Download PDF
CC BY-NC-ND 4.0 · Asian J Neurosurg 2023; 18(02): 414-419
DOI: 10.1055/s-0043-1768571
Brief Report

Step Ladder Expansive Cranioplasty: A Novel Perspective in Cranial Volume Augmentation Surgery

Sudip Kumar Sengupta
1   Department of Neurosurgery, Command Hospital (Southern Command), Pune, Maharashtra, India
,
Shashivadhanan Sundervadhanan
1   Department of Neurosurgery, Command Hospital (Southern Command), Pune, Maharashtra, India
,
Tony J. Rappai
2   Department of Surgery, Military Hospital, Gwalior, Madhya Pradesh, India
,
S.M. Sudumbrekar 
3   Department of Neurosurgery, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
,
Sankar Prasad Gorthi
3   Department of Neurosurgery, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
,
Saurabh K. Verma 
4   Department of Neurosurgery, AFMC, Pune, Maharashtra, India
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background In face of a refractory raised intracranial pressure (ICP), surgeons most commonly resort to decompressive craniectomy (DC). Procedure leaves an unprotected brain underlying the craniectomy defect and Monro-Kellie doctrine: disrupted. Different variants of hinge craniotomies (HC) have been used with clinical outcomes comparable to DC as single stage alternatives. However, both DC and every variant of HC have a limit to the achievable volume augmentation and all invariably cause a compression of the cerebral cortex and its vasculature at the craniotomy site. We believe both these limitations adversely affect the outcome.

Methods A team of neuroscientists in Indian Armed Forces Medical Services has been working for the last 9 years toward developing a novel surgical technique that can mitigate both these drawbacks. Desired procedure should take the centripetal pressure exerted by the combination of the tensile strength of the scalp (with or, without an underlying bone flap) and atmospheric pressure off the brain surface while achieving an assured augmentation of intracranial volume that can be optimized on a case-to-case basis. We call it a “step ladder expansive cranioplasty.”

Results The distance of the parietal eminence was found to have increased by 10.2 mm on the operated side after expansive cranioplasty.

Conclusion From drawing board to bedside, we have made some progress toward our goal, but it is still far away from completion. More studies are required to fill in the gaps in our knowledge necessary to optimize the various parameters of the surgery. Procedure has promise to be of special role in in war and disaster scenarios.

Keywords

augmentation - cranioplasty - decompressive - expansive - hemicraniectomy - volume


Publication History

Article published online:
06 June 2023

© 2023. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Kumar Sengupta S. Presenting step-ladder expansive cranioplasty as the next step after decompressive hemicraniectomy: it is different!. Arch Neurosci 2022; 9 (02) e117417
    CrossrefSearch in Google Scholar
  • 2 Ko K, Segan S. In situ hinge craniectomy. Neurosurgery 2007;60(04, Suppl 2):255–258, discussion 258–259
  • 3 Adeleye AO, Azeez AL. Decompressive craniectomy bone flap hinged on the temporalis muscle: a new inexpensive use for an old neurosurgical technique. Surg Neurol Int 2011; 2: 150
    CrossrefPubMedSearch in Google Scholar
  • 4 Mishra T, Kishore K, Jayan M. et al. When the bone flap expands like bellows of accordion: feasibility study using novel technique of expansile (hinge) craniotomy for severe traumatic brain injury. Neurol India 2021; 69 (04) 973-978
    CrossrefPubMedSearch in Google Scholar
  • 5 Sengupta SK, Bhatoe HS. Cortical pressure injury: a hypothesis to explain the incongruity of clinical and radiologic improvement in decompressive craniectomy. Indian J Neurosurg 2019; 8: 188-190
    Thieme ConnectSearch in Google Scholar
  • 6 Kumar Sengupta S, Shashivadhanan S, Mathai KI, Sudumbrekar SM. In decompressive craniectomy procedures it does not matter which way you do the duraplasty, or, does it? A study on an experimental model. Indian J Neurotrauma 2012; 9: 93-98
    Thieme ConnectSearch in Google Scholar
  • 7 Sengupta S. Step-ladder expansive cranioplasty after decompressive craniotomy and expansive duraplasty: discussing possibilities on a mathematical model. Indian J Neurosurg 2015; 4: 15-21
    Thieme ConnectSearch in Google Scholar
  • 8 Sengupta S, Sahni H, Rappai TJ, Verma S. Step ladder expansive cranioplasty: feasibility study on computed tomographic scan images. Indian J Neurosurg 2015; 4: 102-108
    Thieme ConnectSearch in Google Scholar
  • 9 Sengupta S, Tandon S, Sahi I. Step-ladder expansive cranioplasty: a study on a cadaveric model. Indian J Neurosurg 2018; 7: 16-22
    Thieme ConnectSearch in Google Scholar
  • 10 Sengupta S. Single-step step ladder expansive cranioplasty. Indian J Neurosurg 2017; 6: 107-112
    Thieme ConnectSearch in Google Scholar
  • 11 Sengupta SK, Bajaj H, Maurya V. Single-step ladder expansive cranioplasty: 2-year follow-up. Indian J Neurosurg 2019; 10 (03) 263-265
    Search in Google Scholar
  • 12 Münch E, Horn P, Schürer L, Piepgras A, Paul T, Schmiedek P. Management of severe traumatic brain injury by decompressive craniectomy. Neurosurgery 2000; 47 (02) 315-322 , discussion 322–323
    CrossrefPubMedSearch in Google Scholar
  • 13 Cavuşoğlu H, Kaya RA, Türkmenoğlu ON, Aydin Y. Value of early unilateral decompressive craniectomy in patients with severe traumatic brain injury. Ulus Travma Acil Cerrahi Derg 2010; 16 (02) 119-124
    PubMedSearch in Google Scholar
  • 14 Olivecrona M, Rodling-Wahlström M, Naredi S, Koskinen LO. Effective ICP reduction by decompressive craniectomy in patients with severe traumatic brain injury treated by an ICP-targeted therapy. J Neurotrauma 2007; 24 (06) 927-935
    CrossrefPubMedSearch in Google Scholar
  • 15 Flint AC, Manley GT, Gean AD, Hemphill III JC, Rosenthal G. Post-operative expansion of hemorrhagic contusions after unilateral decompressive hemicraniectomy in severe traumatic brain injury. J Neurotrauma 2008; 25 (05) 503-512
    CrossrefPubMedSearch in Google Scholar
  • 16 Fletcher TL, Kolias AG, Hutchinson PJ, Sutcliffe MPF. A new improved method for assessing brain deformation after decompressive craniectomy. PLoS One 2014; 9 (10) e110408
    CrossrefPubMedSearch in Google Scholar
  • 17 Hernández-Durán S, Meinen L, Rohde V, von der Brelie C. Invasive monitoring of intracranial pressure after decompressive craniectomy in malignant stroke. Stroke 2021; 52 (02) 707-711
    CrossrefPubMedSearch in Google Scholar
  • 18 Bhat AR, Kirmani AR. “Sunken brain and scalp flap” syndrome following decompressive “extra-craniectomy.”. Indian J Neurotrauma 2011; 8: 105-108
    Thieme ConnectSearch in Google Scholar
  • 19 Segal DH, Oppenheim JS, Murovic JA. Neurological recovery after cranioplasty. Neurosurgery 1994; 34 (04) 729-731 , discussion 731
    PubMedSearch in Google Scholar