Decompressive craniectomy (DC) is commonly performed by neurosurgeons for a variety of indications, including traumatic brain injury (TBI), refractory intracranial hypertension, and spontaneous intracerebral hemorrhage (ICH). Cranioplasty following DC is typically performed in a delayed fashion to re-establish calvarial protection of the brain, reset altered post-DC cerebrospinal fluid (CSF) dynamics, and/or to restore cosmesis of the face and head. Despite the necessity and ubiquity of this procedure, however, aggregate rates of surgical site infection (SSI) and wound complications following cranioplasty have been reported anywhere between 10–40% [1], [2], [3], [4], [5], [6].

A variety of factors, such as wound closure techniques, use of surgical drains, patient age, pathology for which DC was originally undertaken, presence of ventriculoperitoneal shunt (VPS), cranioplasty material and DC incision type, have all been implicated as risk factors for SSI after cranioplasty [1], [3], [7], [8], [9], [10], [11]. A variety of incisions are commonly utilized for DC. The most common among these is the reverse question-mark (RQM), which extends from the widow's peak across the parietal boss, above the ear, and to the zygomatic root in front of the tragus. While this incision does provide quick and effective access to the calvarium for decompression, it divides the blood supply from the occipital and posterior auricular arteries and decreases vascular inflow to the posterior aspects of the scalp flap, which are already at higher risk for wound complications as a result of patient positioning and dependent edema. The superficial temporal artery (STA) is also at significant risk of iatrogenic injury during rapid surgical exposure using this approach due to its close proximity to the base of the incision line.

This observed surgical intuition has led to the proposal of several alternative DC incisions with the goal of preserving the STA and/or areas of watershed perfusion throughout the scalp [5], [12], [13], [14], [15]. Because of the relative ubiquity of the RQM incision, however, there may be substantial utility in identifying factors predictive of SSI and wound complications in patients who are scheduled to undergo elective post-DC cranioplasty. Diagnostic imaging with intravenous contrast has been used successfully in plastic and reconstructive surgery to plan and assess various flaps for planned or completed soft-tissue reconstruction. As such, the authors hypothesize that pre-cranioplasty diagnostic imaging can be used to identify patients at elevated risk post-surgical SSI and wound complications.