The Kempe incision for decompressive craniectomy, craniotomy, and cranioplasty in traumatic brain injury and stroke

Abstract

OBJECTIVE Decompressive craniectomy (DC) is an effective, lifesaving option for reducing intracranial pressure (ICP) in traumatic brain injury (TBI), stroke, and other pathologies with elevated ICP. Most DCs are performed via a standard trauma flap shaped like a reverse question mark (RQM), which requires sacrificing the occipital and posterior auricular arteries and can be complicated by wound dehiscence and infections. The Ludwig Kempe hemispherectomy incision (Kempe) entails a T-shaped incision, one limb from the midline behind the hairline to the inion and the other limb from the root of the zygoma to the coronal suture. The authors’ objective in this study was to define their implementation of the Kempe incision for DC and craniotomy, report clinical outcomes, and quantify the volume of bone removed compared with the RQM incision. METHODS A retrospective review of a single-surgeon experience with DC in TBI and stroke was performed. Patient demographics, imaging, and outcomes were collected for all DCs from 2015 to 2020, and the incisions were categorized as either Kempe or RQM. Preoperative and postoperative CT scans were obtained and processed using a combination of automatic segmentation (in Python and SimpleITK) with manual cleanup and further subselection in ITK-SNAP. The volume of bone removed was quantified, and the primary outcome was percentage of hemicranium removed. Postoperative surgical wound infections, estimated blood loss (EBL), and length of surgery were compared between the two groups as secondary outcomes. Cranioplasty data were collected. RESULTS One hundred thirty-six patients were included in the analysis; there were 57 patients in the craniotomy group (44 patients with RQM incisions and 13 with Kempe incisions) and 79 in the craniectomy group (41 patients with RQM incisions and 38 Kempe incisions). The mean follow-up for the entire cohort was 251 ± 368 days. There was a difference in the amount of decompression between approaches in multivariate modeling (39% ± 11% of the hemicranium was removed via the Kempe incision vs 34% ± 10% via the RQM incision, p = 0.047), although this did not achieve significance in multivariate modeling. Wound infection rates, EBL, and length of surgery were comparable between the two incision types. No wound infections in either cohort were due to wound dehiscence. Cranioplasty outcomes were comparable between the two incision types. CONCLUSIONS The Kempe incision for craniectomy or craniotomy is a safe, feasible, and effective alternative to the RQM. The authors advocate the Kempe incision in cases in which contralateral operative pathology or subsequent craniofacial/skull base repair is anticipated.

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

“…According to Ordonez-Rubiano [ 17 ], the RQM and Kempe are both effective techniques with comparable risk for scalp necrosis, infection, and cosmetic complications. As noted by Abecassis, the Kempe incision may allow the performance of a larger decompression than the RQM [ 14 ]. When comparing the RQM and Kempe to the RA, Eltabl and colleagues reported that the RA is a safe substitute for these techniques.…”

“…Of note, the DHC has also become a routine neurosurgical intervention for malignant cerebral ischemia, aneurysmal subarachnoid hemorrhage, and is under investigation for its efficacy in treating ICH. [ 14 ]…”

“…When performing the DHC, also referred to as the frontotemporoparietal craniectomy or “Dandy flap,” the patient is positioned supine with the head placed in rigid 3-point fixation or on a horseshoe head holder and rotated 45 to 60° with the option to place an ipsilateral shoulder roll or sandbag [ 14 ]. Historically, the bilateral frontal craniectomy was performed to alleviate build-up of pressure, but this has fallen out of favor due to the convenience and ability to preserve half of the skull through the unilateral frontotemporoparietal DHC [ 14 ]. This is because the DHC provides better decompression, as it allows the brain to swell laterally to one side, affording the option for quick temporal decompression.…”

“…This incision begins 1–2 cm anterior to the tragus at the temporal root of the zygoma, near the region of the starting point for the RQM technique. Care must be taken not to violate the STA just as is the case for the RQM incision [ 14 ]. In their 2021 series featuring 79 DC patients from 2015 to 2020, Abecassis and colleagues [ 25 ] share that the main issues with the RQM—though it does provide adequate exposure for decompression when craniectomy is performed in the 12 × 15 cm 2 manner—include that it involves sacrificing the occipital and posterior auricular arteries which leads to higher risk for wound infections and other complications.…”

Angiographically Silent Ruptured Dural Arteriovenous Fistula Presenting As Subdural Hematoma

“…Given the mass effect of the patient’s subdural hematoma and declining mental status, the patient was taken to the operating room for evacuation after her catheter angiogram. We placed the patient in Mayfield skull pins and used a Kempe incision for a large frontotemporoparietal craniotomy [ 9 ]. After elevation of the skull flap, we opened the dura in a stellate fashion, and the subdural hematoma immediately egressed under pressure.…”