Infection and bone resorption are major complications of cranioplasty and have been well recognized. However, there are few clinical series describing the epidural fluid collection (EFC) as complication of cranioplasty. This study was planned to identify the predictive factors and fate of EFC after cranioplasty.
We reviewed retrospectively the demographic, clinical, and radiographic data in 59 patients who underwent a first cranioplsty following decompressive craniectomy during a period of 6 years, from January 2004 to December 2009. We compared demographic, clinical, and radiographic factors between EFC group and no EFC group. The predictive factors associated with the development of EFC were assessed by logistic regression analysis.
Overall, 22 of 59 patients (37.3%) suffered from EFC following cranioplasty. EFC had disappeared (n=6, 31.8%) or regressed (n=6, 31.8%) over time on follow up brain computed tomographic (CT) scans. However, 5 patients (22.7%) required reoperation due to symptomatic and persistent EFC. Predictive factors for EFC were male [odds ratio (OR), 5.48; 95% CI, 1.26-23.79], air bubbles in the epidural space (OR, 12.52; 95% CI, 2.26-69.28), and dural calcification on postoperative brain CT scan (OR, 4.21; 95% CI, 1.12-15.84).
The most of EFCs could be treated by conservative therapy. Air bubble in the epidural space and dural calcification are proposed to be the predictive factors in the formation of EFC after cranioplasty.
Cranioplasty; Epidural fluid collection
Cranioplasty is performed using autograft and allograft materials on patients to whom craniectomy was applied previously due to the facts that, this region is open to trauma and the scalp makes irritation and pressure onto the brain paranchyma causing brain atrophy and convulsions. Dramatical improvement of neurological deficits, control of convulsions and partial prevention of cerebral atrophy are achieved after these operations. One of the most important complications of cranioplasty is late infection. Here, we report a 43-year-old male patient admitted with the history of purulant discharge from the right temporal incission site for one year to whom cranioplasty had been performed with allograft material 20 days after craniectomy which had been performed in 1989. Allograft cranioplasty material was removed and cranioplasty was performed using new allograft material with the diagnosis of late cranioplasty infection.
Cranioplasty; Cranioplasty infection; Late cranioplasty infection
Patients with head injury continue to improve over time and a minimum follow-up of six months is considered necessary to evaluate outcome. However, this may be difficult to assess due to lack of follow-up. It is also well known that operated patients who return for cranioplasty usually have the best outcome.
Aims and Objectives:
To assess the outcome following severe head injury using cranioplasty as a surrogate marker for good outcome.
Materials and Methods:
This was a retrospective study carried out from January 2009 to December 2010. All patients with severe head injury who underwent decompressive craniectomy (DC) in the study period were included. Patients who came back for cranioplasty in the same period were also included. Case records, imaging and follow up visit data from all patients were reviewed. Glasgow Coma Score (GCS) on admission and Glasgow Outcome Score (GOS) at discharge were assessed.
Observations and Results:
Of the 273 patients, 84.25% (n=230) were males and 15.75% (n= 43) were females. The mean age was 34.3 years (range 2-81 years, SD 16.817). The mean GCS on admission was 5.615 (range 3-8, SD 1.438). The in-hospital mortality was 54% (n=149). Good outcome (GOS of 4 or 5) at discharge was attained in 22% (n=60) patients. Sixty five patients returned for cranioplasty (with a GOS of 4 or 5) during the study period. There was no statistical difference in the number of patients discharged with good outcome and those coming back for cranioplasty in the study period (P>0.5). Patients who came back for cranioplasty were younger in age (mean age 28.815 years SD 13.396) with better admission GCS prior to DC (mean GCS 6.32 SD1.39).
In operated severe head injury patients significant number of patients (24% in our study) have excellent outcome. However, insignificant number of patients had further improvement to GOS 4 or 5 (good outcome) from the time of initial discharge. This suggests that due to lack of intensive rehabilitative facilities, GOS at discharge may be representative of final outcome in the vast majority of cases of severe head injury in developing countries like India
Cranioplasty; outcome; rehabilitation; severe head injury
The cranioplasty and ventriculoperitoneal (VP) shunt operation have been used to treat a large cranial defect with posttraumatic hydrocephalus (PTH). The aim of this study was to evlauate the difference of outcomes between in the shunting after the cranioplasty (group 1) and the cranioplasty after the shunting (group 2) in a large flaccid cranial defect with PTH.
In this study, a retrospective review was done on 23 patients undergoing the cranioplasty and VP shunt operation after the decompressive craniectomy for a refractory intracranial hypertension from 2002 to 2005. All of 23 cases had a large flaccid concave cranial defect and PTH. Ten cases belong to group 1 and 13 cases to group 2. The outcomes after operations were compared in two groups 6 months later.
The improvement of Glasgow outcome scale (GOS) was seen in 8 cases (80.0%) of total 10 cases in group 1, and 6 cases (46.2%) of 13 cases in group 2. Three (75.0%) of 4 cases with hemiparesis in group 1 and 3 of 6 cases (50.0%) in group 2 were improved. All cases (2 cases) with decrease of visual acuity were improved in each group. Dysphasia was improved in 3 of 5 cases (60%) in group 1 and 4 of 6 cases (66.6%) in group 2.
These results suggest that outcomes in group 1 may be better than in group 2 for a large flaccid concave cranial defect with PTH.
Large flaccid concave cranial defect; Cranioplasty; Shunt
With decompressive craniectomy for ischemic stroke, traumatic brain injury, and skull-infiltrating tumors, the need for cranioplasty has increased. Different materials for custom-made cranioplasties have been evaluated, but a gold standard could not yet be established. We report our experience with the new custom-made titanium CRANIOTOP®cranioplasty (CL Instruments, Germany).
A total of 50 consecutive patients received a CRANIOTOP cranioplasty within a 2 year interval. We reviewed the charts for time between initial surgery and cranioplasty, indication, complications, operative time, and cosmetic outcome. Postoperative imaging (computed tomography [CT] scan n = 48, magnetic resonance imaging (MRI) n = 5) was screened for fitting accuracy and for hemorrhages.
The most common indication for craniectomy were diffuse edema due to traumatic brain injury (n = 17, 34%) and ischemic stroke (n = 12, 24%). All patients were satisfied with the cosmetic result. In the postoperative CT scan accurate fitting was confirmed in all patients, the postoperative MRI was free of artifacts. Surgical revision was necessary in five patients because of empyema (n = 2), wound exposure (n = 2), and one cerebrospinal fluid fistula. Thus, the surgical morbidity was 10%.
With due consideration of the limitations of this retrospective study, we feel the present data allow concluding that the custom-made titanium cranioplasty CRANIOTOP®is safe and feasible.
CL Instruments; craniectomy; CRANIOTOP; titanium cranioplasty
Cranioplasty after postinjury decompressive craniectomy (DC) is routinely performed with a three-month delay to avoid the risk of infection and other complications. Recent experience suggests that performing Cranioplasty surgery at shorter period than three months following DC not only may not cause more infections, but also has the privilege of easier dissection, less bleeding, and reduced costs. The present study was aimed at evaluating the optimal timing of cranioplasty by comparing different parameters using two different time frames.
A total of ninety-five patients underwent cranioplasty surgery during March 2010 to March 2011 in Rajaee Hospital affiliated to Shiraz University of Medical Sciences (Shiraz, Iran). All of them underwent DC surgery because of post traumatic intracranial hypertension. All of patients were divided into two groups with respect o the time period between cranioplasty and DC. For one group this period was 2 months and the other was higher. All relevant demographic and clinical data as well as operative variables such as length of operation, amount of bleeding (post-op Hb drop) and late prognosis were compared between these two groups.
Mean age was 32.2 ± 13.3(SD) years, and 92.6% of patients were male. No significant difference was observed in independent parameters between the two groups with respect to the length of operation (p=0.004) and amount of bleeding (p=0.013) decreased significantly in patients operated earlier than two months from their DC. No significant difference was observed in postoperative complications and final 6 months prognosis.
Findings of the present study showed that performing cranioplasty earlier than two months following craniectomy was associated with shorter surgical duration and lower amounts of bleeding. Performing of cranioplasty in shorter time is accompanied by an easier dissection with no more complications.
Cranioplasty, Decompressive, Craniectomy, TBI
A retrospective review of 53 consecutive patients who underwent a retrosigmoid vestibular nerve section (VNS) or microvascular decompression (MVD) through a modified suboccipital craniectomy with a minimum follow-up of 2 years was performed. Technical modifications to the suboccipital craniectomy included a skin incision designed to avoid the lesser and greater occipital nerves; a small, 2-cm diameter craniectomy with no intradural drilling of bone; and a simplified closure to prevent muscle adhesion to dura without the need for cranioplasty. The presence, duration, and severity of postoperative headache were the primary outcome measures. Craniectomy-related complications, operative time, and length of hospital stay were also reviewed. The incidence of postoperative headache after suboccipital craniectomy was 7.5% at 3 months (4/53), 3.8% at 1 year (2/53), and 3.8% at 2 years (2/53). Complications related to craniectomy included cerebrospinal fluid leakage (5.7%), aseptic meningitis (1.9%), and superficial wound infection (1.9%). The mean operative time was 145 and 98 minutes for VNS and MVD, respectively. The mean hospital stay was 2.2 and 3.6 days for VNS and MVD, respectively. Technical modifications of suboccipital craniectomy during retrosigmoid VNS and MVD lowered the incidence of postoperative headache and craniectomy-related complications and had no adverse effect on operative time or length of hospital stay.
Suboccipital craniectomy; vestibular nerve; microvascular decompression; headache
Most patients with large focal skull bone loss after craniectomy are referred for cranioplasty. Reverse engineering is a technology which creates a computer-aided design (CAD) model of a real structure. Rapid prototyping is a technology which produces physical objects from virtual CAD models. The aim of this study was to assess the clinical usefulness of these technologies in cranioplasty prosthesis manufacturing.
CT was performed on 19 patients with focal skull bone loss after craniectomy, using a dedicated protocol. A material model of skull deficit was produced using computer numerical control (CNC) milling, and individually pre-operatively adjusted polypropylene-polyester prosthesis was prepared. In a control group of 20 patients a prosthesis was manually adjusted to each patient by a neurosurgeon during surgery, without using CT-based reverse engineering/rapid prototyping. In each case, the prosthesis was implanted into the patient. The mean operating times in both groups were compared.
In the group of patients with reverse engineering/rapid prototyping-based cranioplasty, the mean operating time was shorter (120.3 min) compared to that in the control group (136.5 min). The neurosurgeons found the new technology particularly useful in more complicated bone deficits with different curvatures in various planes.
Reverse engineering and rapid prototyping may reduce the time needed for cranioplasty neurosurgery and improve the prosthesis fitting. Such technologies may utilize data obtained by commonly used spiral CT scanners. The manufacturing of individually adjusted prostheses should be commonly used in patients planned for cranioplasty with synthetic material.
cranioplasty; reverse engineering; rapid prototyping; CT
Cranioplasty is a surgical intervention aimed at reestablishing the integrity of skull defects, and should be considered the conclusion of a surgical act that began with bone flap removal. Autologous bone is still considered the treatment of choice for cranioplasty. An alternative choice is bioceramic porous hydroxyapatite (HA) as it is one of the materials that meets and comes closest to the biomimetic characteristics of bone.
The authors analyzed the clinical charts, compiled by the neurosurgeon, of all patients treated with custom-made porous HA devices (Custom Bone Service Fin-Ceramica, Faenza) from which epidemiological and pathological data as well as material-related complications were extrapolated.
From November 1997 to December 2010, 1549 patients underwent cranioplasty with the implantation of 1608 custom-made porous HA devices. HA was used in 53.8% of patients for decompressive craniectomy after trauma or intracranial hemorrhage, while the remaining cases were for treated for comminuted fracture, cutaneous or osseous resection, cranial malformation, autologous bone reabsorption or infection or rejection of previously implanted material. The incidence of adverse events in patients treated for cranioplasty, as first line treatment was 4.78% (56 events/1171 patients), and 5.02%, (19 events/378 patients) at second line.
This study demonstrates that HA is a safe and effective material, is well tolerated in both adult and pediatric patients, and meets the requirements necessary to repair craniolacunia.
Cranioplasty; customized cranioplasty; porous hydroxyapatite prosthesis
Decompressive craniectomy (DC) is a procedure performed increasingly often in current neurosurgical practice. Significant perioperative morbidity may be associated to this procedure because of the large skull defect; also, later closure of the skull defect (cranioplasty) may be associated to post-operative morbidity as much as any other reconstructive operation. The authors present a newly conceived/developed device: The “Skull Flap” (SF). This system, placed at the time of the craniectomy, offers the possibility to provide cranial reconstruction sparing patients a second operation. In other words, DC and cranioplasty essentially take place at the same time and in addition, patients retain their own bone flap. The current study conducted on animal models, represents the logical continuation of a prior recent study, realized on cadaver specimens, to assess the efficacy and safety of this recently developed device.
Materials and Methods:
This is an experimental pilot study on dogs to assess both safety and efficacy of the SF device. Two groups of experimental raised intracranial pressure animal models underwent DC; in the first group of dogs, the bone flap was left in raised position above the skull defect using the SF device; on the second group the flap was discarded. All dogs underwent transcranial Doppler (TCD) to assess brain perfusion. Head computed tomography (CT) scan to determine flap position was also obtained in the group in which the SF device was placed.
SF has proved to be a strong fixation device that allows satisfactory brain decompression by keeping the bone flap elevated from the swollen brain; later on, the SF allows cranial reconstruction in a simple way without requiring a second staged operation. In addition, it is relevant to note that brain perfusion was measured and found to be better in the group receiving the SF (while the flap being in a raised as well as in its natural position) comparing to the other group.
The SF device has proved to be very easy to place, well-adaptable to a different type of flaps and ultimately very effective in maintaining satisfactory brain decompression and later on, making easy bone flap repositioning after brain swelling has subsided.
Brain perfusion; cranioplasty; decompressive craniectomy; new device and technique; skull flap; trans-cranial Doppler
Cranioplasty following decompressive craniectomy is reported to result in improved blood flow, cerebral metabolism, and concomitant neurological recovery. We used multimodal functional imaging technology in a patient with marked neurological recovery after cranioplasty, specifically, imaging of functional MRI resting state networks, auditory responses, and cerebral metabolism before and after cranioplasty. Significant functional changes observed in the images correlated with the subject’s neurological recovery. Our results suggest a link between recovery of cerebral metabolism and intrinsic brain mechanisms of cerebral vascular integration and resting state networks identified with functional MRI following cranioplasty.
Cranioplasty; resting state functional MRI; functional MRI; positron emission tomography
The syndrome of the sinking skin flap (SSSF) with delayed sensorimotor deficits after craniectomy is not well known and often neglected. Among various postulated causes, there is evidence that disturbed brain perfusion may be related to the observed symptoms, and that cranioplasty reliably alleviates these symptoms. We report a case of sinking skin flap syndrome (SSFS) with recovery from neurological sensorimotor deficits after cranioplasty correlated with pre- and postsurgical MR brain perfusion studies.
A 42-year-old woman presented with slowly progressive sensorimotor paresis of her left arm after decompressive extensive craniectomy due to subarachnoid hemorrhage four months ago. Her right cranium showed a "sinking skin flap". After cranioplastic repair of her skull defect, the patient fully recovered from her symptoms. Before cranioplasty, reduced brain perfusion in the right central cortical region was observed in MR-perfusion images. After cranioplasty, a marked increase in brain perfusion was observed which correlated with objective clinical recovery.
There is increasing evidence that impaired blood flow is responsible for delayed motor deficits in patients with sinking skin flap syndrome in the area of compressed brain regions. Symptoms should be evaluated by brain perfusion imaging complementing surgical decision-making.
Subdural posttraumatic collections are called usually Traumatic Subdural Hygroma (TSH). TSH is an accumulation of cerebrospinal fluid (CSF) in the subdural space after head injury. These collections have also been called Traumatic Subdural Effusion (TSE) or External Hydrocephalous (EHP) according to liquid composition, or image features. There is no agreement about the pathogenesis of these entities, how to define them or if they are even different phenomena at all.
We present a case of a complex posttraumatic subdural collection, the role of cranioplasty as definite solution and review the literature related to this complication.
Patients who undergo decompressive craniectomy (DC) have a risk of suffering a subdural collection of 21-50%. Few of these collections will become symptomatic and will need evacuation. When this happens, cranioplasty might be the definitive solution.
Cranioplasty; decompressive craniectomy; subdural effusion; subdural hygroma; traumatic head injury
Difficulty exists in scalp adaptation for cranioplasty with customized computer-assisted design/manufacturing (CAD/CAM) implant in situations of excessive wound tension and sub-cranioplasty dead space. To solve this clinical problem, the CAD/CAM technique should include algorithms to reconstruct a depressed contour to cover the skull defect. Satisfactory CAM-derived alloplastic implants are based on highly accurate three-dimensional (3-D) CAD modeling. Thus, it is quite important to establish a symmetrically regular CAD/CAM reconstruction prior to depressing the contour. The purpose of this study is to verify the aesthetic outcomes of CAD models with regular contours using cranial index of symmetry (CIS).
Materials and methods
From January 2011 to June 2012, decompressive craniectomy (DC) was performed for 15 consecutive patients in our institute. 3-D CAD models of skull defects were reconstructed using commercial software. These models were checked in terms of symmetry by CIS scores.
CIS scores of CAD reconstructions were 99.24±0.004% (range 98.47–99.84). CIS scores of these CAD models were statistically significantly greater than 95%, identical to 99.5%, but lower than 99.6% (p<0.001, p = 0.064, p = 0.021 respectively, Wilcoxon matched pairs signed rank test). These data evidenced the highly accurate symmetry of these CAD models with regular contours.
CIS calculation is beneficial to assess aesthetic outcomes of CAD-reconstructed skulls in terms of cranial symmetry. This enables further accurate CAD models and CAM cranial implants with depressed contours, which are essential in patients with difficult scalp adaptation.
We report a novel technique for closure using titanium mesh cranioplasty in addition to hydroxyapatite cement and abdominal fat graft for acoustic neuroma. We reviewed 15 patients who underwent translabyrinthine craniectomy for resection of acoustic neuroma. Hearing loss was documented prior to surgical procedure. Over 2 years, patients underwent titanium mesh and hydroxyapatite cranioplasty with abdominal fat graft. Participants included seven men and eight women, age range 38 to 65. Main outcome measures included cosmetic outcome and incidence of cerebrospinal fluid (CSF) leak. The lesion was right-sided in seven patients and left-sided in eight. Cosmetic outcome was excellent in all. There were no cases of CSF leak. Closure used one-third the hydroxyapatite required for traditional closure. Our technique yields cosmetic results equivalent to hydroxyapatite cement alone and a comparable incidence of CSF leakage without leaving a drain in place postoperatively. The technique is easy to adopt, is more cost-effective than hydroxyapatite cement cranioplasty alone, offers greater ease of access for reoperation, and does not preclude later implantation of bone-anchored hearing aid.
Translabyrinthine approach; acoustic tumors; hydroxyapatite; titanium mesh
Decompressive craniectomy has been traditionally used as a lifesaving rescue treatment in severe traumatic brain injury (TBI). This study assessed whether objective information on long-term prognosis would influence healthcare workers' opinion about using decompressive craniectomy as a lifesaving procedure for patients with severe TBI.
A two-part structured interview was used to assess the participants' opinion to perform decompressive craniectomy for three patients who had very severe TBI. Their opinion was assessed before and after knowing the predicted and observed risks of an unfavourable long-term neurological outcome in various scenarios.
Five hundred healthcare workers with a wide variety of clinical backgrounds participated. The participants were significantly more likely to recommend decompressive craniectomy for their patients than for themselves (mean difference in visual analogue scale [VAS] −1.5, 95% confidence interval −1.3 to −1.6), especially when the next of kin of the patients requested intervention. Patients' preferences were more similar to patients who had advance directives. The participants' preferences to perform the procedure for themselves and their patients both significantly reduced after knowing the predicted risks of unfavourable outcomes, and the changes in attitude were consistent across different specialties, amount of experience in caring for similar patients, religious backgrounds, and positions in the specialty of the participants.
Access to objective information on risk of an unfavourable long-term outcome influenced healthcare workers' decision to recommend decompressive craniectomy, considered as a lifesaving procedure, for patients with very severe TBI.
Cranial vault reconstruction can be performed with a variety of autologous or alloplastic materials. We describe our experience using high-density porous polyethylene (HDPE) cranial hemisphere for cosmetic and functional restoration of skull defects. The porous nature of the implant allows soft tissue ingrowth, which decreases the incidence of infection. Hence, it can be used in proximity to paranasal sinuses and where previous alloplastic cranioplasties have failed due to implant infection.
Materials and Methods:
We used the HDPE implant in seven patients over a three-year period for reconstruction of moderate to large cranial defects. Two patients had composite defects, which required additional soft tissue in the form of free flap and tissue expansion.
In our series, decompressive craniectomy following trauma was the commonest aetiology and all defects were located in the fronto-parieto-temporal region. The defect size was 10 cm on average in the largest diameter. All patients had good post-operative cranial contour and we encountered no infections, implant exposure or implant migration.
Our results indicate that the biocompatibility and flexibility of the HDPE cranial hemisphere implant make it an excellent alternative to existing methods of calvarial reconstruction.
Calvarial defect; Cranioplasty; high-density porous polyethylene cranial hemispheres
The syndrome of the sinking skin flap was introduced to explain the phenomenon of neurological deterioration after decompressive craniectomy. A 37-year-old man was admitted with acute subdural hematoma and traumatic intraparenchymal hematoma. After decompressive craniectomy, the patient suffered from hydrocephalus for which a ventriculoperitoneal (V-P) shunt was inserted. Following this procedure, the depression of the skin flap became remarkable and his mentation was deteriorated. The patient recovered uneventfully after temporary elevating of valve pressure and cranioplasty. We present a patient who was successfully managed with elevation of valve pressure and cranioplasty for the syndrome of the sinking scalp flap with review of a pertinent literature.
Craniectomy; Cranioplasty; Syndrome of sinking scalp flap; Ventriculoperitoneal shunt
Although decompressive craniectomy is an effective treatment for various situations of increased intracranial pressure, it may be accompanied by several complications. Paradoxical herniation is known as a rare complication of lumbar puncture in patients with decompressive craniectomy. A 38-year-old man underwent decompressive craniectomy for severe brain swelling. He remained neurologically stable for five weeks, but then showed mental deterioration right after a lumbar puncture which was performed to rule out meningitis. A brain computed tomographic scan revealed a marked midline shift. The patient responded to the Trendelenburg position and intravenous fluids, and he achieved full neurologic recovery after successive cranioplasty. The authors discuss the possible mechanism of this rare case with a review of the literature.
Paradoxical herniation; Decompressive craniectomy; Lumbar puncture; Cranioplasty
Objective: To determine long term functional outcome and length of survival of patients undergoing decompressive craniectomy for space occupying infarction of the middle cerebral artery (MCA), and to identify risk factors associated with death and unfavourable outcomes
Methods: Databases of patients undergoing decompressive craniectomy for space occupying MCA infarction compiled at eight neurosurgical departments (1996–2001) were merged, and 188 patients were evaluated. Mortality was calculated by the Kaplan–Meier method. Clinical outcome was rated using the Glasgow outcome scale (GOS). The prognostic impact of patient related covariates on length of survival and the GOS was analysed multivariately.
Results: The unadjusted 3, 6, and 12 month mortality rates were 7.9%, 37.6%, and 43.8%, respectively (median follow up, 26 weeks). In the "best" multivariate model, age >50 years (p<0.02) and the involvement of two or more additional vascular territories (p<0.01) had an unfavourable impact on length of survival. The adjusted six month mortality was as low as 20.0% (no risk factor) and as high as 59.7% (two risk factors). A GOS score of ⩽3 was significantly associated with age >50 years (p<0.0003): 34.9% of the patients ⩽50 years of age achieved a GOS score of >3, as compared with 12.0% of the elderly subpopulation. The side of the infarct did not have prognostic relevance.
Conclusions: Results of surgical treatment in patients <50 years of age undergoing decompressive craniectomy are encouraging. The effectiveness of decompressive craniectomy for patients >50 years remains questionable and should be analysed in the framework of a prospective randomised study.
Adequate management of increased intracranial pressure (ICP) is critical in patients with traumatic brain injury (TBI), and decompressive craniectomy is widely used to treat refractory increased ICP. The authors reviewed and analyzed complications following decompressive craniectomy for the management of TBI.
A total of 89 consecutive patients who underwent decompressive craniectomy for TBI between February 2004 and February 2009 were reviewed retrospectively. Incidence rates of complications secondary to decompressive craniectomy were determined, and analyses were performed to identify clinical factors associated with the development of complications and the poor outcome.
Complications secondary to decompressive craniectomy occurred in 48 of the 89 (53.9%) patients. Furthermore, these complications occurred in a sequential fashion at specific times after surgical intervention; cerebral contusion expansion (2.2 ± 1.2 days), newly appearing subdural or epidural hematoma contralateral to the craniectomy defect (1.5 ± 0.9 days), epilepsy (2.7 ± 1.5 days), cerebrospinal fluid leakage through the scalp incision (7.0 ± 4.2 days), and external cerebral herniation (5.5 ± 3.3 days). Subdural effusion (10.8 ± 5.2 days) and postoperative infection (9.8 ± 3.1 days) developed between one and four weeks postoperatively. Trephined and post-traumatic hydrocephalus syndromes developed after one month postoperatively (at 79.5 ± 23.6 and 49.2 ± 14.1 days, respectively).
A poor GCS score (≤ 8) and an age of ≥ 65 were found to be related to the occurrence of one of the above-mentioned complications. These results should help neurosurgeons anticipate these complications, to adopt management strategies that reduce the risks of complications, and to improve clinical outcomes.
Decompressive craniectomy; Traumatic brain injury; Complication
The purpose of this report is to describe our surgical experiences in the treatment of cerebral decompression with in situ floating resin cranioplasty. We included in this retrospective study 7 patients who underwent in situ floating resin cranioplasty for cerebral decompression between December 2006 and March 2008. Of these patients, 3 patients had traumatic brain injury, 3 cerebral infarction, and one subarachnoid hemorrhage due to aneurysmal rupture. In situ floating resin cranioplasty for cerebral decompression can reduce complications related to the absence of a bone flap and allow reconstruction by secondary cranioplasty without difficulty. Furthermore, it provides cerebral protection and selectively eliminates the need for secondary cranioplasty in elderly patients or patients who have experienced unfavorable outcome.
Decompressive craniectomy; Floating; Resin cranioplasty
Decompressive craniectomy (DC) is a procedure that is currently performed with increasing frequency. The reason is that its indications have become much broader. This procedure may be associated with the relevant morbidity in the postoperative stage due to the creation of a large bone defect. On the other hand, cranioplasty is associated too with some of the common complications related to any reconstructive head surgery. The authors present a newly developed device: The “Skull Flap” (SF). This new device allows the surgeon to complete a DC, yet providing at the same time a cranial reconstruction that will not require the patient to undergo a second reconstructive procedure.
Materials and Methods:
Different size and location craniectomies were carried out on four human cadaveric heads; the bone flaps were then repositioned in a more elevated position with respect to the skull edges. The flaps were placed at a distance of 12 and 15 mm from the skull edges using the SF system. Crash tests were conducted on each flap while in open and closed positions to assess its reliability and efficacy.
SF was shown to be a strong fixation device that allows satisfactory brain decompression by keeping the original bone flap away from the swollen brain; at the same time, in a later stage, it allows cranial reconstruction in a simple way.
The SF device was shown to be very easy to use, adaptable, and practical to apply; thus, allowing both satisfactory brain decompression as well as bone flap repositioning at a later time after the brain swelling has subsided.
Cranioplasty; decompressive craniectomy; new device and technique; skull flap
Cranioplasty is a common, but formidable surgical procedure for neurosurgeons, in patients with scalp and / or calvarial defects. This procedure can be simple or complex. The main objectives of cranioplasty are: To achieve primary wound healing, obliterate dead space, and seal off sterile cranial areas from contaminated oronasal cavities, to restore the normal barriers protecting the intracranial structures (together with a satisfactory cosmetic result) and obtain a permanent or very durable reconstruction, using biologically inert materials, and also to restore the aesthetics. The greatest problem is selecting the optimum material for repair of the cranial defect. Many synthetic substitutions of the dura and bone are often used for reconstruction of the skull base; unfortunately, these methods bear significant disadvantages and can induce chronic inflammation, carry a high risk of infection, and are inferior to biological sources in terms of strength and sealing quality [with the exception of some materials, such as titanium mashes and CortossTM (Orthovita®, Malvern, USA), which are seen to have more strength than the thin split thickness calvarial bone]. The primary aim of this article is to review the basic principles to use the split calvarial graft for the reconstruction of the skull defect.
Autologous bone; bone graft; calvarial bone splitting; calvarial defect; cranioplasty
Objective: We describe a novel technique of cranioplasty using a vascularized mastoid bone flap in patients after translabyrinthine excision of vestibular schwannomas (VS). Postoperative outcomes in terms of pinna and postauricular deformity are evaluated. Study Design: Retrospective study. Setting: Tertiary referral center. Results: Seventeen patients underwent cranioplasty with bone flap after translabyrinthine VS excision. At minimum follow-up of 12 months, none had a cerebrospinal fluid (CSF) leak. The measured pinna projections between the operated and non-operated sides had a mean difference of 0.80 mm (±1.70), which is not statistically significant (p > 0.05). The mean depth of the postauricular depressions was 1.38 mm (±0.93). Over the same period, 10 patients underwent translabyrinthine VS surgery without cranioplasty. In this group, there was a significant difference of 4.71 mm (±1.53) in mean pinna underprojections on the operated sides compared with the non-operated sides. Compared with patients who have undergone cranioplasty, the retroauricular depressions were significantly deeper (p < 0.05) with a mean depth of 2.92 mm (±1.21). Conclusions: Vascularized mastoid cortical bone flap cranioplasty is a simple and effective technique to ameliorate the pinna and retroauricular deformities after translabyrinthine VS excision without increased surgical cost or the use of alloplastic materials.
Vascularized bone flap; cranioplasty; vestibular schwannoma; mastoid reconstruction