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Ritter L, Strohhäcker K, Schebesch KM, Eibl T, Höhne J, Liebert A. Complication rates after autologous cranioplasty following decompressive craniectomy. Acta Neurochir (Wien) 2024; 166:380. [PMID: 39320557 PMCID: PMC11424706 DOI: 10.1007/s00701-024-06282-w] [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: 07/01/2024] [Accepted: 09/20/2024] [Indexed: 09/26/2024]
Abstract
OBJECTIVE The reimplantation of autologous bone grafts after decompressive craniectomy (DC) is still up for debate. The objective of this study was to analyze the surgical revision rate for autologous cranioplasties in our center, aiming to identify predictors for procedure-related-complications. METHODS A retrospective single-center study was conducted for adult patients who underwent autologous cranioplasty after DC. The primary endpoint was the complication rate in terms of surgical revision and removal of the bone graft: infection, new onset seizures, dislocation, haemorrhage, osteolysis, wound dehiscence and cerebrospinal fluid (CSF) fistula. Demographic data, medical records, surgical reports and imaging studies were analysed and risk factors for complications were evaluated. RESULTS 169 consecutive patients were included. The median interval between DC and cranioplasty was 84 days. Mean age was 51 ± 12.4 years. 26 patients (15.3%) had revision surgery for following reasons. n = 9 implant dislocations (5.3%), n = 7 osteolysis (3.6%), n = 6 infections (3.6%), n = 5 had re-bleedings (3%), n = 5 wound dehiscences (3%), and n = 2 CSF fistulas (1.2%). 18 patients developed new seizures (10.7%). Bi- and multivariate analysis revealed three independent risk factors, simultaneous ventriculo-peritoneal (VP) shunting increased the risk for material dislocation (p < 0.001); large bone grafts (> 193.5 cm2) increased the risk for osteolysis (p = 0.001) and bifrontal cranioplasties were associated with higher risk for infections (p = 0.04). CONCLUSION The complication rates in our study were comparable to previously reported data for autologous or artificial cranioplasties. As osteolysis was correlated to larger bone grafts, a synthetic alternative should be considered in selected cases.
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Affiliation(s)
- Leonard Ritter
- Department of Neurosurgery, Paracelsus Medical University, Breslauer Str. 201, 90471, Nuremberg, Germany.
| | - Kilian Strohhäcker
- Department of Neurosurgery, Paracelsus Medical University, Breslauer Str. 201, 90471, Nuremberg, Germany
| | - Karl-Michael Schebesch
- Department of Neurosurgery, Paracelsus Medical University, Breslauer Str. 201, 90471, Nuremberg, Germany
| | - Thomas Eibl
- Department of Neurosurgery, Paracelsus Medical University, Breslauer Str. 201, 90471, Nuremberg, Germany
| | - Julius Höhne
- Department of Neurosurgery, Paracelsus Medical University, Breslauer Str. 201, 90471, Nuremberg, Germany
| | - Adrian Liebert
- Department of Neurosurgery, Paracelsus Medical University, Breslauer Str. 201, 90471, Nuremberg, Germany
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Meng X, Liu H, Zhang J, Gui B, Gao A, Fan Z, Wang Y, Xu H, Fang X, Jiang Z, Liang H, Zhang X. Risk Factors for Seizures After Titanium Cranioplasty: Five-Year Experience from a Single Institution. World Neurosurg 2024; 182:e270-e275. [PMID: 38006935 DOI: 10.1016/j.wneu.2023.11.096] [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: 10/10/2023] [Accepted: 11/20/2023] [Indexed: 11/27/2023]
Abstract
OBJECTIVE Seizures are one of the complications that can occur after cranioplasty (CP). In some regions, titanium mesh remains the material of choice for CP. However, risk factors for seizures after titanium CP have been less studied. The purpose of this study was to identify potential risk factors for early seizures (≤7 days) and late seizures (>8 days) after titanium CP in a single institution. METHODS A retrospective review was conducted of 241 consecutive patients who received titanium CP at the First Affiliated Hospital of Harbin Medical University from January 2016 to December 2020. Univariate and multivariable logistic regression analyses were performed to determine the independent risk factors for new-onset seizures after titanium CP. RESULTS Fifteen patients (6.22%) experienced early post-CP seizures, and late post-CP seizures were observed in 81 patients (33.61%). A flaccid concave cranial defect (P = 0.042) was associated with early post-CP seizures, whereas hypertension (P < 0.001) was the only significant predictor for late seizures after titanium CP. CONCLUSIONS Seizure is a common complication after titanium CP, especially in patients who do not receive prophylactic antiepileptic drugs before the procedure. Risk factors for new-onset seizures at different periods after titanium CP were found to be different. In addition, radiologic factors before titanium CP may play a role in early new-onset seizures after titanium CP and should not be ignored.
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Affiliation(s)
- Xiangyi Meng
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China; NHC Key Laboratory of Cell Transplantation, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China
| | - Hao Liu
- Clinical Laboratory of Molecular Biology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China
| | - Jie Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China; NHC Key Laboratory of Cell Transplantation, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China
| | - Binbin Gui
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China; NHC Key Laboratory of Cell Transplantation, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China
| | - Aili Gao
- School of Life Science, Northeast Agricultural University, Harbin, Heilongjiang Province, PR China
| | - Zhaoxin Fan
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China; NHC Key Laboratory of Cell Transplantation, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China
| | - Yuehua Wang
- Department of Neurosurgery, Shanghai Seventh People's Hospital, Shanghai, PR China
| | - Hangjia Xu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China; NHC Key Laboratory of Cell Transplantation, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China
| | - Xiaofeng Fang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China; NHC Key Laboratory of Cell Transplantation, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China
| | - Zhenfeng Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China; NHC Key Laboratory of Cell Transplantation, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China
| | - Hongsheng Liang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China; NHC Key Laboratory of Cell Transplantation, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China.
| | - Xiangtong Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China; NHC Key Laboratory of Cell Transplantation, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, PR China
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Csámer L, Csernátony Z, Novák L, Kővári VZ, Kovács ÁÉ, Soósné Horváth H, Manó S. Custom-made 3D printing-based cranioplasty using a silicone mould and PMMA. Sci Rep 2023; 13:11985. [PMID: 37491550 PMCID: PMC10368708 DOI: 10.1038/s41598-023-38772-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 07/14/2023] [Indexed: 07/27/2023] Open
Abstract
All types of cranioplasty techniques restore the morphology of the skull and affect patient aesthetics. Safe and easy techniques are required to enhance patients' recovery and the rehabilitation process. We propose a new method of cranioplasty. The 3-dimensional (3D) reconstruction of a thin-layer computed tomography (CT) scan of the skull was used to reflect the intact side onto the defect and subtract the overlapping points from one another. In this way, a 3D model of the planned implant can be built in the required shape and size. The precise fit of the implant can be checked by printing the defective part of the skull in case it can be modified. A sterilisable silicone mould based on the finalized model was created afterwards. Polymethyl methacrylate implants were prepared directly in an aseptic environment in the operating room during surgery. Between 2005 and 2020, we performed 54 cranioplasties on 52 patients whose craniotomies were performed previously for indications of traumatic brain injury, stroke or tumour surgeries. No technical problems were noted during the operations. In 2 cases, septic complications that occurred were not connected to the technique itself, and the implants were removed and later replaced. Our proposed technique based on 3D-printed individual silicone moulds is a reliable, safe, easily reproducible and low-cost method to repair different skull defects.
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Affiliation(s)
- Loránd Csámer
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
| | - Zoltán Csernátony
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Novák
- Department of Neurosurgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Viktor Zsolt Kővári
- Department of Neurosurgery, Health Centre of Hungarian Army, Budapest, Hungary
| | - Ágnes Éva Kovács
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Hajnalka Soósné Horváth
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Sándor Manó
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Fallatah MA, Aldahlawi A, Babateen EM, Saif S, Alnejadi W, Bamsallm M, Lary A. Outcomes of Cranioplasty: A Single-Center Experience. Cureus 2023; 15:e35213. [PMID: 36968927 PMCID: PMC10035764 DOI: 10.7759/cureus.35213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 02/22/2023] Open
Abstract
Background Cranioplasty (CP) is a common cranial reconstructive procedure. It is performed after craniectomy due to various causes such as relieving increased intracranial pressure, infection, and tumor infiltration. Although CP is an easy procedure, it is associated with a high rate of complications. We aimed to retrospectively investigate the outcomes of CP at the King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah (KAMC-J). Methods This is a retrospective observational study that included all patients who had CP (first time or redo) at KAMC-J from 1st January 2010 to 31st December 2020. Patients with congenital cranial malformation were excluded. Result A total of 68 patients underwent CP. Of those, 23 (34%) had complications. The most common complication was infection (10.3%). Twelve of the 23 patients had major complications that necessitated reoperation. Of those 12, six underwent redo CP; three out of these six patients had further complications which were also managed surgically. On bivariate analysis, cranial defects over 50 cm² were associated with a higher rate of both infection and hydrocephalus (p=0.018) while the frontal site was associated with a higher rate of infection (p=0.014). Moreover, traumatic brain injury as an etiology was exclusively associated with post-cranioplasty hydrocephalus (p=0.03). Conclusion Patients undergoing CP after craniectomy are prone to a considerably high rate of adverse outcomes. The overall rate of complications in this study was 34%, with an infection rate of 10.3% and a 1.5% mortality rate. Consistent with other studies, larger cranial defects as well as frontal sites have a higher rate of infection.
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Gerstl JVE, Rendon LF, Burke SM, Doucette J, Mekary RA, Smith TR. Complications and cosmetic outcomes of materials used in cranioplasty following decompressive craniectomy-a systematic review, pairwise meta-analysis, and network meta-analysis. Acta Neurochir (Wien) 2022; 164:3075-3090. [PMID: 35593924 DOI: 10.1007/s00701-022-05251-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/10/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Optimal reconstruction materials for cranioplasty following decompressive craniectomy (DC) remain unclear. This systematic review, pairwise meta-analysis, and network meta-analysis compares cosmetic outcomes and complications of autologous bone grafts and alloplasts used for cranioplasty following DC. METHOD PubMed, Embase, and Cochrane were searched from inception until April 2021. A random-effects pairwise meta-analysis was used to compare pooled outcomes and 95% confidence intervals (CIs) of autologous bone to combined alloplasts. A frequentist network meta-analysis was subsequently conducted to compare multiple individual materials. RESULTS Of 2033 articles screened, 30 studies were included, consisting of 29 observational studies and one randomized control trial. Overall complications were statistically significantly higher for autologous bone compared to combined alloplasts (RR = 1.56, 95%CI = 1.14-2.13), hydroxyapatite (RR = 2.60, 95%CI = 1.17-5.78), polymethylmethacrylate (RR = 1.50 95%CI = 1.08-2.08), and titanium (Ti) (RR = 1.56 95%CI = 1.03-2.37). Resorption occurred only in autologous bone (15.1%) and not in alloplasts (0.0%). When resorption was not considered, there was no difference in overall complications between autologous bone and combined alloplasts (RR = 1.00, 95%CI = 0.75-1.34), nor between any individual materials. Dehiscence was lower for autologous bone compared to combined alloplasts (RR = 0.39, 95%CI = 0.19-0.79) and Ti (RR = 0.34, 95%CI = 0.15-0.76). There was no difference between autologous bone and combined alloplasts with respect to infection (RR = 0.85, 95%CI = 0.56-1.30), migration (RR = 1.36, 95%CI = 0.63-2.93), hematoma (RR = 0.98, 95%CI = 0.53-1.79), seizures (RR = 0.83, 95%CI = 0.29-2.35), satisfactory cosmesis (RR = 0.88, 95%CI = 0.71-1.08), and reoperation (RR = 1.66, 95%CI = 0.90-3.08). CONCLUSIONS Bone resorption is only a consideration in autologous cranioplasty compared to bone substitutes explaining higher complications for autologous bone. Dehiscence is higher in alloplasts, particularly in Ti, compared to autologous bone.
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Affiliation(s)
- Jakob V E Gerstl
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA. .,University College London Medical School, London, WC1E 6DE, UK.
| | - Luis F Rendon
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.,Department of Neurosurgery, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Shane M Burke
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.,Department of Neurosurgery, Tufts Medical Center, Boston, MA, 02111, USA
| | - Joanne Doucette
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.,School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, 02115, USA
| | - Rania A Mekary
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.,School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, 02115, USA
| | - Timothy R Smith
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
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Pöppe JP, Spendel M, Schwartz C, Winkler PA, Wittig J. The "springform" technique in cranioplasty: custom made 3D-printed templates for intraoperative modelling of polymethylmethacrylate cranial implants. Acta Neurochir (Wien) 2022; 164:679-688. [PMID: 34873659 PMCID: PMC8913485 DOI: 10.1007/s00701-021-05077-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/23/2021] [Indexed: 12/19/2022]
Abstract
Background Manual moulding of cranioplasty implants after craniectomy is feasible, but does not always yield satisfying cosmetic results. In contrast, 3D printing can provide precise templates for intraoperative moulding of polymethylmethacrylate (PMMA) implants in cranioplasty. Here, we present a novel and easily implementable 3D printing workflow to produce patient-specific, sterilisable templates for PMMA implant moulding in cranioplastic neurosurgery. Methods 3D printable templates of patients with large skull defects before and after craniectomy were designed virtually from cranial CT scans. Both templates — a mould to reconstruct the outer skull shape and a ring representing the craniectomy defect margins — were printed on a desktop 3D printer with biocompatible photopolymer resins and sterilised after curing. Implant moulding and implantation were then performed intraoperatively using the templates. Clinical and radiological data were retrospectively analysed. Results Sixteen PMMA implants were performed on 14 consecutive patients within a time span of 10 months. The median defect size was 83.4 cm2 (range 57.8–120.1 cm2). Median age was 51 (range 21–80) years, and median operating time was 82.5 (range 52–152) min. No intraoperative complications occurred; PMMA moulding was uneventful and all implants fitted well into craniectomy defects. Excellent skull reconstruction could be confirmed in all postoperative computed tomography (CT) scans. In three (21.4%) patients with distinct risk factors for postoperative haematoma, revision surgery for epidural haematoma had to be performed. No surgery-related mortality or new and permanent neurologic deficits were recorded. Conclusion Our novel 3D printing-aided moulding workflow for elective cranioplasty with patient-specific PMMA implants proved to be an easily implementable alternative to solely manual implant moulding. The “springform” principle, focusing on reconstruction of the precraniectomy skull shape and perfect closure of the craniectomy defect, was feasible and showed excellent cosmetic results. The proposed method combines the precision and cosmetic advantages of computer-aided design (CAD) implants with the cost-effectiveness of manually moulded PMMA implants. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-05077-7.
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Affiliation(s)
- Johannes P Pöppe
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria.
| | - Mathias Spendel
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Christoph Schwartz
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Peter A Winkler
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Jörn Wittig
- Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
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Abstract
PURPOSE OF REVIEW This article discusses neurologic complications encountered in the postoperative care of neurosurgical patients that are common or key to recognize in the immediate postoperative period. The major neurosurgical subspecialty procedures (cerebrovascular neurosurgery, neuro-oncology, epilepsy neurosurgery, functional neurosurgery, CSF diversion, endovascular neurosurgery, and spinal surgery) are broadly included under craniotomy procedures, endovascular/vascular procedures, and spinal procedures. This article focuses on the range of complications inherent in these approaches with specific scenarios addressed as applicable. RECENT FINDINGS The morbidity and mortality related to neurosurgical procedures remains high, necessitating ongoing research and quality improvement efforts in perioperative screening, intraoperative management, surgical approaches, and postoperative care of these patients. Emerging research continues to investigate safer and newer options for routine neurosurgical approaches, such as coiling over clipping for amenable aneurysms, endoscopic techniques for transsphenoidal hypophysectomy, and minimally invasive spinal procedures; postoperative monitoring and care of patients after these procedures continues to be a key component in the continuum of care for improving outcomes. SUMMARY Postoperative care of patients undergoing major neurosurgical procedures is an integral part of many neurocritical care practices. Neurosurgeons often enlist help from neurologists to assist with evaluation, interpretation, and management of complications in routine inpatient settings. Awareness of the common neurologic complications of various neurosurgical procedures can help guide appropriate clinical monitoring algorithms and quality improvement processes for timely evaluation and management of these patients.
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