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Splavski B, Lakicevic G, Kovacevic M, Godec D. Customized alloplastic cranioplasty of large bone defects by 3D-printed prefabricated mold template after posttraumatic decompressive craniectomy: A technical note. Surg Neurol Int 2022; 13:169. [PMID: 35509538 PMCID: PMC9062916 DOI: 10.25259/sni_1239_2021] [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: 12/14/2021] [Accepted: 03/16/2022] [Indexed: 11/09/2022] Open
Abstract
Background Manufacturing of customized three-dimensional (3D)-printed cranioplastic implant after decompressive craniectomy has been introduced to overcome the difficulties of intraoperative implant molding. The authors present and discuss the technique, which consists of the prefabrication of silicone implant mold using additive manufacturing, also known as 3D printing, and polymethyl methacrylate (PMMA) implant casting. Methods To reconstruct a large bone defect sustained after decompressive craniectomy due to traumatic brain injury (TBI), a 3D-printed prefabricated mold template was used to create a customized PMMA implant for cranial vault repair in five consecutive patients. Results A superb restoration of the symmetrical contours and curvature of the cranium was achieved in all patients. The outcome was clinically and cosmetically favorable in all of them. Conclusion Customized alloplastic cranioplasty using 3D-printed prefabricated mold for casting PMMA implant is easy to perform technique for the restoration of cranial vault after a decompressive craniectomy following moderate-to-severe TBI. It is a valuable and modern technique to advance manufacturing of personalized prefabricated cranioplastic implants used for the reconstruction of large skull defects having complex geometry. It is a safe and cost-effective procedure having an excellent cosmetic outcome, which may considerably decrease expenses and time needed for cranial reconstructive surgery.
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Affiliation(s)
- Bruno Splavski
- Department of Neurosurgery, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Goran Lakicevic
- Department of Neurosurgery, Mostar University Hospital, Mostar, Bosnia and Herzegovina, Osijek, Croatia
| | - Marko Kovacevic
- Department of Neurosurgery, Osijek University Hospital Center, Osijek, Croatia
| | - Damir Godec
- Department of Technology, Chair of Polymer Processing, Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
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Memon AR, Wang E, Hu J, Egger J, Chen X. A review on computer-aided design and manufacturing of patient-specific maxillofacial implants. Expert Rev Med Devices 2020; 17:345-356. [PMID: 32105159 PMCID: PMC7175472 DOI: 10.1080/17434440.2020.1736040] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/25/2020] [Indexed: 10/25/2022]
Abstract
Introduction: Various prefabricated maxillofacial implants are used in the clinical routine for the surgical treatment of patients. In addition to these prefabricated implants, customized CAD/CAM implants become increasingly important for a more precise replacement of damaged anatomical structures. This paper reviews the design and manufacturing of patient-specific implants for the maxillofacial area.Areas covered: The contribution of this publication is to give a state-of-the-art overview in the usage of customized facial implants. Moreover, it provides future perspectives, including 3D printing technologies, for the manufacturing of patient-individual facial implants that are based on patient's data acquisitions, like Computed Tomography (CT) or Magnetic Resonance Imaging (MRI).Expert opinion: The main target of this review is to present various designing software and 3D manufacturing technologies that have been applied to fabricate facial implants. In doing so, different CAD designing software's are discussed, which are based on various methods and have been implemented and evaluated by researchers. Finally, recent 3D printing technologies that have been applied to manufacture patient-individual implants will be introduced and discussed.
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Affiliation(s)
- Afaque Rafique Memon
- Institute of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of Mechanical System and Vibration, School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Enpeng Wang
- Institute of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of Mechanical System and Vibration, School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Junlei Hu
- Institute of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of Mechanical System and Vibration, School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jan Egger
- Institute of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of Mechanical System and Vibration, School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
- Institute for Computer Graphics and Vision, Faculty of Computer Science and Biomedical Engineering, Graz University of Technology, Graz, Austria
- Department of Oral &maxillofacial Surgery, Medical University of Graz, Graz, Austria
- The Laboratory of Computer Algorithms for Medicine, Medical University of Graz, Graz, Austria
| | - Xiaojun Chen
- Institute of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of Mechanical System and Vibration, School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
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Chen X, Xu L, Li X, Egger J. Computer-aided implant design for the restoration of cranial defects. Sci Rep 2017; 7:4199. [PMID: 28646207 PMCID: PMC5482863 DOI: 10.1038/s41598-017-04454-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 05/12/2017] [Indexed: 12/03/2022] Open
Abstract
Patient-specific cranial implants are important and necessary in the surgery of cranial defect restoration. However, traditional methods of manual design of cranial implants are complicated and time-consuming. Our purpose is to develop a novel software named EasyCrania to design the cranial implants conveniently and efficiently. The process can be divided into five steps, which are mirroring model, clipping surface, surface fitting, the generation of the initial implant and the generation of the final implant. The main concept of our method is to use the geometry information of the mirrored model as the base to generate the final implant. The comparative studies demonstrated that the EasyCrania can improve the efficiency of cranial implant design significantly. And, the intra- and inter-rater reliability of the software were stable, which were 87.07 ± 1.6% and 87.73 ± 1.4% respectively.
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Affiliation(s)
- Xiaojun Chen
- Institute of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of Mechanical System and Vibration, School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China.
| | - Lu Xu
- Institute of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of Mechanical System and Vibration, School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Xing Li
- Institute of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of Mechanical System and Vibration, School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jan Egger
- Faculty of Computer Science and Biomedical Engineering, Institute for Computer Graphics and Vision, Graz University of Technology, Graz, Austria.
- BioTechMed-Graz, Graz, Austria.
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Abstract
BACKGROUND The authors sought to ascertain the upper limits of secondary skull defect size amenable to autogenous reconstructions and to examine outcomes of a surgical series. Published data for autogenous and alloplastic skull reconstructions were also examined to explore associations that might guide treatment. METHODS A retrospective review of autogenously reconstructed secondary skull defects was undertaken. A structured literature review was also performed to assess potential differences in reported outcomes between autogenous bone and synthetic alloplastic skull reconstructions. Weighted risks were calculated for statistical testing. RESULTS Ninety-six patients underwent autogenous skull reconstruction for an average defect size of 93 cm (range, 4 to 506 cm) at a mean age of 12.9 years. The mean operative time was 3.4 hours, 2 percent required allogeneic blood transfusions, and the average length of stay was less than 3 days. The mean length of follow-up was 28 months. There were no postoperative infections requiring surgery, but one patient underwent secondary grafting for partial bone resorption. An analysis of 34 studies revealed that complications, infections, and reoperations were more commonly reported with alloplastic than with autogenous reconstructions (relative risk, 1.57, 4.8, and 1.48, respectively). CONCLUSIONS Autogenous reconstructions are feasible, with minimal associated morbidity, for patients with skull defect sizes as large as 500 cm. A structured literature review suggests that autogenous bone reconstructions are associated with lower reported infection, complication, and reoperation rates compared with synthetic alloplasts. Based on these findings, surgeons might consider using autogenous reconstructions even for larger skull defects. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Sundseth J, Sundseth A, Berg-Johnsen J, Sorteberg W, Lindegaard KF. Cranioplasty with autologous cryopreserved bone after decompressive craniectomy: complications and risk factors for developing surgical site infection. Acta Neurochir (Wien) 2014; 156:805-11; discussion 811. [PMID: 24493001 PMCID: PMC3956933 DOI: 10.1007/s00701-013-1992-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 12/30/2013] [Indexed: 12/05/2022]
Abstract
Background Renewed interest has developed in decompressive craniectomy, and improved survival is shown when this treatment is used after malignant middle cerebral artery infarction. The aim of this study was to investigate the frequency and possible risk factors for developing surgical site infection (SSI) after delayed cranioplasty using autologous, cryopreserved bone. Methods This retrospective study included 74 consecutive patients treated with decompressive craniectomy during the time period May 1998 to October 2010 for various non-traumatic conditions causing increased intracranial pressure due to brain swelling. Complications were registered and patient data was analyzed in a search for predictive factors. Results Fifty out of the 74 patients (67.6 %) survived and underwent delayed cranioplasty. Of these, 47 were eligible for analysis. Six patients (12.8 %) developed SSI following the replacement of autologous cryopreserved bone, whereas bone resorption occurred in two patients (4.3 %). No factors predicted a statistically significant rate of SSI, however, prolonged procedural time and cardiovascular comorbidity tended to increase the risk of SSI. Conclusions SSI and bone flap resorption are the most frequent complications associated with the reimplantation of autologous cryopreserved bone after decompressive craniectomy. Prolonged procedural time and cardiovascular comorbidity tend to increase the risk of SSI.
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Affiliation(s)
- J Sundseth
- Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Postboks 4950, Nydalen, 0424, Oslo, Norway,
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Single-Step Resection and Reconstruction Using Patient-Specific Implants in the Treatment of Benign Cranio-Orbital Tumors. J Oral Maxillofac Surg 2013; 71:1969-82. [DOI: 10.1016/j.joms.2013.03.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Revised: 03/19/2013] [Accepted: 03/19/2013] [Indexed: 11/22/2022]
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Sundseth J, Berg-Johnsen J. Prefabricated patient-matched cranial implants for reconstruction of large skull defects. J Cent Nerv Syst Dis 2013; 5:19-24. [PMID: 23650475 PMCID: PMC3616596 DOI: 10.4137/jcnsd.s11106] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cranial defects can be caused by injury, infection, or tumor invasion. Large defects should be reconstructed to protect the brain and normalize the cerebral hemodynamics. The conventional method is to cover the defect with bone cement. Custom-made implants designed for the individual patient are now available. We report our experience with one such product in patients with large cranial defects (>7.6 cm in diameter). A CT scan with 2 mm slices and a three-dimensional reconstruction were obtained from the patient. This information was dispatched to the company and used as a template to form the implant. The cranial implant was received within four weeks. From 2005 to 2010, custom-made cranial implants were used in 13 patients with large cranial defects. In 10 of the 13 patients, secondary deep infection was the cause of the cranial defect. All the implants fitted well or very well to the defect. No infections were seen after implantation; however, one patient was reoperated on for an epidural hematoma. A custom-made cranial implant is considerably more expensive than an implant made of bone cement, but ensures that the defect is optimally covered. The use of custom-made implants is straightforward and timesaving, and they provide an excellent medical and cosmetic result.
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Affiliation(s)
- Jarle Sundseth
- Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Oslo, Norway
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Kim BJ, Hong KS, Park KJ, Park DH, Chung YG, Kang SH. Customized cranioplasty implants using three-dimensional printers and polymethyl-methacrylate casting. J Korean Neurosurg Soc 2012; 52:541-6. [PMID: 23346326 PMCID: PMC3550422 DOI: 10.3340/jkns.2012.52.6.541] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 09/15/2012] [Accepted: 12/18/2012] [Indexed: 11/27/2022] Open
Abstract
Objective The prefabrication of customized cranioplastic implants has been introduced to overcome the difficulties of intra-operative implant molding. The authors present a new technique, which consists of the prefabrication of implant molds using three-dimensional (3D) printers and polymethyl-methacrylate (PMMA) casting. Methods A total of 16 patients with large skull defects (>100 cm2) underwent cranioplasty between November 2009 and April 2011. For unilateral cranial defects, 3D images of the skull were obtained from preoperative axial 1-mm spiral computed tomography (CT) scans. The image of the implant was generated by a digital subtraction mirror-imaging process using the normal side of the cranium as a model. For bilateral cranial defects, precraniectomy routine spiral CT scan data were merged with postcraniectomy 3D CT images following a smoothing process. Prefabrication of the mold was performed by the 3D printer. Intraoperatively, the PMMA implant was created with the prefabricated mold, and fit into the cranial defect. Results The median operation time was 184.36±26.07 minutes. Postoperative CT scans showed excellent restoration of the symmetrical contours and curvature of the cranium in all cases. The median follow-up period was 23 months (range, 14-28 months). Postoperative infection was developed in one case (6.2%) who had an open wound defect previously. Conclusion Customized cranioplasty PMMA implants using 3D printer may be a useful technique for the reconstruction of various cranial defects.
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Affiliation(s)
- Bum-Joon Kim
- Department of Neurosurgery, Korea University College of Medicine, Seoul, Korea
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Di Stefano C, Sturiale C, Trentini P, Bonora R, Rossi D, Cervigni G, Piperno R. Unexpected neuropsychological improvement after cranioplasty: a case series study. Br J Neurosurg 2012; 26:827-31. [DOI: 10.3109/02688697.2012.692838] [Citation(s) in RCA: 49] [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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Chrzan R, Urbanik A, Karbowski K, Moskała M, Polak J, Pyrich M. Cranioplasty prosthesis manufacturing based on reverse engineering technology. Med Sci Monit 2012; 18:MT1-6. [PMID: 22207125 PMCID: PMC3560686 DOI: 10.12659/msm.882186] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Most patients with large focal skull bone loss after craniectomy are referred for cranioplasty. Reverse engineering is a technology which creates a computer-aided design (CAD) model of a real structure. Rapid prototyping is a technology which produces physical objects from virtual CAD models. The aim of this study was to assess the clinical usefulness of these technologies in cranioplasty prosthesis manufacturing. Material/Methods CT was performed on 19 patients with focal skull bone loss after craniectomy, using a dedicated protocol. A material model of skull deficit was produced using computer numerical control (CNC) milling, and individually pre-operatively adjusted polypropylene-polyester prosthesis was prepared. In a control group of 20 patients a prosthesis was manually adjusted to each patient by a neurosurgeon during surgery, without using CT-based reverse engineering/rapid prototyping. In each case, the prosthesis was implanted into the patient. The mean operating times in both groups were compared. Results In the group of patients with reverse engineering/rapid prototyping-based cranioplasty, the mean operating time was shorter (120.3 min) compared to that in the control group (136.5 min). The neurosurgeons found the new technology particularly useful in more complicated bone deficits with different curvatures in various planes. Conclusions Reverse engineering and rapid prototyping may reduce the time needed for cranioplasty neurosurgery and improve the prosthesis fitting. Such technologies may utilize data obtained by commonly used spiral CT scanners. The manufacturing of individually adjusted prostheses should be commonly used in patients planned for cranioplasty with synthetic material.
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Affiliation(s)
- Robert Chrzan
- Department of Radiology, Collegium Medicum, Jagiellonian University, Cracow, Poland.
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Kasprzak P, Tomaszewski G, Kotwica Z, Kwinta B, Zwoliński J. Reconstruction of cranial defects with individually formed cranial prostheses made of polypropylene polyester knitwear: an analysis of 48 consecutive patients. J Neurotrauma 2012; 29:1084-9. [PMID: 22320208 DOI: 10.1089/neu.2011.2247] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
This article presents a new method of cranioplasty in which polypropylene polyester knitwear was used as the filling material. The basis for prosthesis shaping was a three-dimensional model of the defect made according to the patient's CT scans. Previously, such material has never been a subject of computer-aided design and computer-aided manufacturing (CAD/CAM) individual forming. The process of the prosthesis design included CT bone scans and mold preparation for each patient. Such prostheses were implanted in 48 patients with cranial defects. The total number of prostheses applied was 51. The follow-up time was at least 6 months up to 36 months. The group of treated patients is described here, and sample pictures are shown to illustrate the results. The smallest defect had a size of 15 cm(2); the biggest, 178 cm(2). The coverage and the aesthetic results were very good in all cases. Two patients had postoperative complications. The cranioplastic solution described here is a valuable addition to the existing reconstructive methods, because of the low cost of the implant, the ease of its adjustment to the shape of the defect, and the short time of preparation.
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Affiliation(s)
- Piotr Kasprzak
- Department of Neurosurgery, Medical University of Lodz, Łódź, Poland.
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Goh RC, Chang CN, Lin CL, Lo LJ. Customised fabricated implants after previous failed cranioplasty. J Plast Reconstr Aesthet Surg 2010; 63:1479-84. [DOI: 10.1016/j.bjps.2009.08.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Revised: 07/25/2009] [Accepted: 08/20/2009] [Indexed: 10/20/2022]
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Lee SC, Wu CT, Lee ST, Chen PJ. Cranioplasty using polymethyl methacrylate prostheses. J Clin Neurosci 2009; 16:56-63. [PMID: 19046734 DOI: 10.1016/j.jocn.2008.04.001] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 04/01/2008] [Accepted: 04/02/2008] [Indexed: 12/28/2022]
Abstract
In this retrospective study we attempted to assess the clinical performance of prefabricated polymethyl methacrylate (PMMA) prostheses and to determine whether they outperform intra-operatively moulded PMMA prostheses in reducing operating time, blood loss and surgical complications in elective delayed cranioplasty operations, after decompressive craniectomy, to repair large (> 100 cm2) cranial defects. Patients (n=131) were divided into three groups according to the cranioplasty technique used. Group 1 patients received fresh frozen autograft bone that had been removed at the craniectomy and refrigerated at -80 degrees C. Group 2 included patients whose PMMA prosthesis was moulded intra-operatively. Group 3 patients received a custom-made prefabricated PMMA prosthesis manufactured using computer-aided design/computer-aided manufacturing (CAD/CAM). Group 2 patients required significantly more operating time than both group 1 (p<0.001) and group 3 (p<0.001) patients, but operating time did not differ significantly between groups 1 and 3 (p>0.05). Mean intra-operative blood loss was significantly higher in group 2 than in group 1 (p=0.015) but did not differ significantly between group 1 and group 3 (p>0.05). The infection rate associated with prefabricated PMMA prostheses was lower than that for intra-operatively moulded PMMA prostheses and was comparable to that for autograft bone flaps. A CAD/CAM PMMA prosthesis is an excellent alternative when no autogenous bone graft harvested during craniectomy is available.
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Affiliation(s)
- Sai-Cheung Lee
- Department of Neurosurgery, Chang Gung University, Taoyuan, Taiwan
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Anderson WS, Kossoff EH, Bergey GK, Jallo GI. Implantation of a responsive neurostimulator device in patients with refractory epilepsy. Neurosurg Focus 2008; 25:E12. [DOI: 10.3171/foc/2008/25/9/e12] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors summarize one center's experience with a novel device, the Responsive Neurostimulation (RNS) system, which is used to treat seizures, and they provide technical details regarding the implantation procedure.
Methods
The authors reviewed seizure detection, cortical stimulation, and clinical data obtained in 7 patients in whom the RNS system was implanted. Data pertaining to seizure alteration are provided for the first 4 implant-treated patients. The implantation procedure in the case of one patient with occipital lobe heterotopia is included.
Results
Based on patients' seizure diaries, the implanted devices functioned at a high sensitivity for clinical seizure detection. Reductions in seizure frequency, based on their diaries and on clinic follow-up notes, ranged from 50 to 75%. No adverse stimulation-induced side effects were noted, and no hardware malfunctions requiring explantation occurred. Generator replacements for battery depletion were required at 11, 17, and 20 months in 3 patients. The implantation procedure was well tolerated, and postoperative hospital stays were short. A revision cranioplasty for a skull defect was performed in the index patient, whose case will be discussed in the most detail.
Conclusions
The results obtained in this small preliminary series demonstrate a safe implantation method for the responsive neurostimulation device.
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Affiliation(s)
- William S. Anderson
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | - George I. Jallo
- 3Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland
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Greene AK, Warren SM, McCarthy JG. Onlay frontal cranioplasty using wire reinforced methyl methacrylate. J Craniomaxillofac Surg 2008; 36:138-142. [DOI: 10.1016/j.jcms.2007.05.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Accepted: 05/21/2007] [Indexed: 11/24/2022] Open
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