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Ribeiro LM, Bhindi N, Fox C, Ramakrishnan A. Cranioplasty is not required in the reconstruction of small combined scalp and calvarial defects. J Plast Reconstr Aesthet Surg 2024; 93:18-23. [PMID: 38608533 DOI: 10.1016/j.bjps.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 03/18/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Treatment of scalp malignancies may include the need for craniectomy. The decision to perform cranioplasty is not straightforward and is frequently subjective. The purpose of this study was to assess the clinical outcomes after reconstruction of complex scalp and calvarial defects by comparing patients with and without cranioplasty. METHODS Retrospective review of the clinical records of a consecutive series of patients who underwent scalp soft tissue reconstruction after craniectomy for malignancy or osteoradionecrosis between 2014 and 2022 at Royal Melbourne Hospital was conducted. Demographics, previous treatments, surgical details, and post-operative complications were assessed. Traumatic injuries and decompressive craniectomies were excluded. Minimum follow-up of 6 months. RESULTS Thirty-seven patients were included in the study. Indications for surgery included skin malignancies, osteoradionecrosis, or both. There was one reconstructive failure (in the non-cranioplasty group). Infection and metalware exposure were common complications in patients who underwent cranioplasty (38.5%). No patient developed neurological symptoms subsequent to craniectomy. One patient needed revision surgery due to esthetic reasons (cranioplasty group). Transposition flaps were associated with more complications and revision procedures. CONCLUSION Combined scalp and calvarial defects pose a difficult reconstructive challenge. Stable soft tissue coverage is more reliably achieved with free flap reconstruction. Cranioplasty is not always mandatory and should be reserved for cases with a very large bony defect or when the defect is located in a cosmetically sensitive area.
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Affiliation(s)
- Luís M Ribeiro
- Department of Plastic and Reconstructive Surgery, Royal Melbourne Hospital, Parkville, VIC 3050, Australia
| | - Nayan Bhindi
- Department of Plastic and Reconstructive Surgery, Royal Melbourne Hospital, Parkville, VIC 3050, Australia.
| | - Carly Fox
- Department of Plastic and Reconstructive Surgery, Royal Melbourne Hospital, Parkville, VIC 3050, Australia
| | - Anand Ramakrishnan
- Department of Plastic and Reconstructive Surgery, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; Department of Surgery, Melbourne Medical School, Royal Melbourne Hospital, University of Melbourne, Parkville VIC 3050, Australia
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Oliveira AMP, De Andrade AF, Pipek LZ, Iaccarino C, Rubiano AM, Amorim RL, Teixeira MJ, Paiva WS. New perspectives on assessment and understanding of the patient with cranial bone defect: a morphometric and cerebral radiodensity assessment. Front Surg 2024; 11:1329019. [PMID: 38379817 PMCID: PMC10876786 DOI: 10.3389/fsurg.2024.1329019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/24/2024] [Indexed: 02/22/2024] Open
Abstract
Background Skull defects after decompressive craniectomy (DC) cause physiological changes in brain function and patients can have neurologic symptoms after the surgery. The objective of this study is to evaluate whether there are morphometric changes in the cortical surface and radiodensity of brain tissue in patients undergoing cranioplasty and whether those variables are correlated with neurological prognosis. Methods This is a prospective cohort with 30 patients who were submitted to cranioplasty and followed for 6 months. Patients underwent simple head CT before and after cranioplasty for morphometric and cerebral radiodensity assessment. A complete neurological exam with Mini-Mental State Examination (MMSE), modified Rankin Scale, and the Barthel Index was performed to assess neurological prognosis. Results There was an improvement in all symptoms of the syndrome of the trephined, specifically for headache (p = 0.004) and intolerance changing head position (p = 0.016). Muscle strength contralateral to bone defect side also improved (p = 0.02). Midline shift of intracranial structures decreased after surgery (p = 0.004). The Anterior Distance Difference (ADif) and Posterior Distance Difference (PDif) were used to assess morphometric changes and varied significantly after surgery. PDif was weakly correlated with MMSE (p = 0.03; r = -0.4) and Barthel index (p = 0.035; r = -0.39). The ratio between the radiodensities of gray matter and white matter (GWR) was used to assess cerebral radiodensity and was also correlated with MMSE (p = 0.041; r = -0.37). Conclusion Morphological anatomy and radiodensity of the cerebral cortex can be used as a tool to assess neurological prognosis after DC.
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Affiliation(s)
- Arthur Maynart Pereira Oliveira
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Almir Ferreira De Andrade
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Leonardo Zumerkorn Pipek
- Department of Neurology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Andres M. Rubiano
- Department of Neurosurgery, Universidad de Bogotá Jorge Tadeo Lozano, Bogotá, Colombia
- Centre for Neuroscience in Education, University of Cambridge, Cambridge, United Kingdom
| | - Robson Luis Amorim
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Wellingson Silva Paiva
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
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Onkarappa S, Prasad GL, Pai A, Menon G. A 2-Year Prospective Study of Complication Rates After Cranioplasty: Is 8 Weeks' Interval Associated with Increased Complications? World Neurosurg 2023; 176:e569-e574. [PMID: 37270098 DOI: 10.1016/j.wneu.2023.05.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND The commonly observed complications after cranioplasty include infections, intracranial hemorrhage, and seizures. The timing of cranioplasty after decompressive craniectomy (DC) is still under debate, with literature available for both early and delayed cranioplasties. The objectives of this study were to note the overall complication rates and more specifically compare complications between 2 different time intervals. METHODS This was a 24-month, single-center, prospective study. Since timing is the most debated variable, the study cohort was divided into 2 groups (≤8 weeks and >8 weeks). Furthermore, other variables such as age, gender, etiology of DC, neurologic condition, and blood loss were correlated with complications. RESULTS A total of 104 cases were analyzed. Two thirds were traumatic etiology. The mean and median DC-cranioplasty intervals were 11.3 weeks (range 4-52 weeks) and 9 weeks, respectively. Seven complications (6.7%) were observed in 6 patients. There was no statistical difference observed between any of the variables and complications. CONCLUSIONS We observed that performing cranioplasty within 8 weeks of the initial DC surgery is safe and noninferior to cranioplasty performed after 8 weeks. Therefore if the general condition of the patient is satisfactory, we are of the opinion that an interval of 6-8 weeks from the primary DC is safe and a reasonable time frame for performing cranioplasty.
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Affiliation(s)
- Sandesh Onkarappa
- Department of Neurosurgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - G Lakshmi Prasad
- Department of Neurosurgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India.
| | - Ashwin Pai
- Department of Neurosurgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
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Ockerman KM, Cox EA, Wiesemann G, Nichols DS, Murad GJA, Ching J, Sorice-Virk S. Healing Exposed Calvarial Hardware Using Negative-Pressure Wound Therapy and Vashe Wound Solution: Case Report. Adv Skin Wound Care 2023; 36:385-391. [PMID: 37224465 DOI: 10.1097/01.asw.0000926628.10995.fc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The management of cranioplasty infections has historically been explantation followed by delayed reimplantation/reconstruction. This treatment algorithm necessitates surgery, tissue expansion, and prolonged disfigurement. In this report, the authors describe a treatment approach consisting of serial vacuum-assisted closure (VAC) with hypochlorous acid (HOCl) solution (Vashe Wound Solution; URGO Medical) as a salvage strategy. METHODS A 35-year-old man who sustained head trauma, neurosurgical complications, and severe syndrome of the trephined (SOT; devastating neurologic decline treated by cranioplasty) underwent titanium cranioplasty with free flap. Three weeks postoperation, he presented with pressure-related wound dehiscence/partial flap necrosis, exposed hardware, and bacterial infection. Given the severity of his precranioplasty SOT, hardware salvage was critical. He was treated with serial VAC with HOCl solution for 11 days followed by VAC for 18 days and definitive split-thickness skin graft placement over resulting granulation tissue. Authors also conducted a literature review of cranial reconstruction infection management. RESULTS The patient remained healed 7 months postoperatively without recurrent infection. Importantly, his original hardware was retained, and his SOT remained resolved. Findings from the literature review support the use of conservative modalities to salvage cranial reconstructions without hardware removal. CONCLUSIONS This study investigates a new strategy for managing cranioplasty infections. The VAC with HOCl solution regimen was effective in treating the infection and salvaging the cranioplasty, thus obviating the complications associated with explantation, new cranioplasty, and recurrence of SOT. There is limited literature on the management of cranioplasty infections using conservative treatments. A larger study to better determine the efficacy of VAC with HOCl solution is underway.
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Affiliation(s)
- Kyle M Ockerman
- At the University of Florida College of Medicine, Gainesville, Florida, USA, Kyle M. Ockerman, BS, and Gayle Wiesemann, BS, are Medical Students; Gregory J. A. Murad, MD, is Full Clinical Professor, Department of Neurosurgery; Jessica Ching, MD, is Assistant Professor, Division of Plastic and Reconstructive Surgery; and Sarah Sorice-Virk, MD, is Assistant Professor, Division of Plastic and Reconstructive Surgery. At Stanford University School of Medicine, Palo Alto, California, Elizabeth A. Cox, MD, is Resident, Division of Plastic and Reconstructive Surgery. At Duke University School of Medicine, Durham, North Carolina, D. Spencer Nichols, MD, is Resident, Division of Plastic and Reconstructive Surgery
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Bedioui A, Elia A, Still M, Aboubakr O, Leclerc A, Planet M, Simboli GA, Moiraghi A, Fathallah H, Parraga E, Benevello C, Dezamis E, Roux A, Zanello M, Pallud J. Predictors of postoperative epidural hematomas after custom-made porous hydroxyapatite cranioplasty: a single-center experience of 194 consecutive cases. Neurosurg Rev 2023; 46:132. [PMID: 37264174 DOI: 10.1007/s10143-023-02039-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/07/2023] [Accepted: 05/25/2023] [Indexed: 06/03/2023]
Abstract
Cranioplasty is important for improving cosmesis and functional recovery after decompressive craniectomy. We assessed the incidence and predictors of post-cranioplasty epidural hematomas requiring surgical evacuation. A single-institution, retrospective study enrolled 194 consecutive patients who underwent a cranioplasty using custom-made hydroxyapatite between February 2008 and April 2022. Variables associated with postoperative epidural hematoma requiring surgical evacuation at the p < 0.1 level in unadjusted analysis were entered into multivariable analyses. Nine patients (4.6%) experienced postoperative epidural hematomas requiring evacuation, with time interval between craniectomy and cranioplasty <6 months (adjusted odds ratio (aOR), 20.75, p = 0.047), cranioplasty-to-bone shift > half of the bone thickness (aOR, 17.53, p = 0.008), >10 mm difference between pre-cranioplasty and post-cranioplasty midline brain shift contralateral to the cranioplasty (aOR, 17.26, p < 0.001), and non-resorbable duraplasty (aOR, 17.43, p = 0.011) identified as independent predictors. Seventeen patients (8.8%) experienced post-cranioplasty hydrocephalus requiring shunt placement. Twenty-six patients (13.4%) experienced postoperative infection. Sixteen patients (8.2%) had postoperative epileptic seizures. The identification of independent predictors of post-cranioplasty epidural hematomas requiring surgical evacuation will help identify at-risk patients, guide prophylactic care, and reduce morbidity of this common and important procedure.
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Affiliation(s)
- Aziz Bedioui
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
| | - Angela Elia
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Inserm, U1266, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Megan Still
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Oumaima Aboubakr
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
| | - Arthur Leclerc
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
- Department of Neurosurgery, Centre Hospitalier Universitaire Caen, Caen, France
| | - Martin Planet
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
| | - Giorgia Antonia Simboli
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
- Inserm, U1266, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Alessandro Moiraghi
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
- Inserm, U1266, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Houssem Fathallah
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
| | - Eduardo Parraga
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
| | - Chiara Benevello
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
| | - Edouard Dezamis
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
| | - Alexandre Roux
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
- Inserm, U1266, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Marc Zanello
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France
- Université Paris Cité, Paris, France
- Inserm, U1266, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Johan Pallud
- Department of Neurosurgery, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 1, rue Cabanis, 75674, Paris, France.
- Université Paris Cité, Paris, France.
- Inserm, U1266, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France.
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6
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Clynch AL, Norrington M, Mustafa MA, Richardson GE, Doherty JA, Humphries TJ, Gillespie CS, Keshwara SM, McMahon CJ, Islim AI, Jenkinson MD, P Millward C, Brodbelt AR. Cranial meningioma with bone involvement: surgical strategies and clinical considerations. Acta Neurochir (Wien) 2023; 165:1355-1363. [PMID: 36877330 PMCID: PMC10140130 DOI: 10.1007/s00701-023-05535-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 02/11/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Intracranial meningioma with bone involvement and primary intraosseous meningioma is uncommon. There is currently no consensus for optimal management. This study aimed to describe the management strategy and outcomes for a 10-year illustrative cohort, and propose an algorithm to aid clinicians in selecting cranioplasty material in such patients. METHODS A single-centre, retrospective cohort study (January 2010-August 2021). All adult patients requiring cranial reconstruction due to meningioma with bone involvement or primary intraosseous meningioma were included. Baseline patient and meningioma characteristics, surgical strategy, and surgical morbidity were examined. Descriptive statistics were performed using SPSS v24.0. Data visualisation was performed using R v4.1.0. RESULTS Thirty-three patients were identified (mean age 56 years; SD 15) There were 19 females. Twenty-nine patients had secondary bone involvement (88%). Four had primary intraosseous meningioma (12%). Nineteen had gross total resection (GTR; 58%). Thirty had primary 'on-table' cranioplasty (91%). Cranioplasty materials included pre-fabricated polymethyl methacrylate (pPMMA) (n = 12; 36%), titanium mesh (n = 10; 30%), hand-moulded polymethyl methacrylate cement (hPMMA) (n = 4; 12%), pre-fabricated titanium plate (n = 4; 12%), hydroxyapatite (n = 2; 6%), and a single case combining titanium mesh with hPMMA cement (n = 1; 3%). Five patients required reoperation for a postoperative complication (15%). CONCLUSION Meningioma with bone involvement and primary intraosseous meningioma often requires cranial reconstruction, but this may not be evident prior to surgical resection. Our experience demonstrates that a wide variety of materials have been used successfully, but that pre-fabricated materials may be associated with fewer postoperative complications. Further research within this population is warranted to identify the most appropriate operative strategy.
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Affiliation(s)
- Abigail L Clynch
- School of Medicine, University of Liverpool, Brownlow Hill, Liverpool, L69 7ZX, UK.
| | - Max Norrington
- The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, L9 7LJ, Liverpool, UK
| | - Mohammad A Mustafa
- School of Medicine, University of Liverpool, Brownlow Hill, Liverpool, L69 7ZX, UK
| | - George E Richardson
- School of Medicine, University of Liverpool, Brownlow Hill, Liverpool, L69 7ZX, UK
| | - John A Doherty
- The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, L9 7LJ, Liverpool, UK
| | - Thomas J Humphries
- The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, L9 7LJ, Liverpool, UK
| | - Conor S Gillespie
- School of Medicine, University of Liverpool, Brownlow Hill, Liverpool, L69 7ZX, UK
| | - Sumirat M Keshwara
- School of Medicine, University of Liverpool, Brownlow Hill, Liverpool, L69 7ZX, UK
| | - Catherine J McMahon
- The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, L9 7LJ, Liverpool, UK
| | - Abdurrahman I Islim
- The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, L9 7LJ, Liverpool, UK.,Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Brownlow Hill, Liverpool, L69 7ZX, UK
| | - Michael D Jenkinson
- The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, L9 7LJ, Liverpool, UK.,Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Brownlow Hill, Liverpool, L69 7ZX, UK
| | - Christopher P Millward
- The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, L9 7LJ, Liverpool, UK.,Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Brownlow Hill, Liverpool, L69 7ZX, UK
| | - Andrew R Brodbelt
- School of Medicine, University of Liverpool, Brownlow Hill, Liverpool, L69 7ZX, UK.,The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, L9 7LJ, Liverpool, UK
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Aziz HF, Baqai MWS, Jooma R. Unusual presentation in syndrome of trephined - A unique case observation. Surg Neurol Int 2022; 13:562. [PMID: 36600760 PMCID: PMC9805635 DOI: 10.25259/sni_988_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/18/2022] [Indexed: 12/03/2022] Open
Abstract
Background Syndrome of trephined (SoT) is a well-recognized complication of decompressive craniectomy (DC). The understanding of SoT has improved more recently with the increasing utilization of DC for severely raised intracranial pressure. It usually presents after a period of weeks or months with a cluster of adverse neurological symptoms, most commonly with worsening of motor strength. Case Description An elderly gentleman with traumatic brain injury underwent DC. He later developed a sinking flap and unexplained agitation which responded to cranioplasty by returning to a state of calm. His cognitive function further improved over a period of 6 months. This is an unusual observation reported in this case. Conclusion Timely recognition of the cognitive complications of craniectomy that may respond to early cranioplasty promises to decrease the length of hospital stay and enhance rehabilitation in such patients.
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Affiliation(s)
- Hafiza Fatima Aziz
- Corresponding author: Hafiza Fatima Aziz, Department of Neurosurgery, The Aga Khan University Hospital, Karachi, Pakistan.
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Safi S, Ali A, Abdelhafez I, Salam A, Alrabayah T, Alyafei A, Belkhair S. Predictors of Clinical Outcomes in Autologous Cranioplasty. World Neurosurg 2022; 167:e561-e566. [PMID: 35977678 DOI: 10.1016/j.wneu.2022.08.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cranioplasty is a common neurosurgical procedure and autologous grafts are preferred due to their aesthetic and biocompatibility benefits. Multiple risk factors are implicated as predictors for neurologic outcome. This study focuses on risk factors that may be associated with complications and analyzes the predictors of neurologic outcomes after autologous cranioplasty. METHODS This is a retrospective observational study conducted at a tertiary care center between 2015 and 2021. Adults with autologous cranioplasty (n = 132) were recruited from procedure logs and the hospital electronic health record. Clinicodemographic parameters, risk factors, and complications were recorded. Neurologic outcomes were measured using the dichotomized Glasgow Outcome Scale (GOS). Primary outcome measure was pre- and post-cranioplasty GOS at the last follow up. Secondary outcome measures were the predicting factors that contributed to enhanced neurologic outcome post-cranioplasty. RESULTS Mean age was 41.4 (standard deviation ± 13.5) years with male predominance (12.2:1). Complications developed in 12.9% (n = 17), with infections in 3.8% (n = 5) and hydrocephalus in 2.3% (n = 3). In bivariate analysis, pre-cranioplasty GOS good grades 4 and 5 (P < 0.001), trauma as an indication for decompressive craniectomy (DC) (P < 0.001), and early cranioplasty ≤12 weeks (P = 0.023) were statistically significant predictors for post-cranioplasty neurologic recovery at follow-up. In a multiple logistic regression model, adjusted odds ratio for pre-cranioplasty GOS was 28.77 (95% confidence interval [CI] 7.21-114.74, P < 0.001), for trauma as indication for DC was 5.15 (95% CI 1.65-16.05, P = 0.003), and for early cranioplasty ≤12 weeks was 3.04 (95% CI 1.12-8.27 P = 0.029). CONCLUSIONS Autologous cranioplasty contributes to a quantifiable neurologic outcome. Pre-cranioplasty neurologic status, cranioplasty done for traumatic DC and early cranioplasty may have potential for enhanced neurologic recovery. Further clinical studies with better evidence may expound upon these findings.
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Affiliation(s)
- Saleh Safi
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar.
| | - Arshad Ali
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar; Department of Clinical Academic Sciences, College of Medicine, Qatar University, Doha, Qatar; Department of Neurological Sciences, Weill Cornell Medicine, Doha, Qatar
| | - Ibrahim Abdelhafez
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Abdul Salam
- Department of Epidemiology and Biostatistics, King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia
| | - Talal Alrabayah
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar; Department of Clinical Academic Sciences, College of Medicine, Qatar University, Doha, Qatar
| | - Abdulnasser Alyafei
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar; Department of Neurological Sciences, Weill Cornell Medicine, Doha, Qatar
| | - Sirajeddin Belkhair
- Department of Neurosurgery, Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar; Department of Clinical Academic Sciences, College of Medicine, Qatar University, Doha, Qatar; Department of Neurological Sciences, Weill Cornell Medicine, Doha, Qatar
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9
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Development of large contralateral MCA infarct following cranioplasty for decompressive craniectomy for ipsilateral large MCA infarct – A rare case report. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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10
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Melin S, Haase I, Nilsson M, Claesson C, Östholm Balkhed Å, Tobieson L. Cryopreservation of autologous bone flaps following decompressive craniectomy: A new method reduced positive cultures without increase in post-cranioplasty infection rate. BRAIN AND SPINE 2022; 2:100919. [PMID: 36248144 PMCID: PMC9560573 DOI: 10.1016/j.bas.2022.100919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022]
Abstract
Introduction Cranioplasty (CP) after decompressive craniectomy (DC) is a common neurosurgical procedure. Implementation of European Union (EU) directives recommending bacterial cultures before cryopreservation, lead to increased number of autologous bone flaps being discarded due to positive cultures. A new method for handling bone flaps prior to cryopreservation, including the use of pulsed lavage, was developed. Research question The aim was to evaluate the effect of a new method on proportion of positive bacterial cultures and surgical site infection (SSI) following CP surgery. Material and methods Sixty-one bone flaps from 53 consecutive DC surgery patients were retrospectively included and the study period was divided into before and after method implementation. Patient demographics, laboratory and culture results, type of CP and occurrence of SSI were analyzed. Results Twenty-six and 18 bone flaps were available for analysis during the first and second period, respectively. The proportion of positive bacterial cultures was higher in the first period compared to the second (n = 9(35%) vs 0(0%); p = 0.001), and thus the use of custom made implants was considerably higher in the first study period (p = 0.001). There was no difference in the frequency of post-cranioplasty SSI between the first and second study period (n = 3 (11.5%) vs 1 (4.8%), p = 0.408). Discussion and conclusion The new method for handling bone flaps resulted in a lower frequency of positive bacterial cultures, without increased frequency of post-cranioplasty SSI, thus demonstrating it is safe to use, allows compliance with the EU-directives, and may reduce unnecessary discarding of bone flaps. New method of bone flap handling and preservation reduced positive bacterial cultures from 35% to 0%. The new method used pulsed lavage of bone flap with saline solution and subsequent swab culture. There was no increase in post-cranioplasty surgical site infection following introduction of the new method.
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Affiliation(s)
- Sofia Melin
- Department of Neurosurgery in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ismene Haase
- Department of Anaesthesiology and Intensive Care in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Martin Nilsson
- Department of Neurosurgery in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Carina Claesson
- Department of Clinical Microbiology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Åse Östholm Balkhed
- Department of Infectious Diseases in Östergötland, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lovisa Tobieson
- Department of Neurosurgery in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Corresponding author. Department of Neurosurgery, University Hospital in Linköping, 581 85, Linköping, Sweden.
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Xie BS, Wang FY, Zheng SF, Lin YX, Kang DZ, Fang WH. A Novel Titanium Cranioplasty Technique of Marking the Coronal and Squamosoparietal Sutures in Three-Dimensional Titanium Mesh as Anatomical Positioning Markers to Increase the Surgical Accuracy and Reduce Postoperative Complications. Front Surg 2022; 8:754466. [PMID: 34970589 PMCID: PMC8712424 DOI: 10.3389/fsurg.2021.754466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/27/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The objective of this research is to modify the titanium cranioplasty (Ti-CP) technique to increase the surgical accuracy and preliminarily verify the effectiveness and safety of this improvement. Methods: We developed a novel technique of marking the coronal and squamosoparietal sutures in three-dimensional (3D) titanium mesh as anatomical positioning markers and designed a prospective trial in patients with a unilateral frontotemporoparietal skull defect. Patients were randomly divided into two groups by the presence or absence of the anatomical positioning markers, and the therapeutic effects of these two groups were compared. Results: Forty-four patients were included in this study, including 28 (64%) males and 16 (36%) females. The mean age was 44.8 ± 15.2 years (range, 13–75 years). Overall postoperative complication rate of the intervention group (18%) was significantly (P = 0.03) lower than the control group (50%). Surgical accuracy of the intervention group (97.8%) was significantly (P < 0.001) higher than the control group (94%). Visual analog scale for cosmesis (VASC) of the intervention group (8.4) was significantly (P < 0.001) higher than the control group (7). The overall postoperative complication rate was 34%. Multivariate analyses showed that surgical accuracy <95.8% (OR = 19.20, 95% CI = 3.17–116.45, P = 0.001) was significantly associated with overall postoperative complications. Independent predictor of overall postoperative complications was surgical accuracy (OR = 0.57, 95% CI = 0.40–0.82, P = 0.002). Conclusions: This novel technique for repairing frontotemporoparietal skull defects increases surgical accuracy, improves cosmetic prognosis, and reduces postoperative complications. Therefore, it is a safe and effective improvement for Ti-CP.
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Affiliation(s)
- Bing-Sen Xie
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Fang-Yu Wang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shu-Fa Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yuan-Xiang Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - De-Zhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wen-Hua Fang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
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Trends and Outcomes of Cranioplasty Alone Versus Single-Stage Composite Scalp and Calvarial Reconstruction. J Craniofac Surg 2021; 33:1271-1275. [PMID: 34855630 DOI: 10.1097/scs.0000000000008395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cranioplasty is a critical intervention to restore the calvarium using autologous or alloplastic materials with single-stage composite scalp and calvarial reconstruction reserved for complex cases. This study aims to identify 30-day outcomes in scalp and calvarial reconstruction using the American College of Surgeons National Surgical Quality Improvement Program database. METHODS The authors conducted a retrospective analysis of the 2010 to 2018 American College of Surgeons National Surgical Quality Improvement Program database. Adult patients who underwent cranioplasty were identified using current procedural terminology coding and included by exposure type (autologous, alloplastic, composite, or other). Subjects with missing exposure or outcome data were excluded. Primary outcome was 30-day reoperation, whereas secondary outcomes were 30-day unplanned readmission and transfusion. Univariate analysis was completed to assess differences in demographics, comorbidities, and postoperative complications. Multivariable logistic regression was used to control for confounders. RESULTS In total, 1719 patients underwent cranioplasty (mean age 54.7 ± 15.3 years, 43.5% male), including 169(9.8%) autologous, 1303(75.8%) alloplastic, 32(1.9%) composite, and 215(12.5%) other procedures. Cranioplasty procedures were associated with 30-day complication and mortality rate of 16.5% and 2.4%, respectively. Composite cranioplasty was associated with decreased 30-day reoperation (adjusted odds ratios 0.11, 95% confidence interval 0.014-0.94, P = 0.044). There was no statistically significant difference in readmission between cranioplasty groups. Alloplastic cranioplasty was associated with decreased odds of postoperative transfusion (adjusted odds ratios 0.47, 95% confidence interval 0.27-0.84, P = 0.01). CONCLUSIONS Cranioplasty is an increasingly common procedure. Alloplastic cranioplasty is associated with decreased 30-day transfusion requirement, whereas single-stage composite reconstruction is a viable option and associated with decreased 30-day reoperation with no difference in readmission.
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Corallo F, Lo Buono V, Calabrò RS, De Cola MC. Can Cranioplasty Be Considered a Tool to Improve Cognitive Recovery Following Traumatic Brain Injury? A 5-Years Retrospective Study. J Clin Med 2021; 10:jcm10225437. [PMID: 34830718 PMCID: PMC8624554 DOI: 10.3390/jcm10225437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 01/19/2023] Open
Abstract
Cranioplasty (CP) is a neurosurgical intervention of skull repairing following a decompressive craniectomy. Unfortunately, the impact of cranioplasty on cognitive and motor function is still controversial. Fifteen TBI subjects aged 26–54 years with CP after decompressive craniectomy were selected in this observational retrospective study. As per routine clinical practice, a neuropsychological evaluation carried out immediately before the cranioplasty (Pre CP) and one month after the cranioplasty (T0) was used to measure changes due to CP surgery. This assessment was performed each year for 5 years after discharge in order to investigate long-term cognitive changes (T1-T5). Before cranioplasty, about 53.3% of subjects presented a mild to severe cognitive impairment and about 40.0% a normal cognition. After CP, we found a significant improvement in all neuropsychological test scores. The more significant differences in cognitive recovery were detected after four years from CP. Notably, we found significant differences between T4 and T0-T1, as well as between T5 and T0-T1-T2 in all battery tests. This retrospective study further suggests the importance of CP in the complex management of patients with TBI showing how these patients might improve their cognitive function over a long period after the surgical procedure.
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Direct Consequences of Cranioplasty to the Brain: Intracranial Pressure Study. J Craniofac Surg 2021; 32:2779-2783. [PMID: 34727479 DOI: 10.1097/scs.0000000000007945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Intracranial pressure (ICP) is a crucial factor that we need to take into account in all major pathophysiological changes of the brain after decompressive craniectomy (DC) and cranioplasty (CP). The purpose of our study was to check ICP values before and after cranioplasty and its relation to various parameters (imaging, demographics, time of cranioplasty, and type of graft) as well as its possible relation to postsurgical complications. The authors performed a prospective study in which they selected as participants adults who had undergone unilateral frontotemporoparietal DC and were planned to have cranioplasty. Intracranial pressure was measured with optical fiber sensor in the epidural space and did not affect cranioplasty in any way.Twenty-five patients met the criteria. The mean vcICP (value change of ICP) was 1.2 mm Hg, the mean ΔICP (absolute value change of the ICP) was 2.24 mm Hg and in the majority of cases there was an increase in ICP. The authors found 3 statistically significant correlations: between gender and ΔICP, Δtime (time between DC and CP) and vcICP, and pre-ICP and ±ICP (quantitative change of the ICP).Μale patients tend to develop larger changes of ICP values during CP. As the time between the 2 procedures (DC and CP) gets longer, the vcICP is decreased. However, after certain time it shows a tendency to remain around zero. Lower pre-ICP values (close to or below zero) are more possible to increase after bone flap placement. It seems that the brain tends to restore its pre-DC conditions after CP by taking near-to-normal ICP values.
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Contemporary Review on Craniectomy and Cranioplasty; Part 1: Decompressive Craniectomy. J Craniofac Surg 2021; 33:838-841. [PMID: 34320589 DOI: 10.1097/scs.0000000000008041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT This paper aims to review clinical benefits of decompressive craniectomy (DC) in both adult and paediatric populations; its indications and factors contributing to its postoperative success. The Glasgow Outcome Scale and the Modified Rankin Scale are the most commonly used scales to assess the long-term outcome in patients post DC. In adult traumatic brain injury patients, 2 randomized clinical trials were carried out; DECRA (Decompressive Craniectomy in Diffuse Traumatic Brain Injury) and RESCUEicp (Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of inter cranial pressure) employing collectively 555 patients. Despite the differences in these trials, their initial results affirm DC can lead to reduced mortality and more favorable outcomes. In ischemic stroke adult patients, different clinical trials of HAMLET (Dutch trial of Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema), DESTINY (German trial of Decompressive Surgery for the treatment of Malignant Infarct of the Middle Cerebral Artery), and DECIMAL (French trial of Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarcts) suggested that DC improves survival compared with best medical management, but with an increased proportion of treated individuals surviving with moderate or severe disability. With regard to the size of bone to be removed, the larger the defect the better the results with a minimum diameter of 11 to 12 cm of bone flap. Cranioplasty timing varies and ranges from 6 weeks to more than 12 months post DC, depending on completion of medical treatment, clinical recovery, resolution of any infection, and an evaluation of soft tissues at the defect site.
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Post-Cranioplasty Complications: Lessons From a Prospective Study Assessing Risk Factors. J Craniofac Surg 2021; 32:530-534. [PMID: 33704976 DOI: 10.1097/scs.0000000000007344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Complication rate related with cranioplasty is described as very high in most of relevant studies. The aim of our study was to try to identify possible factors, that could predict complications following cranioplasty. The authors hypothesized that some physical characteristics on the preoperative brain computed tomography (CT) scan can be predictive for complications.The authors carried out a prospective observational study. All patients were adults after decompressive craniectomy, planned for cranioplasty and had a brain CT scan the day before cranioplasty. Our data pool included demographics, reason of craniectomy, various radiological parameters, the time of cranioplasty after craniectomy, the type of cranioplasty bone flap, and the complications.Twenty-five patients were included in the study. The authors identified statistically significant correlation between time of cranioplasty after craniectomy and the complications, as well as between the type of cranioplasty implant and the complications. There was statistically significant correlation between complications and the distance of the free brain surface from the level of the largest skull defect dimension - free brain surface deformity (FBSD). Moreover, the correlation between FBSD and the time of cranioplasty was statistically significant.It seems that for adult patients with unilateral DC the shorter time interval between craniectomy and cranioplasty lowers the risk for complications. The risk seems to be decreased further, by using autologous bone flap. Low values of the FBSD increase the risk for complications. This risk factor can be avoided, by shortening the time between craniectomy and cranioplasty.
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Complications of cranioplasty following decompressive craniectomy for traumatic brain injury: systematic review and meta-analysis. Acta Neurochir (Wien) 2021; 163:1423-1435. [PMID: 33759012 DOI: 10.1007/s00701-021-04809-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/10/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Decompressive craniectomy (DC) is a common neurosurgical intervention for severe traumatic brain injury (TBI), as well as malignant stroke, malignancy and infection. DC necessitates subsequent cranioplasty. There are significant demographic differences between TBI and non-TBI patients undergoing cranioplasty, which may influence their relative risk profiles for infection, aseptic bone flap resorption (aBFR) and re-operation. OBJECTIVE Perform a meta-analysis to determine the relative infection, aBFR and re-operation risk profiles of TBI patients as compared to other indications for DC. METHODS A systematic review and meta-analysis was performed in accordance with the PRISMA guidelines. PubMed, MEDLINE, EMBASE and Google Scholar were searched until 26/11/2020. Studies detailing rates of infection, re-operation and/or aBFR in specific materials and the post-TBI population were included, while studies in paediatrics or craniosynostosis repair were excluded. RESULTS Twenty-six studies were included. There was no difference in relative risk of infection between TBI and non-TBI cohorts (RR 0.81, 95% CI 0.57-1.17), with insignificant heterogeneity (I2 = 33%). TBI was a risk factor for aBFR (RR 1.54, 95% CI 1.25-1.89), with no significant heterogeneity (I2 = 13%). TBI was a risk factor for re-operation in the autologous sub-group (RR 1.49, 95% CI 1.05-2.11) but not in the alloplastic sub-group (RR = 0.86, 95% CI 0.34-2.18). Heterogeneity was insignificant (I2 = 11%). CONCLUSION TBI is a risk factor for aBFR and re-operation following cranioplasty. Use of an alloplastic graft for primary cranioplasty in these patients may partially mitigate this increased risk.
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Prasad GL, Menon GR, Kongwad LI, Kumar V. Outcomes of Cranioplasty from a Tertiary Hospital in a Developing Country. Neurol India 2020; 68:63-70. [PMID: 32129246 DOI: 10.4103/0028-3886.279676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Although cranioplasty (CP) is a straightforward procedure, it may result in a significant number of complications. These include infections, seizures, intracranial hematomas, and others. Many reports have stated that early CP is associated with higher complications; however, more recent articles have contradicted this opinion. We intend to share our experience and results on outcomes of CP from our university hospital. Materials and Methods This is a 3-year retrospective analysis of patients undergoing CP. Demographic profile, etiology of decompressive craniectomy (DC), DC-CP interval, operative details, complications, and follow-up data were analyzed. Correlation of complications with timing of CP and other factors was studied to look for statistical significance. Results A. total of 93 cases were analyzed. The majority were traumatic and ischemic stroke etiologies. There were eight open/compound head injuries (HIs). Eleven were bilateral and the rest unilateral cases. The mean and median CP interval were 8.5 weeks (range 4-28 weeks) and 8 weeks, respectively. All patients received 48 h to up to 5 days of postoperative antibiotics. Ten complications (10.7%) were noted (including one death). Poor Glasgow Outcome Scale at CP was the only statistically significant factor associated with higher complication rates. There was no statistical difference with respect to gender, CP material, and etiology; however, early CP had slightly fewer complications. Conclusion Patients with poor neurological condition at the time of CP have a significantly higher risk of complications. Contrary to earlier reports, early CP (<12 weeks) was not associated with higher complications but rather fewer complications than delayed procedures. Adherence to a few simple steps may help reduce these complications.
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Affiliation(s)
- G Lakshmi Prasad
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Girish R Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Lakshman I Kongwad
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vinod Kumar
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Determinants of 30-day Morbidity in Adult Cranioplasty: An ACS-NSQIP Analysis of 697 Cases. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2562. [PMID: 32537306 PMCID: PMC7288897 DOI: 10.1097/gox.0000000000002562] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/16/2019] [Indexed: 12/11/2022]
Abstract
Supplemental Digital Content is available in the text. Cranioplasty is performed to restore the function and anatomy of the skull. Many techniques are used, including replacement of the bone flap and reconstruction with autologous or synthetic materials. This study describes the complication profile of adult cranioplasty using a prospective national sample and identifies risk factors for 30-day morbidity.
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Yeap MC, Chen CC, Liu ZH, Hsieh PC, Lee CC, Liu YT, Yi-Chou Wang A, Huang YC, Wei KC, Wu CT, Tu PH. Postcranioplasty seizures following decompressive craniectomy and seizure prophylaxis: a retrospective analysis at a single institution. J Neurosurg 2019; 131:936-940. [PMID: 30239312 DOI: 10.3171/2018.4.jns172519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 04/12/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cranioplasty is a relatively simple and less invasive intervention, but it is associated with a high incidence of postoperative seizures. The incidence of, and the risk factors for, such seizures and the effect of prophylactic antiepileptic drugs (AEDs) have not been well studied. The authors' aim was to evaluate the risk factors that predispose patients to postcranioplasty seizures and to examine the role of seizure prophylaxis in cranioplasty. METHODS The records of patients who had undergone cranioplasty at the authors' medical center between 2009 and 2014 with at last 2 years of follow-up were retrospectively reviewed. Demographic and clinical characteristics, the occurrence of postoperative seizures, and postoperative complications were analyzed. RESULTS Among the 583 patients eligible for inclusion in the study, 247 had preexisting seizures or used AEDs before the cranioplasty and 336 had no seizures prior to cranioplasty. Of these 336 patients, 89 (26.5%) had new-onset seizures following cranioplasty. Prophylactic AEDs were administered to 56 patients for 1 week after cranioplasty. No early seizures occurred in these patients, and this finding was statistically significant (p = 0.012). Liver cirrhosis, intraoperative blood loss, and shunt-dependent hydrocephalus were risk factors for postcranioplasty seizures in the multivariable analysis. CONCLUSIONS Cranioplasty is associated with a high incidence of postoperative seizures. The prophylactic use of AEDs can reduce the occurrence of early seizures.
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Zawy Alsofy S, Stroop R, Fusek I, Sakellaropoulou I, Lewitz M, Nakamura M, Ewelt C, Fortmann T. Early autologous cranioplasty: complications and identification of risk factors using virtual reality visualisation technique. Br J Neurosurg 2019; 33:664-670. [PMID: 31514550 DOI: 10.1080/02688697.2019.1661962] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Cranioplasty (CP) of autologous bone flap after decompressive craniectomy (DC) is known to be associated with a high complication rate, particularly bone flap resorption (BFR). In a retrospective study, we used a novel virtual reality (VR) visualisation technique to identify and evaluate risk factors associated with CP.Method: Twenty-five patients underwent early autologous CP. All complications were recorded. Cranial computed tomography scans were visualised via the VR software to access the fitting accuracy of the bone flap (bone flap size, gap width at trepanation cutting edge, extent of osteoclastic extension).Results: An overall complication rate of 44% was seen, and BFR was the most common (36%). Only 'osteoclastic extension of trepanation' (p = .04) was a significant risk factor for BFR. The factors 'indication for DC' (p = .09) and 'size of bone flap' (p = .09) had a tendency towards influencing the rate of BFR, while 'age' (p = .68), 'time interval between DC and CP' (p = 1.00), and 'gap width' (p = .50) were not considered to influence the BFR rate.Conclusions: DC and subsequent CP is a complication-prone procedure. Therefore, it is relevant to identify and quantify probable risk factors for the most common complications, such as BFR. Here, we found that the extent of osteoclastic extension may impair the patient's healing process. Our investigation was made considerably easier by using the novel VR visualisation technique, which allows parallax free measurements of distances in 3D space.
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Affiliation(s)
- Samer Zawy Alsofy
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-Universität Münster, Hamm, Germany
| | - Ralf Stroop
- Department of Stereotactic Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-Universität Münster, Hamm, Germany
| | - Ivo Fusek
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-Universität Münster, Hamm, Germany
| | - Ioanna Sakellaropoulou
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-Universität Münster, Hamm, Germany
| | - Marc Lewitz
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-Universität Münster, Hamm, Germany
| | - Makoto Nakamura
- Department of Neurosurgery, Academic Hospital Cologne-Merheim, Witten-Herdecke University, Witten, Germany
| | - Christian Ewelt
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-Universität Münster, Hamm, Germany
| | - Thomas Fortmann
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-Universität Münster, Hamm, Germany
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Sun Y, Hu Y, Yuan Q, Yu J, Wu X, Du Z, Wu X, Hu J. Association between metal hypersensitivity and implant failure in patients who underwent titanium cranioplasty. J Neurosurg 2019; 131:40-46. [PMID: 29979123 DOI: 10.3171/2018.1.jns171804] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 01/19/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Digitally designed titanium plates are commonly used for the reconstruction of craniofacial defects, although implant exposure (referred to as failure) is one of the major complications. Metal hypersensitivities have been suggested as possible causes of implant failure of orthopedic, intravascular, gynecological, and dental devices, yet there has been no consensus on the requirement for allergy screening before cranioplasty. METHODS In this study, the authors prospectively investigated the prevalence of metal hypersensitivity in patients for whom cranioplasty is planned and assess its relationship with titanium implant failure (exposure). RESULTS Based on records from 207 included patients, 39.61% of patients showed hypersensitivity to at least one kind of metal. Approximately one-quarter (25.12%) of patients had multiple metal allergies. Co, Cd, and Zn were the 3 most frequently identified metal hypersensitivities. No allergy to titanium was detected in this study. The overall incidence of cranioplasty implant failure was 5.31% (11 of 207). Patients showing hypersensitivities to more than 3 kinds of metal had higher risks of titanium plate exposure. CONCLUSIONS Based on their findings, the authors suggest that routine allergy screening be performed before titanium plate cranioplasty. For patients with hypersensitivities to more than 3 metals, alternative materials, such as polyetheretherketone, should be considered for cranioplasty.
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Affiliation(s)
| | - Yue Hu
- 2Dermatology, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | | | - Jian Yu
- Departments of1Neurosurgery and
| | - Xing Wu
- Departments of1Neurosurgery and
| | | | | | - Jin Hu
- Departments of1Neurosurgery and
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Maricevich JPBR, Cezar-Junior AB, de Oliveira-Junior EX, Veras E Silva JAM, da Silva JVL, Nunes AA, Almeida NS, Azevedo-Filho HRC. Functional and aesthetic evaluation after cranial reconstruction with polymethyl methacrylate prostheses using low-cost 3D printing templates in patients with cranial defects secondary to decompressive craniectomies: A prospective study. Surg Neurol Int 2019; 10:1. [PMID: 30775055 PMCID: PMC6357537 DOI: 10.4103/sni.sni_149_18] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 11/17/2018] [Indexed: 11/09/2022] Open
Abstract
Background: Cranial reconstruction surgery is a procedure used as an attempt to reestablish the cranial bone anatomy. This study evaluates the symptomatic and aesthetic improvement of patients with cranial defects secondary to decompressive craniectomies after cranial reconstruction with customized polymethyl methacrylate (PMMA) prostheses. Secondly, we aim to divide our experience in the production of these prostheses with a low-cost method. Methods: A prospective study was carried out with patients submitted to cranioplasty at the Hospital da Restauração between 2014 and 2017. A total of 63 cranioplasties were performed using customized PMMA prosthesis produced by 3D impression molds. All patients underwent a functional and aesthetic evaluation questionnaire in the preoperative period and in the sixth postoperative month. Results: Sixty-three patients underwent cranioplasty with a mean age of 33 years, ranging from 13 to 58 years, 55 males and 8 females. The mean area of the defect was 147 cm2. The mean postoperative follow-up of the patients was 21 months, ranging from 6 to 33 months. Fifty-five patients attended the 6-month postoperative consultation. All patients presented symptomatic improvement after reconstruction of the skull. The infection rate was 3.2%, 4.8% of extrusion, 1.6% of prosthesis fracture, 7.9% of extradural hematoma, 17.4% of reoperation, 5% of wound dehiscence, and 4.8% of removal of the prosthesis. Conclusion: Cranioplasty, with a customized PMMA prosthesis, improved the symptoms and aesthetic appearance of all operated patients. The use of prototypes to customize cranial prostheses facilitated the operative technique and allowed the recovery of a cranial contour very close to normal.
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Affiliation(s)
| | | | | | | | - Jorge Vicente Lopes da Silva
- Information Technology Center Renato Archer (Ministry of Science and Technology of Brazil), Campinas, Sao Paulo, Brazil
| | - Amanda Amorin Nunes
- Process Engineering and Materials Engineering. Works at Information Technology Center Renato Archer (Ministry of Science and Technology of Brazil), Campinas, Sao Paulo, Brazil
| | - Nivaldo S Almeida
- Department of Neurosurgery, Hospital da Restauração, Recife, Pernambuco, Brazil
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Shih FY, Lin CC, Wang HC, Ho JT, Lin CH, Lu YT, Chen WF, Tsai MH. Risk factors for seizures after cranioplasty. Seizure 2018; 66:15-21. [PMID: 30772643 DOI: 10.1016/j.seizure.2018.12.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/29/2018] [Accepted: 12/18/2018] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Cranioplasty can improve a patient's psychosocial and cognitive functions after decompressive craniectomy, however seizures are a common complication after cranioplasty. The risk factors for early and late seizures after cranioplasty are unclear. This study is to evaluate the risk factors for early and late seizure after cranioplasty. METHODS Two hundred and thirty-eight patients who received cranioplasty following craniectomy between January 2012 and December 2014 were included in this study. The risk factors of the patients with early and late post-cranioplasty seizures were compared to those with no post-cranioplasty seizures. RESULTS Seizures (73/238, 30.3%) were the most common complication after cranioplasty. Of these 73 patients, 17 (7.1%) had early post-cranioplasty seizures and 56 (23.5%) had late post-cranioplasty seizures. Early post-cranioplasty seizures were related to a longer interval between craniectomy and cranioplasty (P = 0.006), artificial materials (P < 0.001), and patients with late post-craniectomy seizures (P = 0.001). Late post-cranioplasty seizures were related to the presence of neurological deficits (P = 0.042). After stepwise logistic regression analysis, a longer interval between craniectomy and cranioplasty (P = 0.012; OR: 1.004, 95% CI: 1.001-1.007) and late post-craniectomy seizures (P = 0.033; OR: 4.335, 95% CI: 1.127-16.675) were independently associated with early post-cranioplasty seizures. CONCLUSION Delayed cranioplasty procedures and seizures before cranioplasty were significantly associated with early post-cranioplasty seizures. Further studies are warranted to investigate whether early surgery after craniectomy can reduce the risk of early post-cranioplasty seizures.
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Affiliation(s)
- Fu-Yuan Shih
- Departments of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Cheng Lin
- Departments of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hung-Chen Wang
- Departments of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jih-Tsun Ho
- Departments of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Hsiang Lin
- Departments of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yan-Ting Lu
- Departments of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wu-Fu Chen
- Departments of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Marine Biotechnology and Resources, National Sun Yat-Sen University, Kaohsiung, Taiwan; Department of Neurosurgery, Xiamen Chang Gung Hospital, Xiamen, Fujian, China
| | - Meng-Han Tsai
- Departments of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Maricevich JPBR, Cezar AB, de Oliveira EX, Silva JAMVE, Maricevich RS, Almeida NS, Azevedo-Filho HRC. Adhesion sutures for seroma reduction in cranial reconstructions with polymethyl methacrylate prosthesis in patients undergoing decompressive craniectomy: A clinical trial. Surg Neurol Int 2018; 9:168. [PMID: 30210901 PMCID: PMC6122284 DOI: 10.4103/sni.sni_102_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/02/2018] [Indexed: 11/05/2022] Open
Abstract
Background: Cranial reconstruction with polymethyl methacrylate (PMMA) prosthesis is used for calvarial defects secondary to decompressive craniectomies. Seroma is one of the most frequent complications of this procedure and can lead to the dehiscence, extrusion, infection, and loss of the prosthesis. The objective of the study is to analyze the effectiveness of the tacking sutures between the prosthesis and the scalp flap in reducing the seroma. Methods: This is a prospective study with 63 patients submitted to cranioplasty between 2014 and 2017 for defects resulting from decompressive craniectomies. All patients were followed up postoperatively for at least 3 months and the diagnosis of seroma was made clinically. In the first 22 patients, the conventional technique was applied and, in the following 41, the technique with tacking sutures was used. The incidence of seroma was collected for both groups. Results: The overall incidence of seroma was 65.1%. Compared to the conventional technique, the use of tacking sutures was associated with a statistically significant reduction in the incidence of seroma from 90.9% to 51.2% (P = 0.002). Conclusion: The use of the tacking sutures in cranioplasties with PMMA prosthesis reduced the incidence of seroma postoperatively.
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Zheng F, Xu H, von Spreckelsen N, Stavrinou P, Timmer M, Goldbrunner R, Cao F, Ran Q, Li G, Fan R, Zhang Q, Chen W, Yao S, Krischek B. Early or late cranioplasty following decompressive craniotomy for traumatic brain injury: A systematic review and meta-analysis. J Int Med Res 2018; 46:2503-2512. [PMID: 29779445 PMCID: PMC6124291 DOI: 10.1177/0300060518755148] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 12/19/2017] [Indexed: 12/03/2022] Open
Abstract
Objective To evaluate the effectiveness of early (<3 months) cranioplasty (CP) and late CP (>3 months) on post-operative complications in patients receiving decompressive craniotomy (DC) for traumatic brain injury (TBI). Methods The Cochrane Library, PubMed and EMBASE databases were systematically searched for studies published prior to May 21, 2017. A meta-analysis examined post-operative overall complication rates, infection rates, subdural fluid collection and operating times according to early and late CP. Results Of the initial 1675 references, five studies, all cohort, involving a total of 413 patients, were selected for the review. There was no difference between early and late CP in post-operative overall complication rate (RR=0.68, 95%CI [0.36, 1.29]) and the post-operative infection rate (RR=0.50, 95%CI [0.20, 1.24]) in patients receiving DC for TBI. However, there was a significant difference in post-operative subdural effusion (RR=0.24, 95%CI [0.07, 0.78]) and mean operative time (mean difference = -33.02 min, 95%CI [-48.19, -17.84]) both in favour of early CP. Conclusions No differences were found between early and late CP in post-operative overall complications and procedural related infections in patients receiving DC for TBI, but early CP reduced the complication of subdural effusion and the mean operating time. These findings need to be confirmed by large, randomised controlled trials.
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Affiliation(s)
- Feng Zheng
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Hao Xu
- Department of Neurosurgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | | | - Pantelis Stavrinou
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Marco Timmer
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Fang Cao
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Qishan Ran
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Gang Li
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Ruiming Fan
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Qiang Zhang
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Wei Chen
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Shengtao Yao
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Boris Krischek
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
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Still M, Kane A, Roux A, Zanello M, Dezamis E, Parraga E, Sauvageon X, Meder JF, Pallud J. Independent Factors Affecting Postoperative Complication Rates After Custom-Made Porous Hydroxyapatite Cranioplasty: A Single-Center Review of 109 Cases. World Neurosurg 2018; 114:e1232-e1244. [PMID: 29625304 DOI: 10.1016/j.wneu.2018.03.181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/24/2018] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Cranioplasties are an important neurosurgical procedure not only for improved cosmesis but also for improved functional recovery after craniectomy with a large cranial defect. The aim of this study was to identify predictive factors of postcranioplasty complications using custom-made porous hydroxyapatite cranioplasty. METHODS Retrospective review was performed of all patients who underwent a reconstructive cranioplasty using custom-made hydroxyapatite at our institution between February 2008 and September 2017. Postoperative complications considered included bacterial infection, seizures, hydrocephalus requiring ventricular shunt placement, and cranioplasty-to-bone shift. Variables associated at P < 0.1 level in unadjusted analysis were entered into backward stepwise logistic regression models. RESULTS Of 109 patients included, 15 (13.8%) experienced postoperative infection, with craniectomy performed at an outside institution (adjusted odds ratio [OR] 10.37 [95% confidence interval [CI], 2.03-75.27], P = 0.012) and a previous infection at the surgical site (adjusted OR 6.15 [95%CI, 1.90-19.92], P = 0.003) identified as independent predictors. Six patients (5.5%) experienced postoperative seizures, with stroke (ischemic and hemorrhagic) as a reason for craniectomy (adjusted OR 11.68 [95% CI, 2.56-24.13], P < 0.001) and the presence of seizures in the month before cranioplasty (adjusted OR 9.39 [95% CI, 2.04-127.67], P = 0.002) identified as independent predictors. Four patients (3.7%) experienced postcranioplasty hydrocephalus necessitating shunt placement, and 5 patients (4.6%) experienced cranioplasty-to-bone shift ≥5 mm, but no significant predictive factors were identified for either complication. CONCLUSIONS This study identified possible predictive factors for postcranioplasty complications to help identify at-risk patients, guide prophylactic care, and improve morbidity of this important surgical procedure.
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Affiliation(s)
- Megan Still
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Abdoulaye Kane
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Alexandre Roux
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; IMABRAIN Team, Inserm, U894, Centre Psychiatrie et Neurosciences, Paris, France
| | - Marc Zanello
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Edouard Dezamis
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Eduardo Parraga
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Xavier Sauvageon
- Department of Neuro-Anaesthesia and Neuro-Intensive Care, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Jean-François Meder
- Department of Neuroradiology, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; IMABRAIN Team, Inserm, U894, Centre Psychiatrie et Neurosciences, Paris, France
| | - Johan Pallud
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; IMABRAIN Team, Inserm, U894, Centre Psychiatrie et Neurosciences, Paris, France.
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Halani SH, Chu JK, Malcolm JG, Rindler RS, Allen JW, Grossberg JA, Pradilla G, Ahmad FU. Effects of Cranioplasty on Cerebral Blood Flow Following Decompressive Craniectomy: A Systematic Review of the Literature. Neurosurgery 2018; 81:204-216. [PMID: 28368505 DOI: 10.1093/neuros/nyx054] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 01/24/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Cranioplasty after decompressive craniectomy (DC) is routinely performed for reconstructive purposes and has been recently linked to improved cerebral blood flow (CBF) and neurological function. OBJECTIVE To systematically review all available literature to evaluate the effect of cranioplasty on CBF and neurocognitive recovery. METHODS A PubMed, Google Scholar, and MEDLINE search adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines included studies reporting patients who underwent DC and subsequent cranioplasty in whom cerebral hemodynamics were measured before and after cranioplasty. RESULTS The search yielded 21 articles with a total of 205 patients (range 3-76 years) who underwent DC and subsequent cranioplasty. Two studies enrolled 29 control subjects for a total of 234 subjects. Studies used different imaging modalities, including CT perfusion (n = 10), Xenon-CT (n = 3), single-photon emission CT (n = 2), transcranial Doppler (n = 6), MR perfusion (n = 1), and positron emission tomography (n = 2). Precranioplasty CBF evaluation ranged from 2 days to 6 months; postcranioplasty CBF evaluation ranged from 7 days to 6 months. All studies demonstrated an increase in CBF ipsilateral to the side of the cranioplasty. Nine of 21 studies also reported an increase in CBF on the contralateral side. Neurological function improved in an overwhelming majority of patients after cranioplasty. CONCLUSION This systematic review suggests that cranioplasty improves CBF following DC with a concurrent improvement in neurological function. The causative impact of CBF on neurological function, however, requires further study.
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Affiliation(s)
- Sameer H Halani
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jason K Chu
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - James G Malcolm
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rima S Rindler
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jason W Allen
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Faiz U Ahmad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
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Shahid AH, Mohanty M, Singla N, Mittal BR, Gupta SK. The effect of cranioplasty following decompressive craniectomy on cerebral blood perfusion, neurological, and cognitive outcome. J Neurosurg 2018; 128:229-235. [PMID: 28298042 DOI: 10.3171/2016.10.jns16678] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEDecompressive craniectomy is an established therapy for refractory intracranial hypertension. Cranioplasty following decompressive craniectomy not only provides protection to the brain along with cosmetic benefits, but also enhances rehabilitation with meaningful functional recovery of potentially reversible cortical and subcortical damaged areas of the affected as well as the contralateral hemisphere. The aim of the study was to assess neurological and cognitive outcome as well as cerebral blood flow after cranioplasty.METHODSThirty-four patients admitted for replacement cranioplasty after decompressive craniectomy for head injury were studied prospectively. Clinical, neurological, and cognitive outcomes were assessed by the Glasgow Outcome Scale (GOS), the Glasgow Coma Scale, and a battery of cognitive tests, respectively. Simultaneously, cerebral blood perfusion was assessed by technetium-99m ethyl cysteinate dimer (99mTc-ECD) brain SPECT imaging 7 days prior to and 3 months after cranioplasty.RESULTSPrior to cranioplasty 9 patients (26.5%) had GOS scores of 5 and 25 patients (73.5%) had GOS scores of 4, whereas postcranioplasty all 34 patients (100%) improved to GOS scores of 5. Approximately 35.3%–90.9% patients showed cognitive improvement postcranioplasty in various tests. Also, on comparison with brain SPECT, 94% of patients showed improvement in cerebral perfusion in different lobes.CONCLUSIONSCranioplasty remarkably improves neurological and cognitive outcomes supported by improvement in cerebral blood perfusion.
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Affiliation(s)
| | | | | | - Bhagwant Rai Mittal
- 2Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Jasey N, Ward I, Lequerica A, Chiaravalloti ND. The therapeutic value of cranioplasty in individuals with brain injury. Brain Inj 2017; 32:318-324. [PMID: 29283285 DOI: 10.1080/02699052.2017.1419283] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PRIMARY OBJECTIVE To examine the effect of cranioplasty on recovery. RESEARCH DESIGN Retrospective cohort study. METHOD AND PROCEDURES Retrospective chart review conducted in 2011 and 2012 on adult inpatients with craniectomy who completed a continuous episode of inpatient rehabilitation before and after receiving their cranioplasty. Patients were matched 1:1 or age, gender, functional level at admission, injury severity and length of stay with inpatients who completed rehabilitation before cranioplasty. Main outcome measures include FIMTM (Functional Independence Measure) and FIMTM efficiency [(FIMTM discharge - FIMTMadmission)/number of days in rehabilitation]. To examine within and between group differences, analyses included paired and independent t-tests, Pearson correlations and chi-square analyses. RESULTS Twenty-six individuals (13 from the cranioplasty group and 13 from the comparison group) were analysed. FIMTM efficiency increased following cranioplasty [0.29 to 0.61; t(12) = -2.77, p = 0.017]. The mean FIMTM efficiency for the cranioplasty group was below that of the comparison group prior to cranioplasty [0.28 ± 0.37 and 0.39 ± 0.32, p = .41], but increased following cranioplasty [0.61 ± 0.71 and 0.39 ± 0.32, p = .32]. An improvement in FIMTM efficiency following cranioplasty was more commonly seen among individuals with less severe brain injuries (75%, χ2 = 3.8, df = 1, p = 0.053). CONCLUSION Rate of recovery increased following cranioplasty and exceeded that of the comparison group suggesting that cranioplasty may contribute to improvement.
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Affiliation(s)
- Neil Jasey
- a Brain Injury Program, Kessler Institute for Rehabilitation , West Orange , NJ , USA.,b Department of Physical Medicine and Rehabilitation New Jersey Medical School Rutgers,The State University of New Jersey , NJ , USA
| | - Irene Ward
- a Brain Injury Program, Kessler Institute for Rehabilitation , West Orange , NJ , USA.,b Department of Physical Medicine and Rehabilitation New Jersey Medical School Rutgers,The State University of New Jersey , NJ , USA
| | - Anthony Lequerica
- b Department of Physical Medicine and Rehabilitation New Jersey Medical School Rutgers,The State University of New Jersey , NJ , USA.,c Brain Injury Research, Kessler Foundation , East Hanover , NJ , USA
| | - Nancy D Chiaravalloti
- b Department of Physical Medicine and Rehabilitation New Jersey Medical School Rutgers,The State University of New Jersey , NJ , USA.,c Brain Injury Research, Kessler Foundation , East Hanover , NJ , USA
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Abdel Hay J, Smayra T, Moussa R. Customized Polymethylmethacrylate Cranioplasty Implants Using 3-Dimensional Printed Polylactic Acid Molds: Technical Note with 2 Illustrative Cases. World Neurosurg 2017; 105:971-979.e1. [DOI: 10.1016/j.wneu.2017.05.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 04/29/2017] [Accepted: 05/02/2017] [Indexed: 11/26/2022]
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32
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Su JH, Wu YH, Guo NW, Huang CF, Li CF, Chen CH, Huang MH. The effect of cranioplasty in cognitive and functional improvement: Experience of post traumatic brain injury inpatient rehabilitation. Kaohsiung J Med Sci 2017; 33:344-350. [DOI: 10.1016/j.kjms.2017.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 04/24/2017] [Accepted: 04/26/2017] [Indexed: 11/26/2022] Open
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Andrabi SM, Sarmast AH, Kirmani AR, Bhat AR. Cranioplasty: Indications, procedures, and outcome - An institutional experience. Surg Neurol Int 2017; 8:91. [PMID: 28607825 PMCID: PMC5461575 DOI: 10.4103/sni.sni_45_17] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/16/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Cranioplasty, the repair of a skull vault defect by insertion of an object (bone or nonbiological materials such as metal or plastic plates), is a well-known procedure in modern neurosurgery. Brain protection and cosmetic aspects are the major indications of cranioplasty. A retroprospective study was conducted for evaluating the indications, materials used, complications, and outcome of cranioplasty. METHODS This study was prospective from August 2013 to September 2015 and retrospective from August 2010 to July 2013. In the retrospective study, patients files were retrieved from the mentioned date (August 2010 to July 2013) from the medical records and the findings were recorded. Abstracted data included age at the time of cranioplasty (years), sex (male or female), medical comorbidities (hypertension, diabetes), indications for craniectomy [Road traffic accident (RTA), fall from height (FFH), hit by stone or cricket ball, physical assault, stroke, infection, shell injury, bullet injury, and intraoperative swelling], laterality of cranioplasty (bilateral, unilateral, or bifrontal), time between craniectomy and cranioplasty (weeks), type of graft (autologous or artificial), type of prosthesis if used (methylmethacrylate, titanium), storage of bone flap if used (subcutaneous or deep freezer), operative time (minutes), and complications fallowing cranioplasty. RESULTS Of the 236 patients included in the study, maximum were in the age group of 21-30 years i.e., 30.93% (n = 73). Mean age of the patients was 33.44 years. A total of 196 (83.05%) were autologous and 40 (16.95%) were artificial. Out of the 40 patients who underwent artificial cranioplasty, 36 (15.25%) had methylmethacrylate graft and 4 (1.7%) had titanium mesh implant. Bone was not preserved in 16.95% (n = 40), preserved in subcutaneous tissue in abdominal wall in 2.54% (n = 6), and preserved in deep freezer in 80.51% (n = 190) of the patients. CONCLUSION Cranioplasty as a procedure is not without complications; however, if performed properly and at proper time with an aseptic technique, good results are achieved.
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Affiliation(s)
- Syed M Andrabi
- Department of Neurosurgery, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Arif H Sarmast
- Department of Neurosurgery, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Altaf R Kirmani
- Department of Neurosurgery, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Abdul R Bhat
- Department of Neurosurgery, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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Abode-Iyamah KO, Chiang HY, Winslow N, Park B, Zanaty M, Dlouhy BJ, Flouty OE, Rasmussen ZD, Herwaldt LA, Greenlee JD. Risk factors for surgical site infections and assessment of vancomycin powder as a preventive measure in patients undergoing first-time cranioplasty. J Neurosurg 2017; 128:1241-1249. [PMID: 28498056 DOI: 10.3171/2016.12.jns161967] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Craniectomy is often performed to decrease intracranial pressure following trauma and vascular injuries. The subsequent cranioplasty procedures may be complicated by surgical site infections (SSIs) due to prior trauma, foreign implants, and multiple surgeries through a common incision. Several studies have found that intrawound vancomycin powder (VP) is associated with decreased risk of SSIs after spine operations. However, no previously published study has evaluated the effectiveness of VP in cranioplasty procedures. The purpose of this study was to determine whether intrawound VP is associated with decreased risk of SSIs, to evaluate VP's safety, and to identify risk factors for SSIs after cranioplasty among patients undergoing first-time cranioplasty. METHODS The authors conducted a retrospective cohort study of adult patients undergoing first-time cranioplasty for indications other than infections from January 1, 2008, to July 31, 2014, at an academic health center. Data on demographics, possible risk factors for SSIs, and treatment with VP were collected from the patients' electronic health records. RESULTS During the study period, 258 patients underwent first-time cranioplasties, and 15 (5.8%) of these patients acquired SSIs. Ninety-two patients (35.7%) received intrawound VP (VP group) and 166 (64.3%) did not (no-VP group). Patients in the VP group and the no-VP group were similar with respect to age, sex, smoking history, body mass index, and SSI rates (VP group 6.5%, no-VP group 5.4%, p = 0.72). Patients in the VP group were less likely than those in the no-VP group to have undergone craniectomy for tumors and were more likely to have an American Society of Anesthesiologists physical status score > 2. Intrawound VP was not associated with other postoperative complications. Risk factors for SSI from the bivariable analyses were diabetes (odds ratio [OR] 3.65, 95% CI 1.07-12.44), multiple craniotomy procedures before the cranioplasty (OR 4.39, 95% CI 1.47-13.18), prior same-side craniotomy (OR 4.73, 95% CI 1.57-14.24), and prosthetic implants (OR 4.51, 95% CI 1.40-14.59). The multivariable analysis identified prior same-side craniotomy (OR 3.37, 95% CI 1.06-10.79) and prosthetic implants (OR 3.93, 95% CI 1.15-13.40) as significant risk factors for SSIs. After adjusting for potential confounders, patients with SSIs were more likely than those without SSIs to be readmitted (OR 7.28, 95% CI 2.07-25.60). CONCLUSIONS In this study, intrawound VP was not associated with a decreased risk of SSIs or with an increased risk of complications. Prior same-side craniotomy and prosthetic implants were risk factors for SSI after first-time cranioplasty.
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Affiliation(s)
| | | | | | - Brian Park
- 3The University of Iowa Carver College of Medicine
| | | | | | | | | | - Loreen A Herwaldt
- 2Internal Medicine.,5Department of Epidemiology, The University of Iowa College of Public Health, Iowa City, Iowa
| | - Jeremy D Greenlee
- Departments of1Neurosurgery and.,3The University of Iowa Carver College of Medicine
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Shibahashi K, Hoda H, Takasu Y, Hanakawa K, Ide T, Hamabe Y. Cranioplasty Outcomes and Analysis of the Factors Influencing Surgical Site Infection: A Retrospective Review of More than 10 Years of Institutional Experience. World Neurosurg 2017; 101:20-25. [PMID: 28179178 DOI: 10.1016/j.wneu.2017.01.106] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/24/2017] [Accepted: 01/26/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND As a large amount of clinical evidence supports the use of craniectomy, the frequency of subsequent cranioplasty is increasing. Conflicting complication rates and risk factors of cranioplasty have been reported. We reviewed >10 years of institutional experience to identify risk factors of surgical site infection (SSI) after cranioplasty. METHODS A retrospective review was conducted of patients who underwent primary cranioplasty. Patients <16 years old, patients with a history of cranial infection, and patients who underwent ventricular shunt surgery were excluded. There were 155 patients eligible for analysis. Complication rate and the risk factors associated with SSI were determined. RESULTS The overall complication rate was 12.3%. There were 13 cases of SSI (8.4%), 4 cases of postoperative epidural hemorrhage (2.6%), and 2 cases of postoperative wound dehiscence (1.3%). There was a significant relationship between operative time and SSI (P < 0.001). The optimal cutoff value of operative time for predicting SSI was 98 minutes, and the relative risk ratio was 7.4 in patients with an operative time of >98 minutes. CONCLUSIONS A high number of complications can occur after cranioplasty. Close attention should be paid to SSI development in patients who require a long operative time.
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Affiliation(s)
- Keita Shibahashi
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
| | - Hidenori Hoda
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yuichi Takasu
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Kazuo Hanakawa
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Takafumi Ide
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yuichi Hamabe
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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Pavlićević G, Lepić M, Perić P, Ivetić D, Roganović A, Roganović Z. Analysis of the factors affecting outcome after combat-related cranial defect reconstruction. J Craniomaxillofac Surg 2016; 45:312-318. [PMID: 28027832 DOI: 10.1016/j.jcms.2016.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 11/24/2016] [Accepted: 11/24/2016] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Reports on the outcomes of cranioplasty after combat-related injuries are relatively rare in the current literature. We present our results on the reconstruction of cranial defects resulting from injuries sustained in combat, comparing outcomes using autologous (iliac bone) grafts or (acrylate) allografts, and analysis of other factors that may influence the final outcome. MATERIAL AND METHODS The study comprised 207 patients with cranial defects resulting from combat-related injuries, repaired with autografts or allografts. The final outcome was defined at least 5 years postoperatively on the basis of cosmetic restoration and the existence of complications as successful (acceptable cosmetic restoration + absence of complications) or unsuccessful (poor cosmetic restoration or acceptable cosmetic restoration + complications). RESULTS Successful outcomes were achieved in 83.6% of patients; there was no operative mortality. There were 25 instances of complications: postoperative infection (n = 15, allograft (7/53), autograft (8/154)), autograft resorption (n = 8), and in two cases, graft luxation. Poor cosmetic restoration was noted in 9 (4.3%) patients who had received an autograft. CONCLUSIONS Thin and poorly vascularized skin, a surface area of the defect larger than 88 cm2, previous local infection and communication with paranasal cavities significantly influenced outcomes after combat-related cranioplasty, the final three being independent predictors of an unsuccessful outcome.
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Affiliation(s)
- Goran Pavlićević
- Department of Neurosurgery, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia.
| | - Milan Lepić
- Department of Neurosurgery, Military Medical Academy, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Predrag Perić
- Department of Neurosurgery, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
| | - Dražen Ivetić
- Department of Neurosurgery, Military Medical Academy, Belgrade, Serbia
| | - Ana Roganović
- Department of Neurosurgery, Military Medical Academy, Belgrade, Serbia
| | - Zoran Roganović
- Department of Neurosurgery, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
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Corallo F, De Cola MC, Lo Buono V, Marra A, De Luca R, Trinchera A, Bramanti P, Calabrò RS. Early vs late cranioplasty: what is better? Int J Neurosci 2016; 127:688-693. [PMID: 27609482 DOI: 10.1080/00207454.2016.1235045] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM OF THE STUDY Cranioplasty is the surgical repair of skull defects, which commonly is performed after traumatic skull injuries due to tumor removal or decompressive craniectomy. Several studies reported improvement in cognitive functions following cranioplasty in patients with severe brain damage. The reasons why exist such clinical improvement is not completely understood, although the increase in cerebrospinal fluid hydrodynamics with the potential improvement of local and global cerebral hemodynamics, blood flow, and metabolism may play a pivotal role. We investigated whether the cranioplasty improved neurological recovery and the whole array of cognitive functions or just some specific domains. MATERIALS AND METHODS A total of 30 consecutive brain-injured subjects with craniectomy were enrolled and underwent a structured neuropsychological assessment immediately before the cranioplasty, 1 month after the cranioplasty and 1 year after the surgical procedure. RESULTS Our results showed that cranioplasty may facilitate the cognitive recovery, independently from the surgical timing. Particularly, we observed an important cognitive recovery in the period immediately after cranioplasty, while the improvement trend settles after a lapse of time, and the recovery starts to slow down. CONCLUSIONS Cranioplasty seems to significantly improve neuropsychological and motor status in the patients with skull defects, independently from cranioplasty timing and patient's clinical status.
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Affiliation(s)
| | | | | | - Angela Marra
- a IRCCS Centro Neurolesi "Bonino Pulejo" , Messina , Italy
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Oh JS, Lee KS, Shim JJ, Yoon SM, Doh JW, Bae HG. Which One Is Better to Reduce the Infection Rate, Early or Late Cranioplasty? J Korean Neurosurg Soc 2016; 59:492-7. [PMID: 27651868 PMCID: PMC5028610 DOI: 10.3340/jkns.2016.59.5.492] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/07/2016] [Accepted: 04/03/2016] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Decompressive craniectomy is an effective therapy to relieve high intracranial pressure after acute brain damage. However, the optimal timing for cranioplasty after decompression is still controversial. Many authors reported that early cranioplasty may contribute to improve the cerebral blood flow and brain metabolism. However, despite all the advantages, there always remains a concern that early cranioplasty may increase the chance of infection. The purpose of this retrospective study is to investigate whether the early cranioplasty increase the infection rate. We also evaluated the risk factors of infection following cranioplasty. METHODS We retrospectively examined the results of 131 patients who underwent cranioplasty in our institution between January 2008 and June 2015. We divided them into early (≤90 days) and late (>90 days after craniectomy) groups. We examined the risk factors of infection after cranioplasty. We analyzed the infection rate between two groups. RESULTS There were more male patients (62%) than female (38%). The mean age was 49 years. Infection occurred in 17 patients (13%) after cranioplasty. The infection rate of early cranioplasty was lower than that of late cranioplasty (7% vs. 20%; p=0.02). Early cranioplasty, non-metal allograft materials, re-operation before cranioplasty and younger age were the significant factors in the infection rate after cranioplasty (p<0.05). Especially allograft was a significant risk factor of infection (odds ratio, 12.4; 95% confidence interval, 3.24-47.33; p<0.01). Younger age was also a significant risk factor of infection after cranioplasty by multivariable analysis (odds ratio, 0.96; 95% confidence interval, 0.96-0.99; p=0.02). CONCLUSION Early cranioplasty did not increase the infection rate in this study. The use of non-metal allograft materials influenced a more important role in infection in cranioplasty. Actually, timing itself was not a significant risk factor in multivariate analysis. So the early cranioplasty may bring better outcomes in cognitive functions or wound without raising the infection rate.
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Affiliation(s)
- Jae-Sang Oh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Kyeong-Seok Lee
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Jai-Joon Shim
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Seok-Mann Yoon
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Jae-Won Doh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hack-Gun Bae
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Malignant cerebral edema following cranioplasty. J Clin Neurosci 2016; 25:130-2. [DOI: 10.1016/j.jocn.2015.06.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 06/17/2015] [Accepted: 06/20/2015] [Indexed: 10/22/2022]
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Paredes I, Castaño AM, Cepeda S, Alén JAF, Salvador E, Millán JM, Lagares A. The Effect of Cranioplasty on Cerebral Hemodynamics as Measured by Perfusion Computed Tomography and Doppler Ultrasonography. J Neurotrauma 2016; 33:1586-97. [PMID: 26541365 DOI: 10.1089/neu.2015.4261] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cranioplasties are performed to protect the brain and correct cosmetic defects, but there is growing evidence that this procedure may result in neurological improvement. We prospectively studied cranioplasties performed at our hospital over a 5-year period. The National Institute of Health Stroke Scale and Barthel index were recorded prior to and within 72 h after the cranioplasty. A perfusion computed tomography (PCT) and transcranial Doppler sonography (TCDS) were performed prior to and 72 h after the surgery. For the PCT, regions irrigated by the anterior cerebral artery, the middle cerebral artery (MCA), the posterior cerebral artery, and the basal ganglia were selected, as well as the mean values for the hemisphere. The sonography was performed in the sitting and the supine position for the MCA and internal carotid. The velocities, pulsatility index, resistance index, and Lindegaard ratio (LR) were obtained, as well as a variation value for the LR (ΔLR = LR sitting - LR supine). Fifty-four patients were included in the study. Of these, 23 (42.6%) patients presented with objective improvement. The mean cerebral blood flow of the defective side (m-CBF-d) increased from 101.86 to 117.17 mL/100 g/min (p = 0.064), and the m-CBF of the healthy side (m-CBF-h) increased from 128.14 to 145.73 mL/100 g/min (p = 0.028). With regard to the TCDS, the ΔLR was greater on the defective side prior the surgery in those patients who showed improvement (1.295 vs. -0.714; p = 0.002). Cranioplasty resulted in clinical improvement in 40% of the patients, with an increase in the post-surgical CBF. The larger variations in the LR when the patient is moved from the sitting to the supine position might predict the clinical improvement.
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Affiliation(s)
- Igor Paredes
- 1 Department of Neurosurgery, University Hospital 12 de Octubre , Madrid, Spain
| | - Ana María Castaño
- 1 Department of Neurosurgery, University Hospital 12 de Octubre , Madrid, Spain
| | - Santiago Cepeda
- 1 Department of Neurosurgery, University Hospital 12 de Octubre , Madrid, Spain
| | | | - Elena Salvador
- 2 Department of Neuroradiology, University Hospital 12 de Octubre , Madrid, Spain
| | - Jose María Millán
- 2 Department of Neuroradiology, University Hospital 12 de Octubre , Madrid, Spain
| | - Alfonso Lagares
- 1 Department of Neurosurgery, University Hospital 12 de Octubre , Madrid, Spain
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The Incidence of Neurologic Susceptibility to a Skull Defect. World Neurosurg 2015; 86:147-52. [PMID: 26433098 DOI: 10.1016/j.wneu.2015.09.081] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 09/22/2015] [Accepted: 09/23/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine whether there is a measureable change in neurologic function after cranioplasty. METHODS This is a prospective single-surgeon, single-center study. Fifty patients who required a cranioplasty procedure were assessed neurologically within 72 hours before and 7 days after surgery. The assessment tools were the Functional Independence Measure (FIM) and the Cognitive assessment report (Cognistat). The scores for both assessments were calculated and then compared before and after surgery. RESULTS FIM assessment was performed on all fifty patients, and a Cognistat assessment was performed on 47 patients. Most improvements were seen in the Cognistat scores; however, there appeared to be no specific areas in which there was consistent improvement. There were substantial improvements in the Cognistat assessment in 9 patients. One patient had a much-improved FIM assessment (improved from 18 to 34), but a Cognistat assessment was not possible because of poor neurologic function. These results suggested that improvements after cranioplasty were more likely to occur in the domain of cognitive function than motor function, although overall these results did not reach statistically significance. Bifrontal (vs. unilateral) cranioplasty, timing between decompression and cranioplasty, and age of the patients did not appear to affect the postoperative FIM scores, after we adjusted for preoperative FIM scores and surgical complications. CONCLUSIONS A small but significant number of patients appear to improve clinically after cranioplasty. Neurologic susceptibility to a skull defect may be more common than had been appreciated previously.
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Dhamapurkar SK, Rose A, Florschutz G, Wilson BA. The natural history of continuing improvement in an individual after a long period of impaired consciousness: The story of I.J. Brain Inj 2015; 30:230-6. [PMID: 26680113 DOI: 10.3109/02699052.2015.1094132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM Recovery of consciousness and recovery of function among patients with prolonged disorders of consciousness rarely occur. Those patients who do regain consciousness typically remain with severe disability. The aim of this retrospective study is to suggest that continuing improvement is possible in a survivor of catastrophic brain injury after being in a prolonged state of disordered consciousness. CASE STUDY This retrospective single case study follows the progress of a 29 year old man, I.J, who sustained a severe traumatic brain injury following an assault in October 2011. He was in a vegetative state for 15 months and in a minimally conscious state for a further 4 months. This was followed by a slow and steady recovery of motor and cognitive functions. At 3 years post-injury I.J is considered to be moderately disabled. He is now living in the community with continuing outpatient support. On the disability rating scale his level of functioning is rated as mildly dependent. CONCLUSION This study shows that continuing recovery to a level of moderate disability is possible, even after a prolonged disorder of consciousness. Intense multi-disciplinary long-term rehabilitation and cranioplasty may be contributing factors for such an unexpected recovery.
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Affiliation(s)
| | - Anita Rose
- a The Raphael Medical Centre , Kent , UK
| | | | - Barbara A Wilson
- a The Raphael Medical Centre , Kent , UK.,b Oliver Zangwill Centre , Cambridgeshire , UK
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Stefano CD, Rinaldesi ML, Quinquinio C, Ridolfi C, Vallasciani M, Sturiale C, Piperno R. Neuropsychological changes and cranioplasty: A group analysis. Brain Inj 2015; 30:164-71. [DOI: 10.3109/02699052.2015.1090013] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Jung YT, Lee SP, Cho JI. An Improved One-Stage Operation of Cranioplasty and Ventriculoperitoneal Shunt in Patient with Hydrocephalus and Large Cranial Defect. Korean J Neurotrauma 2015; 11:93-9. [PMID: 27169072 PMCID: PMC4847518 DOI: 10.13004/kjnt.2015.11.2.93] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/11/2015] [Accepted: 10/05/2015] [Indexed: 12/03/2022] Open
Abstract
Objective The risk of complications is high for patients with a large cranial defect and hydrocephalus, undergoing cranioplasty and ventriculoperitoneal (VP) shunt operation. The purpose of this study is to examine retrospectively such cases with complications and contrive an operative technique to reduce complications. Methods Nineteen patients underwent cranioplasty and VP shunt operation due to large cranial defects and hydrocephalus. These patients were divided into two groups: Group A with 10 patients who underwent staged-operations, and Group B with 9 patients who underwent one-stage operation. Their complications in each group were retrospectively reviewed. Another five patients underwent a one-stage operation with temporary occlusion of the distal shunt catheter to improve on the technique and were categorized as Group C. Complications in these groups were compared and analyzed. Results The results of the data analysis revealed that complications related to anesthesia (40%) and those related to antibiotic prophylaxis (30%) were high in Group A, while non-infectious delayed complications (45%) and perioperative complications such as intracranial hematoma (33%) were high in Group B. However, for patients in Group C, it showed less complication with the operative technique devised by these authors, as opposed to two previous procedures. Conclusion In patients with hydrocephalus and a large cranial defect, complications arising from existing one-stage operation or staged-operations can be reduced by implementing the technique of "one-stage operation with temporary occlusion of the distal shunt catheter."
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Affiliation(s)
- Young Taek Jung
- Department of Neurosurgery, Cheju Halla General Hospital, Jeju, Korea
| | - Sang Pyung Lee
- Department of Neurosurgery, Cheju Halla General Hospital, Jeju, Korea
| | - Jae Ik Cho
- Department of Neurosurgery, Cheju Halla General Hospital, Jeju, Korea
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Kim JS, Park IS, Kim SK, Park H, Kang DH, Lee CH, Hwang SH, Jung JM, Han JW. Analysis of the Risk Factors Affecting the Surgical Site Infection after Cranioplasty Following Decompressive Craniectomy. Korean J Neurotrauma 2015; 11:100-5. [PMID: 27169073 PMCID: PMC4847523 DOI: 10.13004/kjnt.2015.11.2.100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 09/08/2015] [Accepted: 10/12/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The risk factors for surgical site infections (SSIs) after cranioplasty following decompressive craniectomy remain unclear. The goal of this study was to analyze the risk factors related to developing SSIs after cranioplasty and to suggest valuable predictors. METHODS A retrospective review was conducted of patients who underwent cranioplasty following decompressive craniectomy at our institution from January 2011 to December 2014, a total of 78 patients who underwent 78 cranioplasties. Univariate and multivariate logistic regression analyses were carried out to determine possible risk factors related to developing SSIs. We analyzed both patient-specific and surgery-specific factors. RESULTS The overall rate of SSIs was 9.0% (7/78). SSIs after cranioplasty were significantly related to being female, having the primary etiology of traumatic brain injury (TBI) and having had a bilateral cranioplasty in the univariate analysis. Multivariate logistic regression analysis showed that being female [odds ratio (OR) 5.98, p=0.000] and having had a bilateral cranioplasty (OR 4.00, p=0.001) significantly increased the risk of SSIs. CONCLUSION Based on our data, cranioplasty following decompressive craniectomy is associated with a high incidence of SSI. Being female, having a primary etiology of TBI and having had a bilateral cranioplasty may be risk factors for surgical site infections after cranioplasty.
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Affiliation(s)
- Jin Seong Kim
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - In Sung Park
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
- Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sung Kwon Kim
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Hyun Park
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Dong-Ho Kang
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Chul-Hee Lee
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Soo-Hyun Hwang
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jin-Myung Jung
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jong-Woo Han
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
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The efficacy of custom-made porous hydroxyapatite prostheses for cranioplasty: evaluation of postmarketing data on 2697 patients. J Appl Biomater Funct Mater 2015; 13:e136-44. [PMID: 25589160 DOI: 10.5301/jabfm.5000211] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2014] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cranioplasty is a surgical intervention aimed at reestablishing the integrity of skull defects. Autologous bone is still considered the treatment of choice for cranioplasty. The aims of this study were to characterize and evaluate the efficacy of porous hydroxyapatite (HA) to fill skull defects based on its biomimetic characteristics. METHODS The authors analyzed the postmarketing data of all patients treated with custom-made porous HA prostheses (CustomBone Service). Characterization data in terms of physicochemical analysis and mechanical performance of the porous HA prostheses were also reported. RESULTS The low incidence of adverse events (5.72%) due to the use of HA porous custom-made prostheses for cranioplasty is related to the biomimetic performance of the prostheses. The composition and morphology of the porosity enable it to be a useful biomimetic prosthesis for the reconstruction of large and complex skull defects, also able to promote osteointegration. CONCLUSIONS These collected and analyzed data demonstrate that porous HA is a suitable material to produce custom-made prostheses to repair craniolacunia. It is a biomimetic implant well-tolerated in both adult and pediatric patients and has been shown to be an effective and good alternative for cranial reconstruction.
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Sunderland IR, Edwards G, Mainprize J, Antonyshyn O. A technique for intraoperative creation of patient-specific titanium mesh implants. Plast Surg (Oakv) 2015; 23:95-9. [PMID: 26090350 DOI: 10.4172/plastic-surgery.1000909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Prefabricated, patient-specific alloplastic implants for cranioplasty reduce surgical complexity, decrease operative times, minimize exposure and risk of contamination, and have resulted in improved aesthetic results. However, in creating a prefabricated custom implant using a patient's computed tomography data, a stable, unalterable defect must be clearly defined before surgery. In the event that an intraoperative modification of an exiting skull defect is required, or in cases of tumour resection in which the size of the skull defect is unknown preoperatively, these prefabricated implants cannot be used. The ideal method for alloplastic cranioplasty would enable cost-effective creation of a patient-specific implant with the capacity for intraoperative modification. The present article describes a novel technique of cranioplasty that uses a patient's computed tomography data to create a custom forming tool (ie, mold), enabling intraoperative creation of a patient-specific titanium mesh implant. The utility of these implants in creating a custom reconstructive solution in cases in which the size of the skull defect is unknown preoperatively will be demonstrated using two case presentations.
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Affiliation(s)
- Ian Rp Sunderland
- Division of Plastic and Reconstructive Surgery, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Glenn Edwards
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
| | - James Mainprize
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
| | - Oleh Antonyshyn
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
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Williams L, Fan K, Bentley R. Custom-made titanium cranioplasty: early and late complications of 151 cranioplasties and review of the literature. Int J Oral Maxillofac Surg 2015; 44:599-608. [DOI: 10.1016/j.ijom.2014.09.006] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 08/27/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022]
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Sunderland IR, Edwards G, Mainprize J, Antonyshyn O. A technique for intraoperative creation of patient-specific titanium mesh implants. Plast Surg (Oakv) 2015. [DOI: 10.1177/229255031502300204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Prefabricated, patient-specific alloplastic implants for cranioplasty reduce surgical complexity, decrease operative times, minimize exposure and risk of contamination, and have resulted in improved aesthetic results. However, in creating a prefabricated custom implant using a patient's computed tomography data, a stable, unalterable defect must be clearly defined before surgery. In the event that an intraoperative modification of an exiting skull defect is required, or in cases of tumour resection in which the size of the skull defect is unknown preoperatively, these prefabricated implants cannot be used. The ideal method for alloplastic cranioplasty would enable cost-effective creation of a patient-specific implant with the capacity for intraoperative modification. The present article describes a novel technique of cranioplasty that uses a patient's computed tomography data to create a custom forming tool (ie, mold), enabling intraoperative creation of a patient-specific titanium mesh implant. The utility of these implants in creating a custom reconstructive solution in cases in which the size of the skull defect is unknown preoperatively will be demonstrated using two case presentations.
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Affiliation(s)
- Ian Rp Sunderland
- Division of Plastic and Reconstructive Surgery, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Glenn Edwards
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
| | - James Mainprize
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
| | - Oleh Antonyshyn
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
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Zanaty M, Chalouhi N, Starke RM, Clark SW, Bovenzi CD, Saigh M, Schwartz E, Kunkel ESI, Efthimiadis-Budike AS, Jabbour P, Dalyai R, Rosenwasser RH, Tjoumakaris SI. Complications following cranioplasty: incidence and predictors in 348 cases. J Neurosurg 2015; 123:182-8. [PMID: 25768830 DOI: 10.3171/2014.9.jns14405] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECT The factors that contribute to periprocedural complications following cranioplasty, including patient-specific and surgery-specific factors, need to be thoroughly assessed. The aim of this study was to evaluate risk factors that predispose patients to an increased risk of cranioplasty complications and death. METHODS The authors conducted a retrospective review of all patients at their institution who underwent cranioplasty following craniectomy for stroke, subarachnoid hemorrhage, epidural hematoma, subdural hematoma, and trauma between January 2000 and December 2011. The following predictors were tested: age, sex, race, diabetic status, hypertensive status, tobacco use, reason for craniectomy, urgency status of the craniectomy, graft material, and location of cranioplasty. The cranioplasty complications included reoperation for hematoma, hydrocephalus postcranioplasty, postcranioplasty seizures, and cranioplasty graft infection. A multivariate logistic regression analysis was performed. Confidence intervals were calculated as the 95% CI. RESULTS Three hundred forty-eight patients were included in the study. The overall complication rate was 31.32% (109 of 348). The mortality rate was 3.16%. Predictors of overall complications in multivariate analysis were hypertension (OR 1.92, CI 1.22-3.02), increasing age (OR 1.02, CI 1.00-1.04), and hemorrhagic stroke (OR 3.84, CI 1.93-7.63). Predictors of mortality in multivariate analysis were diabetes mellitus (OR 7.56, CI 1.56-36.58), seizures (OR 7.25, CI 1.238-42.79), bifrontal cranioplasty (OR 5.40, CI 1.20-24.27), and repeated surgery for hematoma evacuation (OR 13.00, CI 1.51-112.02). Multivariate analysis was also applied to identify the variables that affect the development of seizures, the need for reoperation for hematoma evacuation, the development of hydrocephalus, and the development of infections. CONCLUSIONS The authors' goal was to provide the neurosurgeon with predictors of morbidity and mortality that could be incorporated in the clinical decision-making algorithm. Control of a patient's risk factors and early recognition of complications may help practitioners avoid the exhaustive list of complications.
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Affiliation(s)
- Mario Zanaty
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Robert M Starke
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Shannon W Clark
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Cory D Bovenzi
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Mark Saigh
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Eric Schwartz
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Emily S I Kunkel
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | | | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Richard Dalyai
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and
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