Cranioplasty after decompressive craniectomy

Rationale Behind the Use of Double-Layer Polypropylene Patch (G-patch) Dural Substitute During Decompressive Craniectomy as an Adhesion Preventive Material for Subsequent Cranioplasty with Special Reference to Flap Elevation Time

OBJECTIVE

Dural substitutes are used in decompressive craniectomy (DC) to prevent adhesions during subsequent cranioplasty. Current literature attributes them to reduced blood loss and reduction in operative time of cranioplasty. The use of double-layer substitute has rarely been documented. We studied the use of double-layer G-patch as a dural substitute in DC and evaluated its outcome during subsequent cranioplasty with special focus on flap elevation time and blood loss during cranioplasty.

METHODS

We performed emergency frontotemporoparietal decompressive craniectomy using a double layer of G-patch as dural substitute. Subsequent cranioplasty was done in these 35 patients. The development of adhesion formation between the tissue layers, amount of blood loss, and flap elevation time were recorded.

RESULTS

During the cranioplasty, a clear and smooth plane of dissection was found between the 2 layers of G-patch in all cases. Average flap elevation time was 21.8 minutes, and average time taken for cranioplasty was 124.12 minutes. Average blood loss was 83 mL. None of the patients required re-exploration for infection of bone flap or postoperative bleed.

CONCLUSIONS

While evaluating the use of dural substitute during DC as an adhesion preventive material for subsequent cranioplasty, flap elevation time and blood loss should be taken into account rather than operative time. Double-layer G-patch during DC facilitates subsequent cranioplasty by preventing adhesions between the layers, resulting in easier dissection and reduced blood loss.

Cranioplasty of Large Cranial Defects With Porous Polyethylene Implants

BACKGROUND

Reconstruction of cranial defects due to trauma or other causes has been carried out since ages with a wide variety of materials. The aim of reconstruction was mainly to restore cosmesis and protect the brain from further injury. However, recent studies have shown that cranioplasty not only improves the cerebral blood flow but also leads to improvement of cognitive functions. The materials used include autologous bone, allogeneic bone, xenografts, and alloplasts. The search for an ideal material continues. The authors present their experience with cranioplasty using prefabricated porous polyethylene implants.

MATERIALS AND METHODS

Patients requiring cranioplasty for reconstruction of large sized (more than 15 cm in any 1 dimension) cranial defects were selected. Three patients were men and 2 were women. The age group of the patient ranged from 18 to 58 years. Preformed Biopore Hemisphere was used in every patient for cranial reconstruction.

RESULTS

No complications were seen in our patients. One patient who had undergone titanium cranioplasty previously showed remarkable improvement in cognitive functions.

CONCLUSION

Porous polyethylene prefabricated implants are a good restorative material for reconstruction of large cranial defects.

Early Cranioplasty in Patients With Posttraumatic Decompressive Craniectomy and Its Correlation with Changes in Cerebral Perfusion Parameters and Neurocognitive Outcome

BACKGROUND

Decompressive craniectomy is a life-saving procedure in many patients after traumatic brain injury. Delayed recovery in such patients can be attributed to various causes. Cranioplasty (CP) helps in early improvement of neurocognitive function along with better brain protection and cosmesis. The mechanism responsible for this functional improvement and the ideal time to perform cranial reconstruction is less understood.

METHODS

We studied 16 patients who underwent CP after decompressive craniectomy (DC) for traumatic brain injury. These patients were divided in 2 groups, early and late CP, depending on the interval between DC and CP. Three months was the cutoff time for early CP. Neurocognitive status was assessed by Glasgow Coma Scale, Glasgow Outcome Scale, and Mini-Mental State Examination scores prior to and after CP. Computed tomography (CT) perfusion was done to correlate the improvement in neurologic status and CT perfusion parameters.

RESULTS

We observed that there was a positive influence of CP on neurologic and psychologic function in all of the patients. The neurocognitive improvement after CP was more remarkable in the early CP group. More complications were noted in patients in the late CP group. Brain perfusion after CP showed improvement in all parameters in both of the groups, both on the operated and contralateral side.

CONCLUSIONS

Neurocognitive improvement is noted after CP in all of the patients. CP should be offered once the brain edema subsides, at the earliest. Improved cerebral perfusion may be the key factor for the improved functional outcome.

Cranioplasty of Hemispherical Defects Using High Impact Methylmethacrylic Plate

Decompressive craniectomy is the most common neurosurgical procedure performed in today's scenario, usually posttrauma or a cerebrovascular event. Cranioplasty is the repair of a cranial defect or deformation. In the last decade, there has been an increase in the number of cranioplasties performed because of an increase in the number of decompressive craniectomies. Although the main purpose of cranioplasty is to protect the brain and restore aesthetics, it has been proved beyond doubt that there is also an improvement in function and patient self-esteem.Reconstructing the skull after a decompressive craniectomy is a challenge because of the size and contour of the defect, the projection of the brain outside in many cases, and the attendant risks of infection, hematoma, seizures, and CSF leak. In the last few decades, an enormous array of biomaterials has been used for cranioplasty, but there is no consensus on the best material. Each has its own advantages and disadvantages. Polymethylmethacrylate has been used for cranioplasty since the World War II and is still the most widely used reconstructive material.

MATERIALS AND METHODS

Patients requiring reconstruction of hemispherical cranial defects were taken up for the study. An impression of the defect was taken over the skin using impression compound first and then silicone impression material. The model was trimmed to size, and an acrylic plate was made from High Impact Acrylic. Under general anesthesia, the acrylic plate was fixed to the margins of the defect using titanium plates and screws. Suction drain was placed and the wound closed with Vicryl Rapid. All patients were followed up for 2 years to note any postoperative complications and change in neurological status. There were 12 male patients and 3 female patients. Age of the patients ranged between 8 and 55 years.

RESULTS

All patients were happy with the aesthetic results. There were no complications in all our patients. A few patients showed dramatic improvement in their neurological status.

CONCLUSION

High Impact Acrylic is an excellent restorative material for reconstructing large sized cranial defects.

Cranioplasty outcomes and associated complications: A single-centre observational study

INTRODUCTION

The resurgence of decompressive craniectomy has led to recent published reviews of the safety of cranioplasties. To date there is a wide range of reported mortality and morbidity. This observational study reports the outcomes of the cranioplasty operations from a single centre and evaluates the factors involved in their management.

METHODS

A retrospective search of all theatre logs was performed for the years 2006-2013 inclusive. 88 operations were documented as 'Cranioplasty'. Data collection include patient demographics, type of cranioplasty used, time lapse between decompression and cranioplasty, seniority of the operating surgeon(s), antibiotic regimen and complications. Outcomes were recorded at the three-month follow-up.

RESULTS

The overall complication rate was 6.8%. The mean patient age was 36.2 years. 52.2% of patients had decompressive craniectomy for trauma, 11.3% had infectious pathology, 9% had subarachnoid haemorrhage, 9% had tumour with bone infiltration and 3.4% had stroke. 55.7% of patients had cranioplasty within 6 months of craniectomy. 61.3% of cranioplasties were with autologous bone, 20.4% titanium, 10.2% acrylic and 7.9% polyetheretherketone (PEEK). Significant complications included one case of infection, two cases of subgaleal haematoma and one extradural collection. No deaths were noted. No correlation was found between infection and the use of drains. 68.6% of cases were done by either a senior surgeon or a supervised registrar. There was an observable difference in complication rates in relation to the seniority and experience of the operator. However, patient numbers and complications were insufficient to achieve statistical significance. Strict antimicrobial prescribing was observed.

CONCLUSION

Some potentially preventable complications have been addressed with a resulting rate of complications lower than other published reports. We use two standard adjuncts: the presence of a senior surgeon and strict antimicrobial regimens. We believe that our results could be transferrable to other units by following similar guidelines.

Cranioplasty of Hemispherical Defects Using Calcium Phosphate Cements Along with Titanium Mesh: Our Experience

INTRODUCTION

Cranial defects may arise due to trauma, infection, surgical ablation or errors in development. Restoration of such defects is important for esthetics, function and morale of the patient. Several materials are available. Each has its advantages and disadvantages. Search is on for an ideal material. Autogenous grafts remain the gold standard in reconstruction of such defects. However, the morbidity associated with their harvest, additional time required, the need for a second surgical site and the limited supply has led to the search for newer substitutes. Although many materials are available today including biologic and non biologic substitutes, there is still no consensus about the best material. In this article we describe our use of calcium phosphate cements for reconstruction of hemispherical cranial defects.

MATERIALS AND METHODS

Cases requiring reconstruction of hemispherical cranial defects (more than 15 cm in any dimension) were selected for study. After exposing the defect under GA, titanium mesh was adapted to the defect for support. Then the calcium phosphate cement was prepared and injected on the mesh to establish good contour. The alloplastic insert in each patient was evaluated for: (a) Immediate post-operative complications (b) Restoration of contour and soft tissue support (c) New bone formation ascertained on HRCT at the end of 2 years. Patients were examined on postoperative first week, at 3 and at 6 months. High resolution computed tomography scans were taken at 2 years postop. There were two female and three male patients.

RESULTS

There were no complications in the post operative period. The general condition of the patients improved post operatively. Even though the cements maintained their contour at 2 years, there were no signs of bone formation within the cement.

CONCLUSION

Calcium phosphate cement is a good bone substitute for use in cranioplasty. In defects requiring mechanical strength, it should be supported by a titanium mesh. It retains the contour but is not replaced by bone even after 2 years.