualitatively evaluate adhesion formation in patients who received intraoperative DHACM interlay/overlay during emergent DC. Secondary outcomes include estimated blood loss during CP, time dedicated to dissection/exposure, and post-surgical complications. The study was reviewed and approved by the site's institutional IRB.
Of the seven patients, five (71%) had undergone emergent decompression due to SDH secondary to TBI while the additional two patients (29%) had right MCA infarctions resulting in malignant edema and large midline shift. Qualitative assessment determined 86% (6/7) of patients demonstrated no adhesions at the time of the CP. One patient (14%) was found to have significant adhesions formed, yet perioperative notes did not show evidence of complications in dissection in this patient. Secondary metrics revealed the estimated time spent dissecting and exposing skull defect prior to implantations was under 3 minutes and the estimated blood loss was minimal ranging from 50-100 mLs with an average of 64.2 mLs. Lastly, of all the patients who had continuous surveillance and follow-up visits, seizures, a known post DC issue, were the most noted complication. However, the secondary outcome analysis, which included post-surgical complications (e.g., seizures) was limited due to insufficient power of the study.
DHACM’s potential as a physical barrier which can aid in supporting an intracranial environment capable of ameliorating reactive fibrosis in decompressive craniectomy patients is promising. Further research with larger patient volume and controls arms would be invaluable in determining the full therapeutic effect compared to current anti-adhesion protocols.