"Basal durotomy" to prevent massive intra-operative traumatic brain swelling

Objective. Massive intraoperative swelling (IOS) is a potential complication of intracranial surgery for traumatic hematomas. We present a novel design of dural opening to minimize the risks of IOS. Methods. Over the last eight years, we have used and evaluated a "reversed U-shaped" durotomy incision, which leaves the dura intact in the parasagittal region. Accordingly, the dura should be opened initially over the fronto-basal eminence of the frontal lobe anterior to the middle meningeal artery and sylvian region. The incision is then carried across the middle meningeal into the temporal region. Additional slit incisions may be made, as needed, around the circumference of the craniotomy in order to obtain sufficient access to remove a subdural hematoma. Results. We have employed this technique in 220 trauma craniotomies without any case of uncontrolled IOS. In all patients a complete dural closure was obtained. Conclusion. When IOS is suspected, basal durotomy proved to be an excellent technique to prevent it, without compromising the total evacuation of the traumatic intracranial hematoma.