The floating anchored craniotomy

Abstract

Background:The “floating anchored” craniotomy is a technique utilized at our tertiary neurosurgery institution in which a traditional decompressive craniectomy has been substituted for a floating craniotomy. The hypothesized advantages of this technique include adequate decompression, reduction in the intracranial pressure, obviating the need for a secondary cranioplasty, maintained bone protection, preventing the syndrome of the trephined, and a potential reduction in axonal stretching.Methods:The bone plate is re-attached via multiple loosely affixed vicryl sutures, enabling decompression, but then ensuring the bone returns to its anatomical position once cerebral edema has subsided.Results:From the analysis of 57 consecutive patients analyzed at our institution, we have found that the floating anchored craniotomy is comparable to decompressive craniectomy for intracranial pressure reduction and has some significant theoretical advantages.Conclusions:Despite the potential advantages of techniques that avoid the need for a second cranioplasty, they have not been widely adopted and have been omitted from trials examining the utility of decompressive surgery. This retrospective analysis of prospectively collected data suggests that the floating anchored craniotomy may be applicable instead of decompressive craniectomy.

Hinge/floating craniotomy as an alternative technique for cerebral decompression: a scoping review

“…Miniplate to prevent flap resorption. Refastening of bone flap in 16/21 cases under local anaethesia No Mezue 2013 [ 27 ] Decompressive craniotomy “Large temporo-parietal trauma flap” “Loosely repaired” Autologous material, temporalis muscle or pericranium In situ free floating or loosely sutured craniotomy No Peethambaran 2015 [ 28 ] Four-quadrant osteoplastic decompressive craniectomy “Traditional craniectomy” Duroplasty Synthetic patch Bone flap divided into four-quadrants then the periosteum on each bone piece was sutured loosely to other pieces, as well as to the periosteum on one side of the calvarium with prolene/silk sutures No Tsermoulas 2016 [ 25 ] Riding craniotomy “Trauma craniotomy and wide exposure” “Dura left open” Not stated Miniplates to prevent flap resorption No Adeleye 2016 [ 26 ] Modified temporal muscle hDC At least 14 cm Duraplasty Composite subgaleal fascia-pericranium flap Bone flap in situ with ipsilateral temporalis muscle; anterior and posterior vertical cuts in muscle sutured allowing mobility Yes Gutman 2017 [ 13 ] Floating anchored craniotomy > 12 × 15 cm Simple onlay Geloforam or dural substitute Loose vicryl sutures (1–2 cm slack) and plates (unscrewed) to prevent flap resorption and skin flap 10 cm clearance to facilitate expansion Subgaleal …”

“…Specifically, of the studies that had pre-operative ICP recorded, patients undergoing HC demonstrated a reduced ICP post-operatively. Patients in the Guttman et al [ 13 ] series had pre-operative ICP of 32.7 ± 8.1 mmHg compared to 16.0 ± 12.1 mmHg post-operatively. In Valenca et al [ 20 ], the pre-operative ICP range was 15–35 mmHg and 6–12 mmHg post-operatively.…”

“…A total of 15 studies [10][11][12][13][18][19][20][21][22][23][24][25][26][27][28] were eligible for inclusion ( Fig. 1), comprising 283 patients with a mean age 45.1 years and a male:female of 199:46 ( Table 1).…”

“…Some of the groups fastened the upper initially unsecured screws several months later to secure the bone flap. Another technique used loosely tied sutures attached to the free bone [13] flap or a resin mould of the skull implanted [18]. This promoted symmetrical room for expansion if the brain was to swell, whilst the hinge technique provides only unilateral, and therefore asymmetrical, expansion potential.…”

“…This is a particularly important consideration in resource-limited settings. Furthermore, unlike for the traditional surgical technique of DC, following HC, there are reports of potential reduction in axonal stretching and there are supposedly fewer complications such as syndrome of the trephined, problems with CSF hydrodynamics, infection and resorption of the autologous bone flap [13].…”