title: Exploration of the Most Effective Dural Incision Design in a Decompressive Craniectomy.
abstract: OBJECTIVE
  During a decompressive craniectomy performed for a severe cerebral infarction, sufficient coverage of the underlying bulging brain by converting the flat dura mater to a more domelike shape is essential. In this procedure, suturing to patch dural substitutes on the dural rifts occupies most of the operative time and is cumbersome. We present a new dural incision design that provides an appropriate volume of subdural space with minimal incisions.
  
  
  METHODS
  The ideal incision design was geometrically analyzed and verified by simulations using a physics engine.
  
  
  RESULTS
  Assuming a quadrilateral area on the dura mater surface termed S, expanding the entire area of S requires 2d (where d is the skull thickness) + a 30-mm extension of the shortest set of line segments connecting each vertex (LSCV) of S to cover the necessary volume of bulging brain. The shortest LSCV comprises 5 line segments connected with two 3-pronged intersections. The ideal incision design consists of a pair of curved line segments that maintain plane continuity along the LSCV, which automatically limits the maximum expansion. The ideal incision design of S consists of 5 uncinate line segments. Four of the line segments originate from each vertex of S and end by crossing over the LSCV, and one of the line segments crosses over 2 separate LSCV. A representative case is shown.
  
  
  CONCLUSIONS
  This technique minimizes the complexity of the operation and shortens the operation time.
authors.affiliation: Department of Neurosurgery, Sano Kousei General Hospital, Sano, Tochigi, Japan. Electronic address: mnagai@jichi.ac.jp.
authors.forename: Mutsumi
authors.initials: M
authors.lastname: Nagai
authors.affiliation: Department of Neurosurgery, Edogawa Hospital, Edogawa, Tokyo, Japan.
authors.forename: Mami
authors.initials: M
authors.lastname: Ishikawa
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001929:Brain Edema / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D002544:Cerebral Infarction / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D056424:Decompressive Craniectomy / Q000379:methods*; D004388:Dura Mater / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D061646:Operative Time; D016896:Treatment Outcome
keywords: Decompressive craniectomy; Design; Dural incision; Geometric analysis