Malignant cerebral edema following cranioplasty

Malignant bihemispheric cerebral edema after cranioplasty - An extension of the Monro-Kellie doctrine and predictive factors

Background

Several changes in normal pressure dynamics on the brain occur with a decompressive craniectomy and subsequent cranioplasty. Dead space volume is an important factor contributing to intracranial volume postcranioplasty. A decrease in this volume due to negative suction drain along with relative negative pressure on the brain with the loss of external atmospheric pressure may lead to fatal cerebral edema.

Case Description

A 52-year-old gentleman with a 210 mL volume and middle cerebral artery territory infarction underwent an emergency craniectomy and 6 months later a titanium mold cranioplasty. Precranioplasty computed tomography (CT) scan evaluation revealed a sunken skin flap with a 9 mm contralateral midline shift. Immediately following an uneventful surgery, the patient had sudden fall in blood pressure to 60/40 mmHg and over a few min had dilated fixed pupils. CT revealed severe diffuse cerebral edema in bilateral hemispheres with microhemorrhages and expansion of the sunken right gliotic brain along with ipsilateral ventricular dilatation. Despite undergoing a contralateral decompressive craniectomy due to the midline shift toward the right, the outcome was fatal.

Conclusion

Careful preoperative risk assessment in cranioplasty and close monitoring postprocedure is crucial, especially in malnourished, poststroke cases, with a sinking skin flap syndrome, and a long interval between decompressive craniectomy and cranioplasty. Elective preventive measures and a low threshold for CT scanning and removal of the bone flap or titanium mold are recommended.

Malignant cerebral edema after cranioplasty: a case report and literature review

BACKGROUND

Cranioplasty is a common surgery in the neurosurgery for patients with skull defects following decompression craniectomy. Concomitant rare complications are increasingly reported, such as malignant cerebral edema after cranioplasty.

CASE REPORT

A 45-year-old man underwent decompression craniectomy due to traumatic brain injury. At 3 months after the decompression craniectomy, the patient developed refractory subdural hydrogen and received ipsilateral refractory subdural effusion capsule resection, but no significant relief was seen. Therefore, the cranioplasty was decided to treat subdural hydrogen and restore the normal appearance of the skull. After the successful cranioplasty surgery and the expected anesthesia recovery period, the pupils of the patients were continued to be dilated and fixed, without light reflection and spontaneous breathing. The Computed Tomography of the patient 1 hour after surgery showed malignant cerebral edema.

CONCLUSIONS

Malignant cerebral edema is a rare and lethal complication after cranioplasty. Negative pressure drainage and deregulation of cerebral blood flow at the end of cranioplasty may partially explain the malignant cerebral after cranioplasty. In addition, patients with epileptic seizures, no spontaneous breathing, dilated pupils without reflection, and hypotension within a short period after cranioplasty may show the occurrence of malignant cerebral.

Adult Cranioplasty Reconstruction With Customized Cranial Implants: Preferred Technique, Timing, and Biomaterials

INTRODUCTION

Complex cranial defects requiring delayed reconstruction present numerous challenges. Delayed cranioplasties accompany frequent complications approaching an incidence of 35 to 40%. Therefore, the authors sought to collate their experience in hopes of sharing their perspective on several topics including technique, timing, and preferred biomaterials.

METHODS

The authors' 5-year consecutive experience over 430 customized cranial implants is described herein. Since its inception in 2012, the authors' team has employed the pericranial-onlay cranioplasty technique instead of the standard epidural approach. Optimal timing for cranioplasty is determined using objective criteria such as scalp healing and parenchymal edema, close collaboration with neuroplastic surgery, conversion from autologous bone to sterile implant in instances of questionable viability/storage, and the first-line use of solid poly(methylmethacrylate) implants for uncomplicated, delayed cases, first-line porous polyethylene (MEDPOR) implants for single-stage cranioplasty, and first-line polyether-ether-ketone implants for cases with short notice. Furthermore, the use of the pterional design algorithm with temporal bulking for all customized implants has helped to correct and/or prevent temporal hollowing deformities.

RESULTS

The authors' team has observed a three-fold reduction in reported complications as compared with the existing literature, with a major complication rate of 11%. The multidisciplinary center has provided an optimal stage for synergy and improved outcomes versus standard cranioplasty techniques.

CONCLUSION

Secondary cranial reconstruction, or cranioplasty, can be challenging due to numerous reasons. These best practices, developed in collaboration with neuroplastic surgery and neurosurgery, appear to encompass the largest published experience to date. The authors find this approach to be both safe and reliable.

Intracranial Hypotension and Hypertension Associated With Reconstructive Cranioplasty After Decompressive Craniectomy: Report of a Lethal Complication With Recommended Strategies for Future Avoidance

Reconstructive cranioplasty can be associated with many complications and add to the not insignificant potential risks associated with decompressive craniectomy. In the setting of post-traumatic hydrocephalus, treatment with a ventriculoperitoneal (VP) shunt prior to reconstructive cranioplasty likely increases these risks even further. The authors report a case of a 17-year-old male with a history of a severe closed head injury who initially suffered a life-threatening complication associated with intracranial hypotension after cranioplasty only to succumb to malignant intracranial hypertension following a second cranioplasty attempt. To our knowledge, this is the first description of a single patient developing both these disparate complications after reconstructive cranioplasty and emphasizes the likely synergistic hazards involved with decompressive craniectomy in the setting of a VP shunt in particular and the overall myriad potential complications that may be associated with reconstructive cranioplasty in general.

Massive Brain Swelling and Death After Cranioplasty: A Systematic Review

BACKGROUND

Although cranioplasty is a common procedure, it may cause a variety of complications. Massive brain swelling after cranioplasty (MBSC) is an unusual complication that has been reported more frequently in recent years. Most of the existing information about this condition is speculative and the cause remains unclear.

METHODS

A PubMed and Scopus search adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed to include studies reporting patients with MBSC. Different information was analyzed in these cases to describe the characteristics and identify risk factors for MBSC.

RESULTS

The search yielded 19 articles with a total of 26 patients. All studies were case reports and small case series. In most patients, preoperative intracranial hypotension and a considerable degree of sinking of skin flap were identified; this was the only constant finding observed in these cases. In addition, we propose a grading system to estimate the degree of preoperative sinking of skin flap and an algorithm with recommendations to decrease the incidence of MBSC.

CONCLUSIONS

MBSC is an unusual, highly lethal, and probably underreported condition. The information gathered in this review indicates that MBSC occurs secondary to a cascade of pathologic events triggered by the bone flap implantation. This evidence suggests that the primary pathologic change is a sudden increase in the intracranial pressure acting on a brain chronically exposed to intracranial hypotension.

Malignant Cerebral Swelling After Cranioplasty: Case Report and Literature Review

BACKGROUND

Cranioplasty is considered a low-risk operation in the field of neurosurgery following decompression craniectomy. Well-known complications after cranioplasty, such as infection, seizure, and titanium plate exposure, may not threaten the lives of patients. Unfortunately, there are many fatal complications that are underreported. In this study, we report a case and perform a literature review to introduce malignant cerebral swelling, which is regarded as a devastating complication.

CASE DESCRIPTION

A 51-year-old man who was a victim of traumatic brain injury underwent emergency clot removal and decompression craniectomy. His neurologic condition improved with subsequent rehabilitation therapy, and he had left sinking skin flap syndrome where the skull was defective. Six months after the initial surgery, he underwent a cranioplasty; however, he did not recover from the uneventful anesthesia. A vacuum suction drain showed 300 mL of flow outflow had drained when his pupils dilated and fixed. An immediate computed tomography scan showed ipsilateral diffuse cerebral swelling with diffuse cerebral hemorrhage. Despite all approaches that were considered, the cerebral swelling continued to worsen until death.

CONCLUSION

Cranioplasty is a high-risk procedure in some cases. Sinking skin flap syndrome and vacuum suction drain may be the main risks of a postoperative venous congestion and stasis, which may result in diffuse cerebral swelling. Once the computed tomography scan shows malignant cerebral swelling, the patient is expected to have a poor prognosis.

Fatal cerebral swelling immediately after cranioplasty: A case report

Background:

Cranioplasty is a standard neurosurgical procedure which is performed after decompressive craniotomy. Fatal complications associated with this procedure are not well documented. Here, we report a case of fatal cerebral swelling after cranioplasty and discuss the possible mechanism of this complication.

Case Description:

A 64-year-old man was admitted with the diagnosis of cerebral hemorrhage, and emergency surgery for hemorrhage removal and decompressive craniotomy were performed. One month after surgery, cranioplasty was performed using a titanium mesh plate. Sixteen hours after the surgery, the patient became comatose with bilateral dilated pupils followed by blood pressure lowering. Computed tomography of the brain showed bilateral massive cerebral edema. The titanium mesh plate was immediately removed, however, the patient’s neurological condition did not recover and he died 7 days after the surgery. We speculated that the negative pressure difference and increase in cerebral blood flow after cranioplasty may have attributed to the fatal cerebral swelling.

Conclusion:

Fatal cerebral swelling after cranioplasty is a rare but devastating complication. Although it is rare, neurosurgeons should keep in mind that this fatal complication can follow cranioplasty.

Malignant Cerebral Swelling After Cranioplasty due to Ipsilateral Intracranial Vasculopathy: Case Report and Literature Review

BACKGROUND

Cranioplasty is a well-established surgical operation that is used worldwide for patients with skull defects following decompressive craniectomy (DC). However, in some cases, potentially fatal complications may occur, such as malignant cerebral swelling after uneventful cranioplasty.

CASE DESCRIPTION

We present a rare case of massive malignant ipsilateral cerebral swelling following uneventful titanium mesh cranioplasty due to rare ipsilateral intracranial vasculopathy confirmed by magnetic resonance angiography (MRA) and magnetic resonance venography (MRV). Fortunately, we performed titanium mesh explantation and extended DC in time, and the patient survived. Malignant cerebral swelling after uneventful cranioplasty is an unpredictable but fatal complication. Most reported cases have had an unfavorable prognosis. To the best of our knowledge, the mechanism was first confirmed by MRA and MRV, which demonstrated that the cerebral swelling was due to unilateral intracranial vasculopathy, including a rare ipsilateral intracranial internal carotid artery occlusion, as well as extremely thin lateral and sigmoid sinuses.

CONCLUSIONS

Our case demonstrates for the first time that ipsilateral intracranial vasculopathy is a risk factor for malignant cerebral swelling after cranioplasty. Patients with traumatic brain injury with suspected intracranial vasculopathy should undergo a comprehensive vascular evaluation before cranioplasty to help prevent malignant cerebral swelling.