Posterior question mark incision preserves arterial supply by starting behind the ear, maintaining superficial temporal artery and occipital artery integrity
Target Population
Patients undergoing emergency decompressive hemicraniectomy for severe brain injury or swelling
Care Setting
Operating room during neurosurgical emergency procedures
Key Highlights
Posterior question mark incision broadens vascular pedicle and preserves superficial temporal artery and occipital artery, enhancing scalp flap perfusion.
Reduced infectious complications after secondary cranioplasty by 14.4% reported with posterior incision compared to traditional anterior incision.
Patient positioning involves supine with ipsilateral shoulder padding to allow 90° head rotation and Mayfield head holder for skull immobilization.
Guideline-Based Recommendations
Diagnosis
Indications for decompressive hemicraniectomy remain consistent with standard practice; detailed indications are beyond this report.
Management
Begin incision two finger breadths posterior to mastoid base, following midline to widow’s peak, then behind ear to mastoid notch.
Preserve occipital artery by limiting initial incision depth to hypodermic layer and bluntly dissecting around vessel.
Use five burr holes (frontal, parietal, keyhole, posterior temporal squama, lambdoid suture) and standard craniotomy techniques.
Apply rapid closure technique without duraplasty; dura draped over brain surface.
Monitoring & Follow-up
Ensure optimal venous outflow by head positioning and moderate elevation of OR table headpiece.
Monitor for flap vascular integrity intraoperatively due to altered incision approach.
Risks
Potential difficulty in downward folding of skin flap due to ear position.
Challenges in exposing temporal and sphenoidal bone may require additional bone rongeuring.
Risk of damaging occipital artery if incision extends below mastoid process tip.
Patient & Prescribing Data
Patients undergoing emergency decompressive hemicraniectomy for brain swelling or injury
Posterior question mark incision may reduce infectious complications in secondary cranioplasty and improve scalp flap vascularization without increasing primary surgery complications.
Clinical Best Practices
Position patient supine with ipsilateral shoulder and pelvis padding to allow 90° head rotation without cervical spine torque.
Use Mayfield head holder for skull immobilization to optimize surgical access and safety.
Mark incision with clipper during shaving to save time in emergencies.
Preserve superficial temporal artery and occipital artery by careful dissection and incision depth control.
Place burr holes strategically and thin minor sphenoid wing if necessary for adequate bone removal.
Apply rapid closure without duraplasty, leaving non-suction epidural drains.
Patients with preoperative vitamin D deficiency had higher postoperative pain scores and opioid use after mastectomy, including more than triple the odds of moderate to severe pain within 24 hours of surgery.
