1) Hinge craniotomy is a potential alternative to decompressive craniectomy for treating traumatic brain injury and stroke that provides adequate cerebral decompression with fewer complications and lower costs compared to craniectomy. 2) Studies found hinge craniotomy resulted in similar reductions in intracranial pressure and brain volume expansion as craniectomy but with fewer infections, wound complications, and cases requiring subsequent craniectomy. 3) While more research is still needed, hinge craniotomy may offer an intermediate surgical option between medical management and traditional craniectomy, particularly as an alternative to primary decompressive craniectomy.

1. Dhaval Shukla
Professor of Neurosurgery,
National Institute of Mental Health and Neurosciences [NIMHANS],
Bangalore, India.
Surgical Alternatives to Decompressive
Craniectomy for TBI and Stroke

2. I have no relevant financial relationships to disclose.

3. TBI and Stroke
• 60% of global neurosurgical burden is Traumatic Brain Injury and
Stroke – especially in middle- to low-income settings.
• High level of morbidity and mortality incurs additional social burden
• Predominantly affects economically productive age group
Horsfall HL, et al. Neurosurgical Review 2019.

4. Decompressive Craniectomy [DC]
TBI
Level IIA–to improve mortality and overall outcomes
1. NEW–Secondary DC performed for late refractory ICP
elevation is recommended.
2. NEW–Secondary DC performed for early refractory ICP
elevation is not recommended.
3. A large frontotemporoparietal DC (not less than 12 × 15 cm
in diameter) is recommended
Level IIA–for ICP control
4. NEW–Secondary DC, performed as a treatment for either
early or late refractory ICP elevation, is suggested to reduce
ICP and duration of intensive care, though the relationship
between these effects and favorable outcome is uncertain.
Stroke
Hawryluk GW, et al. Neurosurgery 2020.
Huttner H, et al. Lancet Neurol 2009.

5. Why not Decompressive Craniectomy [DC]?
Gopalkrishnan MS, et al. Frontiers in Neurology 2018.

6. Cranioplasty after DC!
Satpathy D, et al. World Neurosurgery 2019.
Chaturvedi J, et al. Brit J Neurosurg 2016.

7. Cranioplasty after DC!
Satpathy D, et al. World Neurosurgery 2019.
Chaturvedi J, et al. Brit J Neurosurg 2016.

8. Volume Expansion Procedure Volume Reduction Procedure
Horsfall HL, et al. Neurosurgical Review 2019.

9. Hinge Craniotomy
Ko K, et al. Oper Neurosurg 2007.
Schmidt JH, et al. J Neurosurg 2007.
Goettler CE, J Trauma Acute Care 2007.

10. HINGE CRANIOTOMY – POTENTIAL BENEFITS
• Controls atleast moderate cerebral edema
• Eliminates the need for a subsequent cranioplasty
• Potential reduction in axonal stretching
• Fewer complications
Horsfall HL, et al. Neurosurgical Review 2019.

11. Indication and patient demographics
• 15 studies [283 patients] were included with mean age of 45.1
• 230 patients (81.3%) underwent HC following TBI.
1. Acute SDH (n = 182, 79.1%)
2. ICH (n = 33, 14.3%)
• 53 patients (18.7%) underwent HC following stroke.
1. Haemorrhagic (n = 40, 75.5%)
2. Ischaemic (n =13, n =24.5%).
Horsfall HL, et al. Neurosurgical Review 2019.

13. Does Hinge Craniotomy Cause Volume Expansion?
Horsfall HL, et al. Neurosurgical Review 2019.
Variables
Expansile
craniotomy
(n=31)
DC
(n=36)
Age in years, mean ± SD 36.4 ± 12.1 41.8 ± 12.4
GCS at admission, median
(IQR)
8 (6.5-10) 7 (5-10)
Rotterdam score at
admission, median (IQR)
4 (3-4) 4 (3-4)
Pre-operative ICV, mean ±
SD
1171.5 ± 140.9 1163.4 ± 154.1
Post-operative ICV, mean ±
SD
1217.6 ±
160.21
1212.1 ±
157.02
Volume expansion, mean ±
SD
47.5±33.1 48.6±47.7
Volume expansion (%) 3.8 ± 2.8 4.3 ± 3.7
Mishra T, et al. Neurology India 2019.

14. 1
2
3 1
2 3
Data represented as mean ± SD
Does Hinge Craniotomy Cause ICP Reduction?
Horsfall HL, et al. Neurosurgical Review 2019.
Out of 283 patients, only 9 patients (3.2%) required subsequent DC
Mishra T, et al. Neurology India 2019.

16. Hinge Craniotomy - Clinical outcomes
• 283 patients underwent HC, of which 211 survived (74.6%).
• There was a paucity of data reported relating to functional outcome and duration of
follow-up.
• TBI
• No significant difference in mortality.
• More patients in the DC group had
poor functional outcome.
• Stroke
• HC for stroke was associated with
better long-term functional outcome
Horsfall HL, et al. Neurosurgical Review 2019.
Mishra T, et al. Neurology India 2019.

17. Is Hinge Craniotomy Safe?
• There were 54 reported complications in the HC cohort.
• 15 infections (8.7%) in the DC group versus 12 infections (4.2%) in the
HC (p =0.065).
Horsfall HL, et al. Neurosurgical Review 2019.
Type(s) of complication
Expansile craniotomy
(%)
Decompressive
craniectomy (%)
Total 22.6 30.5
Wound complications/infections/subgaleal collection 9.7 11.1
Hydrocephalus requiring VP shunt 0 2.7
Sunken flap syndrome 0 2.7
Cosmetic failure 12.9 13.8
Mishra T, et al. Neurology India 2019.

18. • It must be appreciated that HC cannot, as yet, be considered an alternative to all
the DCs, but rather an alternative to primary DC, not to secondary DC.
• To further develop HC, additional evaluation of the technique prospectively and
co-operatively may help mature consensus over definition, quality and
indications.
• Ultimately, an international effort, with a multi-centre randomised controlled
trial, with participation from low- and middle-income countries is required.
• The trial could compare HC to DC with criteria for progression from HC to DC in
selected cases.
Should One Switch Over to Hinge Craniotomy?
Horsfall HL, et al. Neurosurgical Review 2019.
Mishra T, et al. Neurology India 2019.

19. Hinge Craniotomy - Verdict
• HC has a potential role in the surgical management of TBI/stroke, yielding
adequate cerebral decompression in the majority of reported cases, a reduction
in complications and potentially offers substantial economic savings (both
operative costs and the cost of living with significant morbidity).
• It is likely that HC offers an intermediate intervention between treatment-
refractive medical therapy and traditional decompressive craniectomy.
Horsfall HL, et al. Neurosurgical Review 2019.
Mishra T, et al. Neurology India 2019.
To D or not to D ?
Opt for E

20. www.ntsi.co.in

21. External Ventricular Drainage [EVD] of CSF
Chau CYK, et al. J Cli Med 2019

22. EVD
• Monitoring of ICP
• Drainage of even small volumes can lower ICP significantly
• Clearance of haemorrhage from a ventricle
• Cerebral perfusion pressure
• Cerebral oxygenation (PbtO2)
Czosnyka M, et al. JNNP 2004.
Akbik OS, J Neurotrauma 2017

23. EVD Insertion in TBI
• 10 cm from the nasion
• 3 to 5 cm laterally from the midline
• Directing the catheter to the nasion or the contralateral medial canthus
Raabe C, et al. J. Neurosurg 2018

24. Continuous Vs. Intermittent Drainage
Continuous
• Drainage
• Lower overall ICP burden
• Lower levels of biochemical markers
• Ventricular collapse
• EVD obstruction
Intermittent
• Certain duration
• Amount determined
• Monitoring
Chau CYK, et al. J Cli Med 2020

25. When to use EVD
• 1st-tier
• United States, Australia, and most parts of Europe
• 2nd-tier
• United Kingdom and Israel
• 3rd-tier
Chau CYK, et al. J Cli Med 2019.
Maas A. Acta Neurochir 2013.

26. EVD Vs DC
Bhargava D, et al. Acta Neurochir 2013

27. DC following EVD
Chau CYK, et al. J Cli Med 2020

28. Effect of EVD on Functional Outcome
• Hospital mortality
• 28-day mortality
• Unfavorable outcome
• Extended Glasgow Outcome Scale at 6 months
• 2.46 to 2.81
Griesdale DE, et al. Can J Neurol Sci 2010

29. EVD Complications
Chau CYK, et al. J Cli Med 2020

30. Developing the evidence base
• To continue developing the evidence base for HC, they advocated following the
IDEAL Methodology.
• This is a 5 stage description of the surgical development process, a crucial tool for
systematic evaluation of surgical innovation and that is instrumental for achieving
improved design, conduct and reporting of surgical research.
• Currently, HC is between ‘Exploration’ and ‘Assessment’, i.e. the technique is
stable, has been replicated by numerous study groups and there is some
literature demonstrating comparison to existing practice (DC).

31. All Nation - One Fashion
dhavalshukla@nimhans.ac.in