{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,20]],"date-time":"2026-10-20T01:16:57Z","timestamp":1792459017144,"version":"4.5.0"},"reference-count":32,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2024,2,14]],"date-time":"2024-02-14T00:00:00Z","timestamp":1707868800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,2,14]],"date-time":"2024-02-14T00:00:00Z","timestamp":1707868800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Neurosurg Rev"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Decompressive hemicraniectomy (DHC) is a critical procedure used to alleviate elevated intracranial pressure (ICP) in emergent situations. It is typically performed to create space for the swelling brain and to prevent dangerous and potentially fatal increases in ICP. DHC is indicated for pathologies ranging from MCA stroke to traumatic subarachnoid hemorrhage\u2014essentially any cause of refractory brain swelling and elevated ICPs. Scalp incisions for opening and closing the soft tissues during DHC are crucial to achieve optimal outcomes by promoting proper wound healing and minimizing surgical site infections (SSIs). Though the reverse question mark (RQM) scalp incision has gained significant traction within neurosurgical practice, alternatives\u2014including the retroauricular (RA) and Kempe incisions\u2014have been proposed. As choice of technique can impact postoperative outcomes and complications, we sought to compare outcomes associated with different scalp incision techniques used during DHC. We queried three databases according to PRISMA guidelines in order to identify studies comparing outcomes between the RQM versus \u201calternative\u201d scalp incision techniques for DHC. Our primary outcome of interest in the present study was postoperative wound infection rates according to scalp incision type. Secondary outcomes included estimated blood loss (EBL) and operative duration. We identified seven studies eligible for inclusion in the formal meta-analysis. The traditional RQM technique shortened operative times by 36.56\u00a0min, on average. Additionally, mean EBL was significantly lower when the RQM scalp incision was used. Postoperatively, there was no significant association between DHC incision type and mean intensive care unit (ICU) length of stay (LOS), nor was there a significant difference in predisposition to developing wound complications or infections between the RQM and retroauricular\/Kempe incision cohorts. Superficial temporal artery (STA) preservation and reoperation rates were collected but could not be analyzed due to insufficient number of studies reporting these outcomes. Our meta-analysis suggests that there is no significant difference between scalp incision techniques as they relate to surgical site infection and wound complications. At present, it appears that outcomes following DHC can be improved by ensuring that the bone flap is large enough to enable sufficient cerebral expansion and decompression of the temporal lobe, the latter of which is of particular importance. Although previous studies have suggested that there are several advantages to performing alternative scalp incision techniques during DHC, the present study (which is to our knowledge the first to meta-analyze the literature on outcomes in DHC by scalp incision type) does not support these findings. As such, further investigations in the form of prospective trials with high statistical power are merited.<\/jats:p>","DOI":"10.1007\/s10143-024-02307-1","type":"journal-article","created":{"date-parts":[[2024,2,14]],"date-time":"2024-02-14T08:02:31Z","timestamp":1707897751000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Scalp incision technique for decompressive hemicraniectomy: comparative systematic review and meta-analysis of the reverse question mark versus alternative retroauricular and Kempe incision techniques"],"prefix":"10.1007","volume":"47","author":[{"given":"Nolan J.","family":"Brown","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julian","family":"Gendreau","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Redi","family":"Rahmani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joshua S.","family":"Catapano","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael T.","family":"Lawton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2024,2,14]]},"reference":[{"issue":"3","key":"2307_CR1","doi-asserted-by":"publisher","first-page":"203","DOI":"10.4103\/1793-5482.161191","volume":"10","author":"H Bansal","year":"2015","unstructured":"Bansal H, Chaudhary A, Singh A, Paul B, Garg R (2015) Decompressive craniectomy in malignant middle cerebral artery infarct: an institutional experience. Asian J Neurosurg 10(3):203\u2013206","journal-title":"Asian J Neurosurg"},{"issue":"16","key":"2307_CR2","doi-asserted-by":"publisher","first-page":"1493","DOI":"10.1056\/NEJMoa1102077","volume":"364","author":"DJ Cooper","year":"2011","unstructured":"Cooper DJ, Rosenfeld JV, Murray L et al (2011) Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364(16):1493\u20131502","journal-title":"N Engl J Med"},{"issue":"11","key":"2307_CR3","first-page":"CD014989","volume":"11","author":"A Dower","year":"2022","unstructured":"Dower A, Mulcahy M, Maharaj M et al (2022) Surgical decompression for malignant cerebral oedema after ischaemic stroke. Cochrane Database Syst Rev 11(11):CD014989","journal-title":"Cochrane Database Syst Rev"},{"issue":"1","key":"2307_CR4","doi-asserted-by":"publisher","first-page":"66","DOI":"10.3171\/2008.10.PEDS08116","volume":"3","author":"N Aghakhani","year":"2009","unstructured":"Aghakhani N, Durand P, Chevret L et al (2009) Decompressive craniectomy in children with nontraumatic refractory high intracranial pressure. J Neurosurg Pediatr 3(1):66\u201369","journal-title":"J Neurosurg Pediatr"},{"key":"2307_CR5","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1053\/j.otns.2004.04.006","volume":"7","author":"M Holland","year":"2004","unstructured":"Holland M, Nakaji P (2004) Surgical indica- tions and technique. Oper Tech Neurosurg 7:10\u201315","journal-title":"Oper Tech Neurosurg"},{"issue":"6","key":"2307_CR6","doi-asserted-by":"publisher","first-page":"874","DOI":"10.1161\/01.STR.21.6.874","volume":"21","author":"JB Delashaw","year":"1990","unstructured":"Delashaw JB, Broaddus WC, Kassell NF et al (1990) Treatment of right hemispheric cerebral infarction by hemicraniectomy. Stroke 21(6):874\u2013881","journal-title":"Stroke"},{"issue":"4","key":"2307_CR7","doi-asserted-by":"publisher","first-page":"326","DOI":"10.1016\/S1474-4422(09)70047-X","volume":"8","author":"J Hofmeijer","year":"2009","unstructured":"Hofmeijer J, Kappelle LJ, Algra A et al (2009) Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 8(4):326\u2013333","journal-title":"Lancet Neurol"},{"key":"2307_CR8","doi-asserted-by":"crossref","unstructured":"Hendricks B, Burgett K, Cohen-Gadol A (2020) Decompressive craniectomy. In: Neurosurgical Atlas. Neurosurgical Atlas, Inc.","DOI":"10.18791\/nsatlas.v8.ch03.2"},{"issue":"1\u20132","key":"2307_CR9","doi-asserted-by":"publisher","first-page":"89","DOI":"10.1016\/j.jns.2007.04.040","volume":"261","author":"P Mitchell","year":"2007","unstructured":"Mitchell P, Gregson BA, Vindlacheruvu RR, Mendelow AD (2007) Surgical options in ICH including decompressive craniectomy. J Neurol Sci 261(1\u20132):89\u201398","journal-title":"J Neurol Sci"},{"issue":"3","key":"2307_CR10","first-page":"1262","volume":"134","author":"M Veldeman","year":"2020","unstructured":"Veldeman M, Daleiden L, Hamou H, H\u00f6llig A, Clusmann H (2020) An altered posterior question-mark incision is associated with a reduced infection rate of cranioplasty after decompressive hemicraniectomy. J Neurosurg 134(3):1262\u20131270","journal-title":"J Neurosurg"},{"key":"2307_CR11","doi-asserted-by":"crossref","unstructured":"Greenberg MS (2019) Handbook of neurosurgery. 9th ed. Thieme Medical","DOI":"10.1055\/b-006-161147"},{"issue":"6","key":"2307_CR12","doi-asserted-by":"publisher","first-page":"549","DOI":"10.1093\/ons\/opab021","volume":"20","author":"E Dowlati","year":"2021","unstructured":"Dowlati E, Mortazavi A, Keating G et al (2021) The retroauricular incision as an effective and safe alternative incision for decompressive hemicraniectomy. Oper Neurosurg (Hagerstown) 20(6):549\u2013558","journal-title":"Oper Neurosurg (Hagerstown)"},{"issue":"1","key":"2307_CR13","doi-asserted-by":"publisher","first-page":"11419","DOI":"10.1038\/s41598-023-37689-7","volume":"13","author":"A Fr\u00fch","year":"2023","unstructured":"Fr\u00fch A, Zdunczyk A, Wolf S et al (2023) Craniectomy size and decompression of the temporal base using the altered posterior question-mark incision for decompressive hemicraniectomy. Sci Rep 13(1):11419","journal-title":"Sci Rep"},{"issue":"6","key":"2307_CR14","doi-asserted-by":"publisher","first-page":"1807","DOI":"10.3171\/2020.11.JNS203567","volume":"135","author":"IJ Abecassis","year":"2021","unstructured":"Abecassis IJ, Young CC, Caldwell DJ et al (2021) The Kempe incision for decompressive craniectomy, craniotomy, and cranioplasty in traumatic brain injury and stroke. J Neurosurg 135(6):1807\u20131816","journal-title":"J Neurosurg"},{"issue":"9","key":"2307_CR15","first-page":"e29260","volume":"14","author":"N Nerntengian","year":"2022","unstructured":"Nerntengian N, Abboud T, Stepniewski A, Felmerer G, Rohde V, Tanrikulu L (2022) Tissue healing in hemicraniectomy. Cureus 14(9):e29260","journal-title":"Cureus"},{"key":"2307_CR16","doi-asserted-by":"publisher","unstructured":"Eltabl MA, Ammar AS, Saif DS (2022) Evaluating the retro-auricular incision versus reversed question mark incision and Kempe\u2019s \u201cT-bar\u201d incision for decompressive hemicraniectomy. Egypt J Neurosurg 37(1). https:\/\/doi.org\/10.1186\/s41984-022-00155-z","DOI":"10.1186\/s41984-022-00155-z"},{"issue":"295","key":"2307_CR17","doi-asserted-by":"publisher","first-page":"295","DOI":"10.25259\/SNI_59_2022","volume":"13","author":"EG Ord\u00f3\u00f1ez-Rubiano","year":"2022","unstructured":"Ord\u00f3\u00f1ez-Rubiano EG, Figueredo LF, Gamboa-O\u00f1ate CA et al (2022) The reverse question mark and L.G. Kempe incisions for decompressive craniectomy: a case series and narrative review of the literature. Surg Neurol Int 13(295):295","journal-title":"Surg Neurol Int"},{"issue":"5","key":"2307_CR18","doi-asserted-by":"publisher","first-page":"1635","DOI":"10.1007\/s00068-020-01367-4","volume":"47","author":"M Hanko","year":"2021","unstructured":"Hanko M, Sor\u0161\u00e1k J, Snopko P, Op\u0161en\u00e1k R, Zele\u0148\u00e1k K, Kolarovszki B (2021) Incidence and risk factors of early postoperative complications in patients after decompressive craniectomy: a 5-year experience. Eur J Trauma Emerg Surg 47(5):1635\u20131647","journal-title":"Eur J Trauma Emerg Surg"},{"issue":"6","key":"2307_CR19","doi-asserted-by":"publisher","first-page":"E7","DOI":"10.3171\/2009.4.FOCUS0965","volume":"26","author":"SI Stiver","year":"2009","unstructured":"Stiver SI (2009) Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus 26(6):E7","journal-title":"Neurosurg Focus"},{"issue":"2","key":"2307_CR20","first-page":"125","volume":"41","author":"A Gerl","year":"1980","unstructured":"Gerl A, Tavan S (1980) Bilateral craniectomy in the treatment of severe traumatic brain edema. Zentralbl Neurochir 41(2):125\u2013138","journal-title":"Zentralbl Neurochir"},{"issue":"4","key":"2307_CR21","doi-asserted-by":"publisher","first-page":"488","DOI":"10.3171\/jns.1971.34.4.0488","volume":"34","author":"RN Kjellberg","year":"1971","unstructured":"Kjellberg RN, Prieto A (1971) Bifrontal decompressive craniotomy for massive cerebral edema. J Neurosurg 34(4):488\u2013493","journal-title":"J Neurosurg"},{"issue":"5","key":"2307_CR22","doi-asserted-by":"publisher","first-page":"622","DOI":"10.3171\/jns.1973.39.5.0622","volume":"39","author":"RA Morantz","year":"1973","unstructured":"Morantz RA, Abad RM, George AE, Rovit RL (1973) Hemicraniectomy for acute extracerebral hematoma: an analysis of clinical and radiographic findings. J Neurosurg 39(5):622\u2013628","journal-title":"J Neurosurg"},{"issue":"3","key":"2307_CR23","doi-asserted-by":"publisher","first-page":"427","DOI":"10.1093\/neuros\/nyaa278","volume":"87","author":"GWJ Hawryluk","year":"2020","unstructured":"Hawryluk GWJ, Rubiano AM, Totten AM et al (2020) Guidelines for the management of severe traumatic brain injury: 2020 update of the decompressive craniectomy recommendations. Neurosurgery 87(3):427\u2013434","journal-title":"Neurosurgery"},{"issue":"9","key":"2307_CR24","doi-asserted-by":"publisher","first-page":"2518","DOI":"10.1161\/STROKEAHA.107.485649","volume":"38","author":"E J\u00fcttler","year":"2007","unstructured":"J\u00fcttler E, Schwab S, Schmiedek P et al (2007) Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 38(9):2518\u20132525","journal-title":"Stroke"},{"key":"2307_CR25","doi-asserted-by":"publisher","first-page":"e66","DOI":"10.1016\/j.wneu.2023.05.068","volume":"177","author":"H Hoffman","year":"2023","unstructured":"Hoffman H, Draytsel DY, Beutler T (2023) Comparison of retroauricular and reverse question mark incisions for decompressive hemicraniectomy. World Neurosurg 177:e66\u2013e76","journal-title":"World Neurosurg"},{"issue":"7","key":"2307_CR26","doi-asserted-by":"publisher","first-page":"799","DOI":"10.1136\/jnnp.2008.155630","volume":"80","author":"E G\u00fcresir","year":"2009","unstructured":"G\u00fcresir E, Raabe A, Setzer M et al (2009) Decompressive hemicraniectomy in subarachnoid haemorrhage: the influence of infarction, haemorrhage and brain swelling. J Neurol Neurosurg Psychiatry 80(7):799\u2013801","journal-title":"J Neurol Neurosurg Psychiatry"},{"issue":"12","key":"2307_CR27","doi-asserted-by":"publisher","first-page":"3207","DOI":"10.1161\/STROKEAHA.112.666537","volume":"43","author":"C Fung","year":"2012","unstructured":"Fung C, Murek M, Z\u2019Graggen WJ et al (2012) Decompressive hemicraniectomy in patients with supratentorial intracerebral hemorrhage. Stroke 43(12):3207\u20133211","journal-title":"Stroke"},{"key":"2307_CR28","doi-asserted-by":"publisher","first-page":"e922","DOI":"10.1016\/j.wneu.2018.08.005","volume":"119","author":"P Reid","year":"2018","unstructured":"Reid P, Say I, Shah S et al (2018) Effect of bone flap surface area on outcomes in decompressive hemicraniectomy for traumatic brain injury. World Neurosurg 119:e922-927","journal-title":"World Neurosurg"},{"issue":"6","key":"2307_CR29","doi-asserted-by":"publisher","first-page":"623","DOI":"10.1089\/neu.2005.22.623","volume":"22","author":"JY Jiang","year":"2005","unstructured":"Jiang JY, Xu W, Li WP et al (2005) Efficacy of standard trauma craniectomy for refractory intracranial hypertension with severe traumatic brain injury: a multicenter, prospective, randomized controlled study. J Neurotrauma 22(6):623\u2013628","journal-title":"J Neurotrauma"},{"key":"2307_CR30","doi-asserted-by":"publisher","first-page":"e430","DOI":"10.1016\/j.wneu.2020.01.232","volume":"137","author":"S Schur","year":"2020","unstructured":"Schur S, Martel P, Marcoux J (2020) Optimal bone flap size for decompressive craniectomy for refractory increased intracranial pressure in traumatic brain injury: taking the patient\u2019s head size into account. World Neurosurg 137:e430\u2013e436","journal-title":"World Neurosurg"},{"issue":"2","key":"2307_CR31","doi-asserted-by":"publisher","first-page":"208","DOI":"10.1001\/jamaneurol.2020.3745","volume":"78","author":"H Reinink","year":"2021","unstructured":"Reinink H, J\u00fcttler E, Hacke W et al (2021) Surgical decompression for space-occupying hemispheric infarction: a systematic review and individual patient meta-analysis of randomized clinical trials. JAMA Neurol 78(2):208\u2013216","journal-title":"JAMA Neurol"},{"issue":"9","key":"2307_CR32","doi-asserted-by":"publisher","first-page":"2506","DOI":"10.1161\/STROKEAHA.107.485235","volume":"38","author":"K Vahedi","year":"2007","unstructured":"Vahedi K, Vicaut E, Mateo J et al (2007) Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 38(9):2506\u20132517","journal-title":"Stroke"}],"container-title":["Neurosurgical Review"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s10143-024-02307-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s10143-024-02307-1\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s10143-024-02307-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,3,4]],"date-time":"2025-03-04T05:38:29Z","timestamp":1741066709000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s10143-024-02307-1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,2,14]]},"references-count":32,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["2307"],"URL":"https:\/\/doi.org\/10.1007\/s10143-024-02307-1","relation":{"has-preprint":[{"id-type":"doi","id":"10.21203\/rs.3.rs-3435845\/v1","asserted-by":"object"}]},"ISSN":["1437-2320"],"issn-type":[{"value":"1437-2320","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,2,14]]},"assertion":[{"value":"12 October 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"27 December 2023","order":2,"name":"revised","label":"Revised","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"18 January 2024","order":3,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"14 February 2024","order":4,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}},{"value":"N\/A","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}},{"value":"This protocol was not registered, nor was it reported in a publicly accessible repository prior to submission.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Preparation"}},{"value":"The authors declare no competing interests.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}}],"article-number":"79"}}