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122          Romanian Neurosurgery (2010) XVII 1: 122 - 124 

 
 
 

Consideration on Hemicraniectomy – Part II 

H. Stan, B. Suciu, Al. Iosif, Adriana Cocis 

Departament of Neurosurgey, Medical University of Cluj 

Abstract 
Decompressive hemicraniectomy is a surgical technique used to relieve the increased 
intracranial pressure. The aim of the current paper is to present our surgical technique and 
experience used in performing hemicraniectomies, technique that we consider optimal for his 
purpose. Our experience consists in 17 operated cases and eleven patients (64.7%) were long 
term survivors. 

Keywords: decompressive hemicraniectomy, increased intracranial pressure, surgical 
technique 

 

Consideration on hemicraniectomy, 
part I was published in Volume XVI, no. 
1/2009 of Romanian Neurosurgery We 
presented our experience in the field and 
discussed clinical aspects, indication and 
outcomes. The part II of this paper comes 
to detail our surgical technique with 
images. 

Surgical technique considerations 
The patient is placed with the side of 

craniotomy upward, head elevated to 15 
degrees. The line of skin incision is 
described from posterior to anterior: 
beginning retro-auricular (to the 
mastoid), extended in a supero-posterior 
manner and than reversed to anterior 
approximately 2 cm parallel to the sagittal 
line until the widow peak, then reversed 
infero-basal, respecting the hair line to the 
preauricular region (Figure 1). Care must 
be taken to preserve the principal 
ramifications of temporary artery inside 
de musculocutaneous flaps to avoiding 
devascularisation and necrosis of the 
incision edge.  

A large periosteal tissue flap is 
harvested from the entire exposed area for 
ulterior duroplasty (Figure 2). Using a 
monopolar subperiostal dissection the 
temporalis muscle is reflected basally.  

The margins and burr holes for 
hemicraniectomy, described from 
anterobasal to posterior are: temporo-
basal, under the level of ear pina; 
pterional at the site of the classic keyhole; 
fronto-basal, above the level of frontal 
sinus, to expose frontal pole but avoid 
entry in the frontal air cells sinus; then 
along the planned paramedial 
craniectomy margin, 2 cm parasagittal 
(avoid lesions over saggital sinus bridging 
veins and arachnoid’s granulations), to 
lambda point; then antero-basal, tangent 
with lambdoid suture, until 1 cm above 
the asterion (to avoid lacerations of 
transverse-sigmoid sinus) (Figure 3). The 
sphenoid wing is fractured and removed. 
Decompression was extended far enough 
to the floor of the middle fossa to relieve 
pressure from the herniating mediobasal 
temporal lobe and up to the midline to 



 
 
 

H. Stan et al         Consideration on Hemicraniectomy          123 

 
 
 

avoid compression of the bridging veins 
(1-2 cm) (1). The cranial vault is 
removed. 

Dura is opened by a large radial 
incision to allow the brain to expand 
outward (Figure 4) (2). Prophylactic, if 
the intracranial pressure is not elevated, 
dural edges are tacked up to bony 
margins.  

Large duraplasty with extra space for 
brain to enlarge, using all periostal tissue 
from the cranial vault is performed 
(Figure 5). It is important that the 
duroplasty to have a “sun flower shape”, 
to permit free enlargement of the brain 
without damaging the cortical substance. 
The temporalis muscle is resting on the 
dural surface. Extradural drain is placed. 
Cutaneous flap is sutured in one plane in 
a Donati manner. 
 

 
Figure 1 The patient is placed within the 
side of craniotomy upward, head elevated 
to 15 degree. The line of skin incision is 

described from posterior to anterior: 
beginning retro-auricular (to the 
mastoid), extended in a supero-posterior 
manner and than reversed to anterior 
approximately 2 cm parallel to the sagittal 
line until the widow peak, then reversed 
infero-basal, respecting the hair line to 
preauricular region. To avoid necrosis of 
the skin incision edge, care must be 
tacked to preserve the principal 
ramifications of temporary artery inside 
de musculocutaneous flaps. 
 

 
Figure 2 An large periosteal tissue flaps is 

recoltated for ulterior duroplasty 

 

 
Figure 3 The temporalis muscle is 
reflected basally. The margins and key-
hole for hemicraniectomy, described 



 
 
 
124          Romanian Neurosurgery (2010) XVII 1: 122 - 124 

 
 
 

from anterobasal to posterior are: 
temporo-basal, under the level of ear 
pina; pterional aproximatively at the site 
of the classic keyhole; fronto-basal, above 
the level of frontal sinus, to expose frontal 
pole but avoid entry in the frontal air cells 
sinus; then along the planned paramedial 
craniectomy margin, 2 cm parasagittal 
(avoid lesions over saggital sinus and 
bridging vains), until lambda point; than 
antero-basal, tangential with lambdoid 
suture, until aproximatively 1 cm above 
the asterion (to evoid entry in transverse-
sigmoid sinus). 
 

 
Figure 4 The dura is opened by a linear 

incision extended radial to allow the brain to 
expand outward. 

 

 
Figure 5 Large duroplasty with extra space for 
brain to enlarge, using all periostal tissue 
recoltated from the cranial vault is made. 

 

References 
1.Hemicraniectomy with dural augmentation in 
medically uncontrollable hemispheric infarction. 
Christian Rainer Wirtz, M.D., Thorsten Steiner, M.D., 
Alfred Aschoff, M.D., Ph.D., Stefan Schwab, M.D., 
Holger Schnippering, M.D., Hans Herbert Steiner, 
M.D., Werner Hacke, M.D., Ph.D., and Stefan Kunze, 
M.D., Ph.D. Neurosurgical Focus 2(5): Article 3, 1997. 
2.Surgery for brain edema. Peter Hutchinson, 
f.r.c.s.(sn), Ivan Timofeev, m.r.c.s., and Peter 
Kirkpatrick, f.r.c.s.(sn). Neurosurg Focus 22 (5):E14, 
2007