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Mracek J, Seidl M, Dostal J, Kasik P, Holeckova I, Tupy R, Priban V. Three-dimensional personalized porous polyethylen cranioplasty in patients at increased risk of surgical site infection. Acta Neurochir (Wien) 2024; 166:383. [PMID: 39327320 DOI: 10.1007/s00701-024-06281-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Accepted: 09/18/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Surgical site infection (SSI) is the most consistently reported complication of cranioplasty. No material showed a categorical superiority in the incidence of infection. Porous polyethylene (PE) is considered a low risk material regarding SSI. However, the literature data are very limited. Thus, our objective was to verify the assumed low incidence of SSI after PE cranioplasty in patients at high risk of SSI. The primary objective was the infection rate, while secondary objectives were implant exposure, revision and cosmetic results. METHOD Patients who underwent three-dimensional (3D) personalized PE cranioplasty in the period 2014-2023 were evaluated prospectively. Only patients with an increased risk of SSI, and a satisfactory clinical conditions were included in the study. RESULTS Thirty procedures were performed in 30 patients. Cranioplasty was performed 23 times after hemispheric decompressive craniectomy, five times after limited size craniotomy and two times after bifrontal decompressive craniectomy. Risk factors for the development of infection were 18 previous SSIs, 16 previous repeated revision surgeries, four intraoperatively opened frontal sinuses and two times radiotherapy. Neither infection nor implant exposure was detected in any patient. All patients were satisfied with the aesthetic result. In two cases, a revision was performed due to postoperative epidural hematoma. CONCLUSIONS Three-dimensional personalized PE cranioplasty is associated with an extremely low incidence of SSI even in high-risk patients. However, our conclusions can only be confirmed in larger studies.
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Affiliation(s)
- Jan Mracek
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Faculty Hospital Pilsen, Pilsen, Czech Republic.
| | - Miroslav Seidl
- Department of Neurosurgery, Faculty of Medicine, University of Ostrava, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jiri Dostal
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Faculty Hospital Pilsen, Pilsen, Czech Republic
| | - Petr Kasik
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Faculty Hospital Pilsen, Pilsen, Czech Republic
| | - Irena Holeckova
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Faculty Hospital Pilsen, Pilsen, Czech Republic
| | - Radek Tupy
- Department of Imaging Methods, Faculty of Medicine in Pilsen, Charles University, Faculty Hospital Pilsen, Pilsen, Czech Republic
| | - Vladimir Priban
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Faculty Hospital Pilsen, Pilsen, Czech Republic
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Kayhan S, Kırmızıgöz Ş, Kırık A, Tehli Ö, İzci Y. Revision Cranioplasty with Three-dimensional Custom-made Titanium Implants in Patients with Failed Cranioplasty. World Neurosurg 2024:S1878-8750(24)01524-9. [PMID: 39242027 DOI: 10.1016/j.wneu.2024.08.154] [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: 08/27/2024] [Accepted: 08/29/2024] [Indexed: 09/09/2024]
Abstract
OBJECTIVE Graft failure is a common complication of cranioplasty. Revision cranioplasty is required to overcome this complication. However, no previous studies have reported outcomes in revision cranioplasty with 3-dimensional (3D) custom-made titanium implants. We describe our experience with 3D titanium implants in patients with revision cranioplasty. METHODS We evaluated 43 consecutive patients between January 2011 and December 2019 who underwent revision cranioplasty using 3D custom-made titanium implants. The 3D image of the patient's cranium and the plan to close the cranium defect were created in a virtual environment using software programs. Demographic and radiologic features were compared based on the materials used in the initial cranioplasty. RESULTS Previous material was autologous graft (AG) in 27 patients and polymethyl methacrylate (PMMA) in 16 patients. The mean time without revision cranioplasty is longer in patients with PMMA implants than in patients with AG. There was no statistically significant difference in the length of hospital stay between patients with PMMA implants and patients with AG. There were no postoperative adverse events such as infection, wound dehiscence, convulsions, or epidural hematoma in 38 patients during hospitalization. Wound dehiscence developed in 5 patients and surgical repair was required in one. CONCLUSIONS Initial cranioplasty with PMMA provides a longer time period than the AG before the revision. However, both of them have similar outcomes based on length of hospital stay and cranial defect area. Custom-made 3D titanium implant is a good option for revision cranioplasty to prevent implant failure and reduce patients' cosmetic concerns.
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Affiliation(s)
- Sait Kayhan
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey.
| | - Şahin Kırmızıgöz
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Alparslan Kırık
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Özkan Tehli
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Yusuf İzci
- Department of Neurosurgery, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
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Geroski T, Kovačević V, Nikolić D, Filipović N. From imaging to personalized 3D printed molds in cranioplasty. Med Eng Phys 2024; 130:104215. [PMID: 39160013 DOI: 10.1016/j.medengphy.2024.104215] [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: 02/24/2024] [Revised: 06/30/2024] [Accepted: 07/31/2024] [Indexed: 08/21/2024]
Abstract
Cranioplasty is the surgical repair of a bone defect in the skull resulting from a previous operation or injury, which involves lifting the scalp and restoring the contour of the skull with a graft made from material that is reconstructed from scans of the patient's own skull. The paper introduces a 3D printing technology in creating molds, which are filled with polymethyl methacrylate (PMMA) to reconstruct the missing bone part of the skull. The procedure included several steps to create a 3D model in an STL format, conversion into a G-code which is further used to produce the mold itself using a 3D printer. The paper presents our initial experience with 5 patients who undergone cranioplasty utilizing 3D printed molds. Making a patient-specific model is a very complex process and consists of several steps. The creation of a patient-specific 3D model loading of DICOM images obtained by CT scanning, followed by thresholding-based segmentation and generation of a precise 3D model of part of the patient's skull. Next step is creating the G-code models for 3D printing, after which the actual models are printed using Fused Deposition Modeling printer and PLA material. All surgeries showed good match of the missing bone part and part created using 3D printed mold, without additional steps in refinement. In such a way, 3D printing technology helps in creating personalized and visually appealing bone replacements, at a low cost of the final product.
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Affiliation(s)
- Tijana Geroski
- Faculty of Engineering, University of Kragujevac, Sestre Janjić 6, Kragujevac 34000, Serbia; Bioengineering Research and Development Centre (BioIRC), Prvoslava Stojanovića 6, Kragujevac 34000, Serbia.
| | - Vojin Kovačević
- Center for Neurosurgery, Clinical Centre Kragujevac, Zmaj Jovina 30, Kragujevac 34000, Serbia; Faculty of Medical Sciences, Department of Surgery, University of Kragujevac, Svetozara Markovića 69, Kragujevac 34000, Serbia
| | - Dalibor Nikolić
- Bioengineering Research and Development Centre (BioIRC), Prvoslava Stojanovića 6, Kragujevac 34000, Serbia; Institute for Information Technologies, Jovana Cvijića bb, Kragujevac 34000, Serbia
| | - Nenad Filipović
- Faculty of Engineering, University of Kragujevac, Sestre Janjić 6, Kragujevac 34000, Serbia; Bioengineering Research and Development Centre (BioIRC), Prvoslava Stojanovića 6, Kragujevac 34000, Serbia
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Bajaj A, Khazanchi R, Sadagopan NS, Weissman JP, Gosain AK. Identifying Independent Predictors of Short-Term Postoperative Morbidity in Patients Undergoing Cranioplasty. J Craniofac Surg 2024; 35:1394-1397. [PMID: 38836796 DOI: 10.1097/scs.0000000000010281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 04/06/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND The present study intends to identify independent predictors of short-term postoperative complications and health utilization in patients undergoing cranioplasty. METHODS Demographic, clinical, and intraoperative characteristics were collected for each patient undergoing cranioplasty in the National Surgery Quality Improvement Program database from 2011 to 2020. The 30-day outcomes analyzed were medical complications, wound complications, return to the operating room, extended hospital stay, and non-home discharge. Bivariate analyses were initially used to identify variables that yielded a P value less than 0.2 which were subsequently analyzed in a multivariate logistic regression to identify independent predictors of the aforementioned outcomes. RESULTS In total, 2316 patients undergoing cranioplasty were included in the analysis. Increased operative time and totally dependent functional status significantly increased odds of returning to the operating room. Increased age, operative time, cranioplasty size >5 cm, and various comorbidities were associated with increased odds of non-home discharge. Bleeding disorders were independently associated with increased odds of wound complications. Increased age, operative time, cranioplasty size >5 cm, and several medical history features predisposed to medical complications. Demographic characteristics, including age and race, along with various operative and medical history characteristics were associated with increased odds of extended length of stay. CONCLUSIONS Identification of risk factors can help guide preoperative risk management in cranioplasty.
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Affiliation(s)
- Anitesh Bajaj
- Division of Plastic Surgery, Lurie Children's Hospital of the Northwestern University, Feinberg School of Medicine, Chicago, IL
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Montalvo-Afonso A, Castilla-Díez JM, Martín-Velasco V, Martín-Alonso J, Diana-Martín R, Delgado-López PD. Perioperative risk factors for major complications after bone replacement in decompressive craniectomy. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:145-151. [PMID: 38452931 DOI: 10.1016/j.neucie.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 02/05/2024] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Bone flap replacement after a decompressive craniectomy is a low complexity procedure, but with complications that can negatively impact the patient's outcome. A better knowledge of the risk factors for these complications could reduce their incidence. PATIENTS AND METHODS A retrospective review of a series of 50 patients who underwent bone replacement after decompressive craniectomy at a tertiary center over a 10-year period was performed. Those clinical variables related to complications after replacement were recorded and their risk factors were analyzed. RESULTS A total of 18 patients (36%) presented complications after bone flap replacement, of which 10 (55.5%) required a new surgery for their treatment. Most of the replacements (95%) were performed in the first 90 days after the craniectomy, with a tendency to present more complications compared to the subsequent period (37.8% vs 20%, p > 0.05). The most frequent complication was subdural hygroma, which appeared later than infection, the second most frequent complication. The need for ventricular drainage or tracheostomy and the mean time on mechanical ventilation, ICU admission, or waiting until bone replacement were greater in patients who presented post-replacement complications. Previous infections outside the nervous system or the surgical wound was the only risk factor for post-bone flap replacement complications (p = 0.031). CONCLUSIONS Postoperative complications were recorded in more than a third of the patients who underwent cranial bone flap replacement, and at least half of them required a new surgery. A specific protocol aimed at controlling previous infections could reduce the risk of complications and help establish the optimal time for cranial bone flap replacement.
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Affiliation(s)
| | | | | | | | - Rubén Diana-Martín
- Departamento de Neurocirugía, Hospital Universitario de Burgos, Burgos, Spain
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Zhao YH, Gao H, Ma C, Huang WH, Pan ZY, Wang ZF, Li ZQ. Earlier cranioplasty following posttraumatic craniectomy is associated with better neurological outcomes at one-year follow-up: a two-centre retrospective cohort study. Br J Neurosurg 2023; 37:1057-1060. [PMID: 33252289 DOI: 10.1080/02688697.2020.1853042] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 11/16/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Cranioplasty (CP) after decompressive craniectomy (DC) is routinely performed for reconstructive purposes and improves rehabilitation. However, the optimal timing of CP remains controversial. This study aimed to assess differences in clinical outcomes following different timings of CP in patients with traumatic brain injury. MATERIALS AND METHODS Patients with traumatic brain injury who underwent CP after DC in Zhongnan Hospital of Wuhan University from 1 January 2010 to 1 May 2017, and in Affiliated Hospital of Guizhou Medical University from 1 January 2015, to 1 May 2017, were retrospectively reviewed. According to the timing of CP, patients were divided into an 'early group' (3-6 months) and a 'late group' (6-12 months). The clinical characteristics of patients and postoperative complications occurred within 1-year follow-up were analysed. The neurological function was assessed with Barthel Index (BI). RESULTS A total of 100 patients (58 cases in early group and 42 cases in late group) were included. The median interval between DC and CP was 135 days and 225 days in the early and late CP groups, respectively. The overall complication rate after CP was 16%, and no significant difference in complication rate was observed between the early and late CP groups (17.2% vs.14.3%, p = 0.69). The neurological function was improved in early CP group (pre-CP 85.77 ± 11.61 vs. post-CP 95.34 ± 9.02, p < 0.001, but not in late CP group (pre-CP 82.74 ± 22.82 vs. post-CP 88.93 ± 22.86, p = 0.22). In addition, a significantly higher proportion of patients in the early CP group showed neurological functional improvement in comparison with the late CP group (early vs. late: 74.1% vs. 57.1%, p = 0.04). Multivariate analysis further demonstrated that the timing of CP is an independent predictor for neurological outcomes (OR = 0.32, 95% CI 0.13-0.82, p = 0.02). CONCLUSION Early CP (3-6 months) following posttraumatic DC was associated with better neurological outcomes than late CP (>6 months).
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Affiliation(s)
- Yu-Hang Zhao
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Hong Gao
- Department of Neurosurgery, affiliated Hospital of Guizhou Medical University, Guizhou Medical University, Guiyang, China
| | - Chao Ma
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Wen-Hong Huang
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Zhi-Yong Pan
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Ze-Fen Wang
- Department of Physiology, Wuhan University School of Basic Medicine Sciences, Wuhan, China
| | - Zhi-Qiang Li
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, China
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Moncayo-Matute FP, Vázquez-Silva E, Peña-Tapia PG, Torres-Jara PB, Moya-Loaiza DP, Viloria-Ávila TJ. Finite Element Analysis of Patient-Specific 3D-Printed Cranial Implant Manufactured with PMMA and PEEK: A Mechanical Comparative Study. Polymers (Basel) 2023; 15:3620. [PMID: 37688247 PMCID: PMC10490355 DOI: 10.3390/polym15173620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 09/10/2023] Open
Abstract
This article reports on a patient who required a cranial protection system. Using additive manufacturing techniques and surgical planning with the help of bio-models, a patient-specific bone implant solution was proposed that allows aesthetic restoration of the affected area and provides an adequate level of protection. In addition, through a comparative analysis with finite elements, the mechanical response to external actions of the medical device, printed with two materials: polymethylmethacrylate (PMMA) and polyether-ether-ketone (PEEK), is simulated. The tested materials have recognized biocompatibility properties, but their costs on the market differ significantly. The results obtained demonstrate the similarities in the responses of both materials. It offers the possibility that low-income people can access these devices, guaranteeing adequate biomechanical safety, considering that PMMA is a much cheaper material than PEEK.
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Affiliation(s)
- Freddy P. Moncayo-Matute
- Grupo de Investigación en Nuevos Materiales y Procesos de Transformación (GIMAT), Universidad Politécnica Salesiana, Sede Cuenca EC010102, Ecuador; (F.P.M.-M.); (P.B.T.-J.); (D.P.M.-L.)
| | - Efrén Vázquez-Silva
- Grupo de Investigación en Nuevos Materiales y Procesos de Transformación (GIMAT), Universidad Politécnica Salesiana, Sede Cuenca EC010102, Ecuador; (F.P.M.-M.); (P.B.T.-J.); (D.P.M.-L.)
| | - Pablo G. Peña-Tapia
- Instituto oncológico SOLCA, Sociedad de Lucha Contra el Cáncer, Cuenca EC010109, Ecuador;
| | - Paúl B. Torres-Jara
- Grupo de Investigación en Nuevos Materiales y Procesos de Transformación (GIMAT), Universidad Politécnica Salesiana, Sede Cuenca EC010102, Ecuador; (F.P.M.-M.); (P.B.T.-J.); (D.P.M.-L.)
| | - Diana P. Moya-Loaiza
- Grupo de Investigación en Nuevos Materiales y Procesos de Transformación (GIMAT), Universidad Politécnica Salesiana, Sede Cuenca EC010102, Ecuador; (F.P.M.-M.); (P.B.T.-J.); (D.P.M.-L.)
| | - Tony J. Viloria-Ávila
- Grupo de Investigación en Biotecnología y Ambiente (INBIAM), Universidad Politécnica Salesiana, Sede Cuenca EC010102, Ecuador;
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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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9
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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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10
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The grim truth in Murphýs law: Routine subgaleal suction drain may cause rapid and fatal brain damage. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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11
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Hevia Rodríguez P, Samprón N, Plou García MP, Elúa Pinín A, Úrculo Bareño E. Atypical facial pain after cranioplasty: A too perfect design?: Dolor facial atípico asociado a craneoplastia: ¿un encaje demasiado perfecto? NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:361-365. [PMID: 35256328 DOI: 10.1016/j.neucie.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/01/2021] [Accepted: 07/11/2021] [Indexed: 06/14/2023]
Abstract
Cranioplasty is a procedure routinely performed in neurosurgery. It is associated with significant morbidity and several types of postsurgical complications. The most common are infections, bone flap resorption and hematomas. Atypical facial pain has not been documented yet as a potential postoperative complication. We present a case of atypical facial pain reported at inmediate postoperative period after cranioplasty. The pain was refractory to medical treatment and sphenopalatine ganglion block. Eventually, the pain totally disappeared after surgical revision of the cranial implant.
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Affiliation(s)
| | - Nicolás Samprón
- Servicio de Neurocirugía, Hospital Universitario Donostia, San Sebastián, Spain
| | - María Pilar Plou García
- Servicio de Unidad del Dolor, Anestesiología y Reanimación, Hospital Universitario Donostia, San Sebastián, Spain
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12
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Santander X, Hidalgo YG, Flores JC, Gómez-Jordana B. Sinking skin syndrome in a decompressive craniectomy series: Clinical and radiological features. Surg Neurol Int 2022; 13:422. [PMID: 36324973 PMCID: PMC9610374 DOI: 10.25259/sni_582_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background: The sinking skin syndrome (SSS) is a particular complication after a decompressive craniectomy (DC). It still remains a poorly understood and underestimated entity. Methods: Retrospective case series of craniectomized patients with and without SSS. Clinical and radiological features (DC diameter, shape of craniectomy flap, and midline deviation) were described and relative volumes of intracranial loss were quantified. Results: Twenty-seven patients (63% with SSS). The most common indication for DC was traumatic brain injury: 48.15%. The p50 diameter of DC was 12.8 cm for patients with SSS and 11.1 cm for patients without (Z score = 0.32). DC area was 81.5 cm2 for patients with SSS and 71.43 cm2 for patients without the syndrome (Z score = 0.61). According to the shape of the craniectomy flap, we classified our patients as: «same level» (51.8%), «sunken» (25.9%), and «extracranial herniation» (14.8%). Two patients (7.4%) had paradoxical herniation. Midline deviation was present in 12 (70.6%) patients with SSS. The 3rd ventricle volume average was 1.2 cc for patients with SSS versus 2.35 cc for patients without (Z score = 0.04). About 94.11% of patients (16 out of 17) clearly improved after replacement of the cranial defect. Conclusion: In our series, low 3rd ventricle volumes had a good relation with SSS. The presence of a sunken flap does not guarantee SSS per se and we propose the following radiologic description: A = sunken, B = same level, C = extracranial herniation, and D = paradoxical. Replacement of the skull defect is the main treatment.
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Affiliation(s)
- Xavier Santander
- Department of Neurosurgery, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | - Yolanda García Hidalgo
- Department of Radiology, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | - José Carlos Flores
- Department of Radiology, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | - Blanca Gómez-Jordana
- Department of Neurosurgery, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
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Ten-Year Institutional Experience to Predict Risk of Calvarial Bone Flap Loss Using Long-Term Outcome Data. J Craniofac Surg 2022; 33:2394-2399. [PMID: 35859273 DOI: 10.1097/scs.0000000000008784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/11/2022] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Calvarial bone flap (CBF) loss is a common complication following craniotomy and subsequent skull reconstruction can be challenging. Defining predictors of CBF failure not only improves patient outcomes but reduces the need for complex reconstruction often requiring plastic surgery consultation. As CBF failure can occur many years following craniotomy, this study aimed to determine risk factors of CBF loss using long-term follow-up. MATERIALS AND METHODS This retrospective study included patients who underwent craniotomy with CBF reinsertion between 2003 and 2013 at a tertiary academic institution. Patients were included if demographics, comorbidities, and long-term outcomes were available. Multivariable logistic regression modeled the odds of CBF failure, defined as permanent removal for bone flap-related issues. The median follow-up was 6.9 years (interquartile range: 1.8-10.8 y). RESULTS There were 222 patients who met inclusion criteria and underwent craniotomy with CBF reinsertion, primarily for tumor resection or intracranial pressure relief. CBF failure occurred in 76 (34.2%) patients. Up to 4 CBF reinsertions were performed in both failure and nonfailure groups. The risks of CBF loss increased with each additional CBF elevation by 17-fold (P<0.001), male sex by 3-fold (P=0.005), and tumor etiology by 3-fold (P=0.033) (C-index=0.942). CONCLUSIONS Each CBF reinsertion dramatically increases the risk of CBF loss. This finding may optimize patient selection and surgical planning. Early multidisciplinary discussions between plastic surgeons and neurosurgeons may avoid multiple CBF elevations and prevent the adverse sequela of high-risk calvarial reconstruction efforts.
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Yoon HG, Ko Y, Kim YS, Bak KH, Chun HJ, Na MK, Yang S, Yi HJ, Choi KS. Efficacy of 3D-Printed Titanium Mesh-Type Patient-Specific Implant for Cranioplasty. Korean J Neurotrauma 2021; 17:91-99. [PMID: 34760819 PMCID: PMC8558026 DOI: 10.13004/kjnt.2021.17.e25] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/20/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Autologous bone grafting for cranioplasty is associated with a high infection rate and bone absorption. Synthetic implant materials for cranioplasty have been developed. In this study, we evaluated the efficacy of titanium mesh-type patient-specific implants (PSIs) for patients with skull defects using the dice similarity coefficient (DSC), clinical outcomes, and artifacts caused by implants. Methods This retrospective study included 40 patients who underwent cranioplasty with a titanium mesh PSI at our institution. Based on preoperative and postoperative computed tomography scans, we calculated DSC and artifacts. Results The calculated DSC of 40 patients was 0.75, and the noise was 13.89% higher in the region of interest (ROI) near the implanted side (average, 7.64 hounsfield unit [HU]±2.62) than in the normal bone (average, 6.72 HU±2.35). However, the image signal-to-noise ratio did not significantly differ between the ROI near the implanted side (4.77±1.78) and normal bone (4.97±1.88). The patients showed no significant perioperative complications that required a secondary operation. Conclusion Titanium mesh-type PSIs for cranioplasty have excellent DSC values with lower artifacts and complication rates.
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Affiliation(s)
- Hong-Gyu Yoon
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Yong Ko
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Young-Soo Kim
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Koang-Hum Bak
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Hyoung-Joon Chun
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Min-Kyun Na
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Korea
| | | | - Hyeong-Joong Yi
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Korea
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15
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Clinical improvement after cranioplasty and its relation to body position and cerebral hemodynamics. Neurosurg Rev 2021; 45:1463-1472. [PMID: 34626266 DOI: 10.1007/s10143-021-01668-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/29/2021] [Accepted: 10/04/2021] [Indexed: 12/24/2022]
Abstract
Cranioplasty after decompressive craniectomy (DC) has been found to improve the neurological condition. The underlying mechanisms are still unknown. The aim of this study is to investigate the roles of the postural changes and atmospheric pressure (AP) in the brain hemodynamics and their relationship with clinical improvement. Seventy-eight patients were studied before and 72 h after cranioplasty with cervical and transcranial color Doppler ultrasound (TCCS) in the sitting and supine positions. Craniectomy size, shape, and force exerted by the AP (torque) were calculated. Neurological condition was assessed with the National Institutes of Health Stroke Scale (NIHSS) and the Barthel index. Twenty-eight patients improved after cranioplasty. Their time elapsed from the DC was shorter (214 vs 324 days), preoperative Barthel was worse (54 vs 77), internal carotid artery (ICA) mean velocity of the defect side was lower while sitting (14.4 vs 20.9 cm/s), and torque over the craniectomy was greater (2480.3 vs 1464.3 N*cm). Multivariate binary logistic regression showed the consistency of these changes. TCCS findings were no longer present postoperatively. Lower ICA (defect side) velocity in the sitting position correlates significantly with clinical improvement. Greater torque exerted by the AP might explain different susceptibilities to postural changes, corrected by cranioplasty.
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16
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Hevia Rodríguez P, Samprón N, Plou García MP, Elúa Pinín A, Úrculo Bareño E. Dolor facial atípico asociado a craneoplastia: ¿un encaje demasiado perfecto? Neurocirugia (Astur) 2021. [DOI: 10.1016/j.neucir.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Tora MS, Malcolm JG, Mahmooth Z, Pujari A, Rindler RS, Boulis NM, Pradilla G, Grossberg JA, Ahmad FU. Complication Rates in Early Versus Late Cranioplasty-A 14-Year Single-Center Case Series. Oper Neurosurg (Hagerstown) 2021; 20:389-396. [PMID: 33469653 DOI: 10.1093/ons/opaa408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 09/26/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Cranioplasty (CP) following decompressive craniectomy (DC) is a common neurosurgical procedure for cranial cosmesis and protection. There is uncertainty regarding the complication rates and potential benefits related to the timing of CP. OBJECTIVE To investigate the impact of the timing of CP on complication rates for different etiologies of DC. METHODS A retrospective chart review was performed of all CP cases between 2004 and 2018 for traumatic and nontraumatic indications of DC. Demographics, clinical characteristics, and complications were collected. Early and late CP were defined as replacement of the bone flap at ≤90 and >90 d following DC, respectively. RESULTS A total of 278 patients were included, receiving 81 early and 197 late CPs. When analyzing all patients, early CP was associated with a statistically significant higher odds of any complication (odds ratio [OR]: 3.25, P < .001), reoperation (OR: 2.57, P = .019), hydrocephalus (OR: 6.03, P = .003), and symptomatic extra-axial collections (OR: 9.22, P = .003). Subgroup analysis demonstrated statistically significant higher odds of these complications only for the CP trauma subgroup, but not the nontrauma subgroup. The odds of complications postCP demonstrated a statistically significant decrease of 4.4% for each week after DC (Unit Odds Ratio [U-OR]: 0.956, P = .0363). CONCLUSION In our retrospective series, early CP was associated with higher odds of postoperative complications compared to late CP in the trauma subgroup. Greater care should be taken in preoperative planning and increased vigilance postoperatively for complications with this potentially more vulnerable subpopulation. Future prospective controlled trials are needed to elucidate optimal timing for CP.
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Affiliation(s)
- Muhibullah S Tora
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - James G Malcolm
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Zayan Mahmooth
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Amit Pujari
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rima S Rindler
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Nicholas M Boulis
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan A Grossberg
- 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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18
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Shepetovsky D, Mezzini G, Magrassi L. Complications of cranioplasty in relationship to traumatic brain injury: a systematic review and meta-analysis. Neurosurg Rev 2021; 44:3125-3142. [PMID: 33686551 PMCID: PMC8592959 DOI: 10.1007/s10143-021-01511-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Abstract
Despite being a common procedure, cranioplasty (CP) is associated with a variety of serious, at times lethal, complications. This study explored the relationship between the initial injury leading to decompressive craniectomy (DC) and the rates and types of complications after subsequent CP. It specifically compared between traumatic brain injury (TBI) patients and patients undergoing CP after DC for other indications.A comprehensive search of PubMed, Scopus, and the Cochrane Library databases using PRISMA guidelines was performed to include case-control studies, cohorts, and clinical trials reporting complication data for CP after DC. Information about the patients' characteristics and the rates of overall and specific complications in TBI and non-TBI patients was extracted, summarized, and analyzed.A total of 59 studies, including the authors' institutional experience, encompassing 9264 patients (4671 TBI vs. 4593 non-TBI) met the inclusion criteria; this total also included 149 cases from our institutional series. The results of the analysis of the published series are shown both with and without our series 23 studies reported overall complications, 40 reported infections, 10 reported new-onset seizures, 13 reported bone flap resorption (BFR), 5 reported post-CP hydrocephalus, 10 reported intracranial hemorrhage (ICH), and 8 reported extra-axial fluid collections (EFC). TBI was associated with increased odds of BFR (odds ratio [OR] 1.76, p < 0.01) and infection (OR 1.38, p = 0.02). No difference was detected in the odds of overall complications, seizures, hydrocephalus, ICH, or EFC.Awareness of increased risks of BFR and infection after CP in TBI patients promotes the implementation of new strategies to prevent these complications especially in this category of patients.
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Affiliation(s)
- David Shepetovsky
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Viale Brambilla 74, 27100, Pavia, Italy
| | - Gianluca Mezzini
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Viale Brambilla 74, 27100, Pavia, Italy
| | - Lorenzo Magrassi
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Viale Brambilla 74, 27100, Pavia, Italy. .,IRCCS Fondazione Policlinico S. Matteo, Pavia, Italy.
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Sengupta SK, Kumar AN, Maurya V, Bajaj H, Yadav KK, G. AK, Faujdar DS. Bony Union and Flap Resorption in Cranioplasty with Autologous Subcutaneous Pocket Preserved Bone Flap: Early Report on an Ambidirectional CT Scan-Based Study. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0040-1714317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Introduction Absence of sufficient number of prospective randomized controlled studies and comparatively small sample size and short follow-up period of most of the studies, available so far, have left ambiguity and lack of standardization of different aspects of cranioplasty.
Materials and Methods This is an early report of a computed tomography scan image-based ambidirectional study on cranioplasties performed with autologous subcutaneous pocket preserved bone flaps. Retrospective arm compared bony union and factors influencing it between cranioplasties and craniotomies. Patients with poor bony union and aseptic resorption were followed up in the prospective arm.
Results Retrospective arm of the study, followed up for five years (mean 32.2 months), comprised 42 patients as cases (Group 1) and 29 as controls (Group 2). Twenty-seven individuals (64.3%) in Group 1 had good bony union, as compared with 20 (68.9%) good unions in Group 2 out of the 29 patients. Four patients (9.5%) in Group 1 showed evidence of flap resorption, a finding absent in any patient in Group 2. Age, sex, smoking habits, superficial skin infection, and method of fixation did not appear to have any implication on bony union. Craniotomies done using Gigli saws fared better as compared with those done with pneumatic saw with lesser flap size–craniectomy size discrepancy, though it was not statistically significant. Fifteen patients have been included in the Prospective arm at the time of submission of this article.
Conclusion Ours is a study with a small sample size, unable to put its weight on any side, but can surely add some more data to help the Neurosurgeons in choosing the best for their patients.
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Affiliation(s)
- Sudip Kumar Sengupta
- Department of Neurosurgery, Command Hospital (Southern Command), Pune, Maharashtra, India
| | - Andrews Navin Kumar
- Department of Maxillofacial Surgery, Command Medical Dental Centre (Eastern Command), Kolkata, West Bengal, India
| | - Vinay Maurya
- Department of Radiodiagnosis, Base Hospital Delhi Cantonment, New Delhi, India
| | - Harish Bajaj
- Department of Neurosurgery, Command Hospital (Eastern Command), Kolkata, West Bengal, India
| | - Krishan Kumar Yadav
- Department of Neurosurgery, Command Hospital (Eastern Command), Kolkata, West Bengal, India
| | - Ashwath K. G.
- Department of Neurosurgery, Command Hospital (Eastern Command), Kolkata, West Bengal, India
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Iaccarino C, Kolias A, Adelson PD, Rubiano AM, Viaroli E, Buki A, Cinalli G, Fountas K, Khan T, Signoretti S, Waran V, Adeleye AO, Amorim R, Bertuccio A, Cama A, Chesnut RM, De Bonis P, Estraneo A, Figaji A, Florian SI, Formisano R, Frassanito P, Gatos C, Germanò A, Giussani C, Hossain I, Kasprzak P, La Porta F, Lindner D, Maas AIR, Paiva W, Palma P, Park KB, Peretta P, Pompucci A, Posti J, Sengupta SK, Sinha A, Sinha V, Stefini R, Talamonti G, Tasiou A, Zona G, Zucchelli M, Hutchinson PJ, Servadei F. Consensus statement from the international consensus meeting on post-traumatic cranioplasty. Acta Neurochir (Wien) 2021; 163:423-440. [PMID: 33354733 PMCID: PMC7815592 DOI: 10.1007/s00701-020-04663-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/28/2020] [Indexed: 12/26/2022]
Abstract
Background Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach. Methods The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP. Results The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations. Conclusions This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.
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21
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The storage of skull bone flaps for autologous cranioplasty: literature review. Cell Tissue Bank 2021; 22:355-367. [PMID: 33423107 DOI: 10.1007/s10561-020-09897-2] [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: 04/28/2020] [Accepted: 12/27/2020] [Indexed: 01/10/2023]
Abstract
The use of autologous bone flap for cranioplasty after decompressive craniectomy is a widely used strategy that allows alleviating health expenses. When the patient has recovered from the primary insult, the cranioplasty restores protection and cosmesis, recovering fluid dynamics and improving neurological status. During this time, the bone flap must be stored, but there is a lack of standardization of tissue banking practices for this aim. In this work, we have reviewed the literature on tissue processing and storage practices. Most of the published articles are focused from a strictly clinical and surgical point of view, paying less attention to issues related to tissue manipulation. When bone resorption is avoided and the risk of infection is controlled, the autograft represents the most efficient choice, with the lowest risk of complication. Otherwise, depending on the degree of involvement, the patient may have to undergo new surgery, assuming further risks and higher healthcare costs. Therefore, tissue banks must implement protocols to provide products with the highest possible clinical effectiveness, without compromising safety. With a centralised management of tissue banking practices there may be a more uniform approach, thus facilitating the standardization of procedures and guidelines.
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Paredes I, Lagares A, San-Juan R, Castaño-León AM, Gómez PA, Jimenez-Roldán L, Panero I, Eiriz C, García-Perez D, Moreno LM, Perez-Nuñez A, Gonzalez-León P, Alén JAF. Reduction in the infection rate of cranioplasty with a tailored antibiotic prophylaxis: a nonrandomized study. Acta Neurochir (Wien) 2020; 162:2857-2866. [PMID: 32720014 DOI: 10.1007/s00701-020-04508-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/20/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Cranioplasty carries a high risk of surgical site infections (SSIs) for a scheduled procedure, particularly with antibiotic-resistant bacteria. METHODS The goal of this retrospective study was to measure the effect of tailored antibiotic prophylaxis on SSIs resulting from cranioplasties. The authors collected a prospective database of cranioplasties from 2009 to 2018. Risk factors for SSI were registered, as well as infection occurring during the first year postoperatively. A new protocol was initiated in 2016 consisting of antibiotic prophylaxis tailored to the colonizing flora of the skin of the scalp and decolonization of patients who were nasal carriers of methicillin-resistant S. aureus (MRSA); infection rates were compared. RESULTS One hundred nine cranioplasties were identified, 64 in the old protocol and 45 in the new protocol. Of the 109 cranioplasties, 16 (14.7%) suffered an infection, 14 (21.9%) in the old protocol group and 2 (4.4%) in the new protocol group (OR for the new protocol 0.166, 95% CI 0.036-0.772). Multiple surgeries (OR 3.44), Barthel ≤ 70 (OR 3.53), and previous infection (OR 3.9) were risk factors for SSI. Of the bacteria identified in the skin of the scalp, 22.2% were resistant to routine prophylaxis (cefazoline). Only one patient was identified as a nasal carrier of MRSA and was decolonized. CONCLUSIONS A high percentage of bacteria resistant to routine prophylaxis (cefazoline) was identified in the skin of these patients' scalps. The use of tailored antibiotic prophylaxis reduced significantly the infection rate in this particular set of patients.
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Affiliation(s)
- Igor Paredes
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain.
| | - Alfonso Lagares
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Rafael San-Juan
- Unit of Infectious Diseases, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Ana María Castaño-León
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Pedro-Antonio Gómez
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Luis Jimenez-Roldán
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Irene Panero
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Carla Eiriz
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Daniel García-Perez
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Luis Miguel Moreno
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Angel Perez-Nuñez
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Pedro Gonzalez-León
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - José Antonio F Alén
- Neurosurgery Department, University Hospital 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
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Jiang HS, Wang YZ. Super early cranial repair improves the prognosis of patients with craniocerebral injury. J Int Med Res 2020; 48:300060520959485. [PMID: 32996793 PMCID: PMC7536486 DOI: 10.1177/0300060520959485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective Craniocerebral injury has high disability and mortality rates. The timing of
cranioplasty has an important impact on patients’ prognosis. This study was
performed to compare the functional prognosis between super early repair and
conventional repair. Methods This observational study included 60 patients who underwent cranioplasty
after surgical treatment of severe craniocerebral trauma. The patients were
divided into two groups according to the time of cranial repair after the
surgical treatment of craniocerebral injury: the super early group and the
conventional repair group. Sex, age, Karnofsky performance status (KPS)
score, Zubrod performance status (ZPS) score, psychological function score,
quality of life score, and complications were recorded. Results The KPS score, ZPS score, psychological function score, and quality of life
score were significantly related to the intervention period. Each of these
scores had a clear correlation with the performance of super early
treatment. Conclusion Super early cranial repair does not increase the incidence of surgical
complications, and it can improve the postoperative KPS, ZPS, and quality of
life scores.
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Affiliation(s)
- Hong-Sheng Jiang
- Department of Fourth Neurosurgery, Cangzhou Central Hospital, Cangzhou, Hebei Province, P.R. China
| | - Yan-Zhou Wang
- Department of Fourth Neurosurgery, Cangzhou Central Hospital, Cangzhou, Hebei Province, P.R. China
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24
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Liu L, Lu ST, Liu AH, Hou WB, Cao WR, Zhou C, Yin YX, Yuan KS, Liu HJ, Zhang MG, Zhang HJ. Comparison of complications in cranioplasty with various materials: a systematic review and meta-analysis. Br J Neurosurg 2020; 34:388-396. [PMID: 32233810 DOI: 10.1080/02688697.2020.1742291] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective: Meta-analysis to evaluate complications in the use of autogenous bone and bone substitutes and to compare bone substitutes, specifically HA, polyetheretherketone (PEEK) and titanium materials.Methods: Search of PubMed, Cochrane, Embase and Google scholar to identify all citations from 2010 to 2019 reporting complications regarding materials used in cranioplasty.Results: 20 of 2266 articles met the inclusion criteria, including a total of 2913 patients. The odds of overall complication were significantly higher in the autogenous bone group (n = 214/644 procedures, 33.2%) than the bone substitute groups (n = 116/436 procedures, 26.7%, CI 1.29-2.35, p < 0.05). In bone substitutes groups, there was no significant difference in overall complication rate between HA and Ti (OR, 1.2; 95% CI, 0.47-3.14, p = 0.69). PEEK has lower overall complication rates (OR, 0.51; 95% CI, 0.30-0.87, p = 0.01) and lower implant exposure rates (OR, 0.17; 95% CI, 0.06-0.53, p = 0.002) than Ti, but there was no significant difference in infection rates and postoperative hematoma rates.Conclusions: Cranioplasty is associated with high overall complication rates with the use of autologous bone grafts compared with bone substitutes. PEEK has a relatively low overall complication rates in substitutes groups, but still high infection rates and postoperative hematoma rates. Thus, autologous bone grafts should only be used selectively, and prospective long-term studies are needed to further refine a better material in cranioplasty.
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Affiliation(s)
- Liming Liu
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China
| | - Shou-Tao Lu
- Tenth People's Hospital, Tongji University, Shanghai, China
| | - Ai-Hua Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Neurointerventional Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wen-Bo Hou
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China
| | - Wen-Rui Cao
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China
| | - Chao Zhou
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China
| | - Yu-Xia Yin
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China
| | - Kun-Shan Yuan
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China
| | - Han-Jie Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming-Guang Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hai-Jun Zhang
- National United Engineering Laboratory for Biomedical Material Modification, Dezhou, China.,Tenth People's Hospital, Tongji University, Shanghai, China.,Faculty of Medicine, Aalborg University, Alborg, Denmark
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Woo PYM, Mak CHK, Mak HKF, Tsang ACO. Neurocognitive recovery and global cerebral perfusion improvement after cranioplasty in chronic sinking skin flap syndrome of 18 years: Case report using arterial spin labelling magnetic resonance perfusion imaging. J Clin Neurosci 2020; 77:213-217. [DOI: 10.1016/j.jocn.2020.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/04/2020] [Indexed: 02/07/2023]
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Goedemans T, Verbaan D, van der Veer O, Bot M, Post R, Hoogmoed J, Lequin MB, Buis DR, Vandertop WP, Coert BA, van den Munckhof P. Complications in cranioplasty after decompressive craniectomy: timing of the intervention. J Neurol 2020; 267:1312-1320. [PMID: 31953606 PMCID: PMC7184041 DOI: 10.1007/s00415-020-09695-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/30/2019] [Accepted: 01/02/2020] [Indexed: 12/16/2022]
Abstract
Objective To prevent complications following decompressive craniectomy (DC), such as sinking skin flap syndrome, studies suggested early cranioplasty (CP). However, several groups reported higher complication rates in early CP. We studied the clinical characteristics associated with complications in patients undergoing CP, with special emphasis on timing. Methods A single-center observational cohort study was performed, including all patients undergoing CP from 2006 to 2018, to identify predictors of complications. Results 145 patients underwent CP: complications occurred in 33 (23%): 18 (12%) epi/subdural hemorrhage, 10 (7%) bone flap infection, 4 (3%) hygroma requiring drainage, and 1 (1%) post-CP hydrocephalus. On univariate analysis, acute subdural hematoma as etiology of DC, symptomatic cerebrospinal fluid (CSF) flow disturbance (hydrocephalus) prior to CP, and CP within three months after DC were associated with higher complication rates. On multivariate analysis, only acute subdural hematoma as etiology of DC (OR 7.5; 95% CI 1.9–29.5) and symptomatic CSF flow disturbance prior to CP (OR 2.9; 95% CI 1.1–7.9) were associated with higher complication rates. CP performed within three months after DC was not (OR 1.4; 95% CI 0.5–3.9). Pre-CP symptomatic CSF flow disturbance was the only variable associated with the occurrence of epi/subdural hemorrhage. (OR 3.8; 95% CI 1.6–9.0) Conclusion Cranioplasty has high complication rates, 23% in our cohort. Contrary to recent systematic reviews, early CP was associated with more complications (41%), explained by the higher incidence of pre-CP CSF flow disturbance and acute subdural hematoma as etiology of DC. CP in such patients should therefore be performed with highest caution.
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Affiliation(s)
- Taco Goedemans
- Amsterdam Medical Center, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (UMC), University of Amsterdam, Meibergdreef 9, Room H2-241, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Amsterdam Medical Center, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (UMC), University of Amsterdam, Meibergdreef 9, Room H2-241, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Olivier van der Veer
- Department of Neurosurgery, Medical Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, The Netherlands
| | - Maarten Bot
- Amsterdam Medical Center, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (UMC), University of Amsterdam, Meibergdreef 9, Room H2-241, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - René Post
- Amsterdam Medical Center, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (UMC), University of Amsterdam, Meibergdreef 9, Room H2-241, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jantien Hoogmoed
- Amsterdam Medical Center, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (UMC), University of Amsterdam, Meibergdreef 9, Room H2-241, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Michiel B Lequin
- Amsterdam Medical Center, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (UMC), University of Amsterdam, Meibergdreef 9, Room H2-241, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Dennis R Buis
- Amsterdam Medical Center, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (UMC), University of Amsterdam, Meibergdreef 9, Room H2-241, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Amsterdam Medical Center, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (UMC), University of Amsterdam, Meibergdreef 9, Room H2-241, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Bert A Coert
- Amsterdam Medical Center, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (UMC), University of Amsterdam, Meibergdreef 9, Room H2-241, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Amsterdam Medical Center, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers (UMC), University of Amsterdam, Meibergdreef 9, Room H2-241, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Zhang J, Tian W, Chen J, Yu J, Zhang J, Chen J. The application of polyetheretherketone (PEEK) implants in cranioplasty. Brain Res Bull 2019; 153:143-149. [PMID: 31425730 DOI: 10.1016/j.brainresbull.2019.08.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/19/2019] [Accepted: 08/13/2019] [Indexed: 02/06/2023]
Abstract
Cranioplasty is a challenge to neurosurgeons, especially considering protection of intracranial contents. In recent years, material choice for cranioplasty is still controversial, which brings complexity to this seemingly straightforward procedure. PEEK, a tough, rigid, biocompatible material, has been used more recently in cranioplasty to provide better protection. The aim of this review is to summarize the outcome of research conducted on the material for cranioplasty applications. We also reviewed the comparison of PEEK with several common materials in previous articles. This is also the most complete data review article at present. In addition, the combination of nano-materials and PEEK is also a hotspot of research, so we have made a careful review of this aspect. We also summarized our own experience, telling about the future prospects of PEEK in the field of clinical cranioplasty should be highlighted. Improving the bioactivity, porosity, thinning, biocompatibility, antibacterial ability, integration and cost reduction of PEEK implants without affecting their mechanical properties is a major challenge.
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Affiliation(s)
- Jibo Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Weiqun Tian
- Department of Biomedical Engineering, School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China
| | - Jiayi Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Jin Yu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Jianjian Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
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Ganau M, Ligarotti GKI, Ganau L, Prisco L. Letter: Early Cranioplasty is Associated With Greater Neurological Improvement: A Systematic Review and Meta-Analysis. Neurosurgery 2019; 83:E87-E89. [PMID: 29846710 DOI: 10.1093/neuros/nyy205] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mario Ganau
- Harvard Medical School Boston, Massachusetts.,School of Medicine University of Cagliari Cagliari, Italy
| | | | - Laura Ganau
- School of Medicine University of Cagliari Cagliari, Italy
| | - Lara Prisco
- John Radcliffe Hospital University of Oxford Oxford, United Kingdom
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29
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Hutchinson PJ, Kolias AG, Tajsic T, Adeleye A, Aklilu AT, Apriawan T, Bajamal AH, Barthélemy EJ, Devi BI, Bhat D, Bulters D, Chesnut R, Citerio G, Cooper DJ, Czosnyka M, Edem I, El-Ghandour NMF, Figaji A, Fountas KN, Gallagher C, Hawryluk GWJ, Iaccarino C, Joseph M, Khan T, Laeke T, Levchenko O, Liu B, Liu W, Maas A, Manley GT, Manson P, Mazzeo AT, Menon DK, Michael DB, Muehlschlegel S, Okonkwo DO, Park KB, Rosenfeld JV, Rosseau G, Rubiano AM, Shabani HK, Stocchetti N, Timmons SD, Timofeev I, Uff C, Ullman JS, Valadka A, Waran V, Wells A, Wilson MH, Servadei F. Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement. Acta Neurochir (Wien) 2019; 161:1261-1274. [PMID: 31134383 PMCID: PMC6581926 DOI: 10.1007/s00701-019-03936-y] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/29/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. METHODS The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. RESULTS The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. CONCLUSIONS In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.
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Affiliation(s)
- Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK.
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK.
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Tamara Tajsic
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Amos Adeleye
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria
| | - Abenezer Tirsit Aklilu
- Neurosurgical Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Tedy Apriawan
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia
| | - Abdul Hafid Bajamal
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia
| | - Ernest J Barthélemy
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - B Indira Devi
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Dhananjaya Bhat
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Diederik Bulters
- Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Randall Chesnut
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neuro-Intensive Care, Department of Emergency and Intensive Care, ASST, San Gerardo Hospital, Monza, Italy
| | - D Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Idara Edem
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa and University of Thessaly, Larissa, Greece
| | - Clare Gallagher
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Corrado Iaccarino
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Parma, Parma, Italy
| | - Mathew Joseph
- Department of Neurosurgery, Christian Medical College, Vellore, India
| | - Tariq Khan
- Department of Neurosurgery, North West General Hospital and Research Center, Peshawar, Pakistan
| | - Tsegazeab Laeke
- Neurosurgical Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Oleg Levchenko
- Department of Neurosurgery, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tiantan Medical Hospital, Capital Medical University, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Medical Hospital, Capital Medical University, Beijing, China
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Paul Manson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Anna T Mazzeo
- Anesthesia and Intensive Care Unit, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Daniel B Michael
- Oakland University William Beaumont School of Medicine and Michigan Head & Spine Institute, Auburn Hills, MI, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesia/Critical Care & Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kee B Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Gail Rosseau
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Shelly D Timmons
- Department of Neurological Surgery, Penn State University Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Chris Uff
- Department of Neurosurgery, The Royal London Hospital, London, UK
- Queen Mary University of London, London, UK
| | - Jamie S Ullman
- Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Vicknes Waran
- Neurosurgery Division, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Adam Wells
- Department of Neurosurgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Mark H Wilson
- Imperial Neurotrauma Centre, Department of Surgery and Cancer, Imperial College, London, UK
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
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Long-Term Complications of Cranioplasty Using Stored Autologous Bone Graft, Three-Dimensional Polymethyl Methacrylate, or Titanium Mesh After Decompressive Craniectomy: A Single-Center Experience After 596 Procedures. World Neurosurg 2019; 128:e841-e850. [PMID: 31082551 DOI: 10.1016/j.wneu.2019.05.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Cranioplasty is a technically simple procedure intended to repair defects of the skull to provide protection after craniectomy, improve functional outcomes, and restore cosmesis. Several materials have been used for the restoration of skull defects, including autologous bone grafts (AGs), polymethyl methacrylate (PMMA) flaps, and titanium mesh (T-mesh). However, the long-term results of cranioplasty after use of these materials are controversial. METHODS Medical records of 596 patients who underwent cranioplasty at our medical center between 2009 and 2015 with at least 2.5 years of follow-up were retrospectively reviewed. Patients were classified into 3 groups according to the materials used: AG, three-dimensional PMMA, and T-mesh. Demographic and clinical characteristics and postoperative complications were analyzed. RESULTS Cranioplasty with AG had the highest bone flap depression rate (4.9%; P = 0.02) and was associated with a 26% long-term bone flap resorption. Younger age was a risk factor for bone flap resorption. T-mesh had a higher risk of postoperative skin erosion and bone exposure (17%; P = 0.004). Patients with diabetes, previous craniotomy, or hydrocephalus showed a higher risk of postoperative skin erosion. PMMA was associated with the highest rate of postoperative infection (14.4% <3 months, 28.1% >3 months; P < 0.05), and previous craniotomy may increase the infection risk after cranioplasty with PMMA. CONCLUSIONS Complications after cranioplasty are high, and the various types of cranioplasty materials used are associated with different complications. Surgeons need to be aware of these potential complications and should choose the appropriate material for each individual patient.
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Kim JH, Hwang SY, Kwon TH, Chong K, Yoon WK, Kim JH. Defining "early" cranioplasty to achieve lower complication rates of bone flap failure: resorption and infection. Acta Neurochir (Wien) 2019; 161:25-31. [PMID: 30511143 DOI: 10.1007/s00701-018-3749-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/26/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although cranioplasty (CP) is a frequently performed and simple procedure, complications are common, particularly bone flap resorption and infection. The timing of surgery is as an important contributory factor, but the optimal timing has not been clearly determined. OBJECTIVE We retrospectively investigated bone flap resorption and surgical site infection after CP to determine the optimal timing of surgery for reduction of complications. METHODS The study enrolled 126 patients who underwent decompressive craniectomy (DC) and subsequent CP. Patients with bone flap resorption or surgical site infection were analyzed as the "complication" group. Receiver operating characteristic curve analysis was performed and the Youden index was used to dichotomize "early CP" and "late CP" groups. Univariate and multivariate survival analyses were performed. RESULTS The complication group included 42 patients. The Youden index was used to identify a cutoff value for the DC-CP interval of > 44 days, and this was used to define early (< 45 days) and late (≥ 45 days) CP. Late CP was a significant risk factor in univariate and multivariate Cox regression analyses. CONCLUSION This study showed that early CP before 45 days after DC is associated with a lower rate of bone flap resorption and surgical site infection than late CP.
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Affiliation(s)
- Jang Hun Kim
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
- Focused Training Center for Trauma, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Soon-Young Hwang
- Biostatistical consulting lab, Medical Science Research Center, Korea University College of Medicine, Seoul, Republic of Korea
| | - Taek-Hyun Kwon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyuha Chong
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Won-Ki Yoon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jong Hyun Kim
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
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Malcolm JG, Mahmooth Z, Rindler RS, Allen JW, Grossberg JA, Pradilla G, Ahmad FU. Autologous Cranioplasty is Associated with Increased Reoperation Rate: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 116:60-68. [DOI: 10.1016/j.wneu.2018.05.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/01/2018] [Accepted: 05/02/2018] [Indexed: 11/15/2022]
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Robles LA, Cuevas-Solórzano A. Massive Brain Swelling and Death After Cranioplasty: A Systematic Review. World Neurosurg 2017; 111:99-108. [PMID: 29269069 DOI: 10.1016/j.wneu.2017.12.061] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/07/2017] [Accepted: 12/09/2017] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Luis A Robles
- Section of Neurosurgery, Hospiten, Puerto Vallarta, Mexico.
| | - Abel Cuevas-Solórzano
- Department of Neurosurgery, Hospital San Javier, Guadalajara, Mexico; Center of Neuro-Radiosurgery San Javier Gamma Knife, Hospital San Javier, Guadalajara, Mexico
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Chen B, Li W, Chen D, Fu S, Gao Y, Li R, Meng F, Wang H, Zhang S. Partial titanium mesh explantation cured post-cranioplasty implant-associated scalp infection. J Clin Neurosci 2017; 44:196-202. [PMID: 28690016 DOI: 10.1016/j.jocn.2017.06.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/14/2017] [Accepted: 06/18/2017] [Indexed: 11/16/2022]
Abstract
Titanium mesh cranioplasty is routinely used worldwide for skull defect patients given its advantages, such as stability and biocompatibility. However, there are very few reports concerning the treatment of implant-associated scalp infection, which is one of the most common complications. The aim of the study is to retrospectively evaluate a novel operation technique for the treatment of titanium mesh-associated scalp infection post-cranioplasty, namely partial titanium mesh explantation (PTME). A retrospective study was conducted in all patients who underwent surgical treatment for implant-associated scalp infection from January 2012 to September 2016 in our hospital. In total, 17 patients were selected for study analysis among 231 patients who underwent cranioplasty. The treatment success rate of PTME was 85.7%. There was no statistically significant difference in demographics and characteristics except for follow-up length of time between the PTME group and TTME (total titanium mesh explantation) group (Non-paired Student's t-test, P=0.037). While, The PTME group exhibited a significantly reduced skull defect area post-operation compared with the TTME group (Non-paired Student's t-test, P=0.002). Moreover, post-PTME skull area also exhibited a significantly reduced skull defect area compared with the pre-cranioplasty area in the same patient (Non-paired Student's t-test, P=0.006). Compared with traditional surgical treatment of implant-associated scalp infection, PTME combined with strict debridement and antibiotic therapy can cure implant-associated scalp infection. Moreover, PTME could preserve sufficient titanium mesh for brain protection and cosmesis.
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Affiliation(s)
- Bo Chen
- Neurotrauma & Neurosurgery Department of the First Hospital of Jilin University, Chang Chun, China
| | - Wenchen Li
- Neurotrauma & Neurosurgery Department of the First Hospital of Jilin University, Chang Chun, China
| | - Dawei Chen
- Neurotumor & Neurosurgery Department of the First Hospital of Jilin University, Chang Chun, China
| | - Shuanglin Fu
- Neurotrauma & Neurosurgery Department of the First Hospital of Jilin University, Chang Chun, China
| | - Yanli Gao
- The First Hospital of Jilin University, Chang Chun, China
| | - Ri Li
- The First Hospital of Jilin University, Chang Chun, China
| | - Fanyang Meng
- Radiology Department of the First Hospital of Jilin University, Chang Chun, China
| | - Haifeng Wang
- Neurotrauma & Neurosurgery Department of the First Hospital of Jilin University, Chang Chun, China.
| | - Shuyan Zhang
- Neurotrauma & Neurosurgery Department of the First Hospital of Jilin University, Chang Chun, China.
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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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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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Parichay PJ, Khanapure K, Joshi KC, Aniruddha TJ, Sandhya M, Hegde AS. Clinical and radiological assessment of cerebral hemodynamics after cranioplasty for decompressive craniectomy - A Clinical study. J Clin Neurosci 2017; 42:97-101. [PMID: 28457859 DOI: 10.1016/j.jocn.2017.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 04/03/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To find the correlation between radiologically proven improvement in cerebral hemodynamics with clinical improvement in patients undergoing cranioplasty. MATERIAL AND METHODS The study is a prospective observational study of 10 cases, in M S Ramaiah Institute of Neurosciences, involving patients treated by a decompressive craniectomy for intractable intra cranial hypertension either due to trauma or stroke and afterwards underwent cranioplasty. RESULTS Of the 10 patients, 70% patients showing significant improvement in motor functions on Barthel index scale, 60% patients showed improvement in speech, mean duration from date of decompressive craniectomy to cranioplasty being 122.4days. Cerebral perfusion was remarkably better after cranioplasty, as demonstrated decrease in the Pulsatility index on the ipsilateral side of decompression on Trans cranial Doppler (<0.73 mean). This data also favored improved cerebral blood flow and permeability on the CT perfusion with increase in cerebral blood flow (CBF), Cerebral Blood Volume (CBV) and decrease in Time to Peak (TTP) and a positive outcome when correlated with Barthel index with P-values of 0.093, 0.017 and 0.001 respectively. CONCLUSION Cranioplasty influences the cerebral hemodynamics after cranioplasty and has a positive correlation on the functional outcome and cerebral blood flow in the MCA territory.
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Affiliation(s)
- Perikal J Parichay
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, New BEL Road, Bangalore 54, India.
| | - Kiran Khanapure
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, New BEL Road, Bangalore 54, India
| | - Krishna C Joshi
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, New BEL Road, Bangalore 54, India
| | - T J Aniruddha
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, New BEL Road, Bangalore 54, India
| | - M Sandhya
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India
| | - A S Hegde
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, New BEL Road, Bangalore 54, India
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Malcolm JG, Rindler RS, Chu JK, Chokshi F, Grossberg JA, Pradilla G, Ahmad FU. Early Cranioplasty is Associated with Greater Neurological Improvement: A Systematic Review and Meta-Analysis. Neurosurgery 2017; 82:278-288. [DOI: 10.1093/neuros/nyx182] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 03/19/2017] [Indexed: 11/13/2022] Open
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Prasad GL. Optimal Timing of Cranioplasty: Controversial Debate? World Neurosurg 2017; 97:743-744. [PMID: 28109516 DOI: 10.1016/j.wneu.2016.08.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 08/30/2016] [Indexed: 11/30/2022]
Affiliation(s)
- G Lakshmi Prasad
- Department of Neurosurgery, Kasturba Medical College, Manipal University, Manipal, India.
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40
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Complications following cranioplasty and relationship to timing: A systematic review and meta-analysis. J Clin Neurosci 2016; 33:39-51. [DOI: 10.1016/j.jocn.2016.04.017] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 03/28/2016] [Accepted: 04/02/2016] [Indexed: 11/21/2022]
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Ashayeri K, M Jackson E, Huang J, Brem H, Gordon CR. Syndrome of the Trephined: A Systematic Review. Neurosurgery 2016; 79:525-34. [PMID: 27489166 DOI: 10.1227/neu.0000000000001366] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Syndrome of the trephined (SoT) is a rare, important complication of a craniectomy characterized by neurological dysfunction that improves with cranioplasty. Its varied symptoms include motor, cognitive, and language deficits. Its exact characterization appears suboptimal, with differing approaches of evaluation. Accordingly, this topic is in great need of further investigation. OBJECTIVE To accurately describe SoT and explore methods of an objective diagnosis/evaluation. METHODS Electronic searches of PubMed, MEDLINE, Web of Knowledge, and PsycINFO databases used the key words "syndrome of the trephined" and "sinking skin flap." Non-English-language and duplicate articles were eliminated. Title and abstract reviews were selected for relevance. Full-text reviews were selected for articles providing individual characteristics of SoT patients. RESULTS This review identified that SoT most often occurs in male patients (60%) at 5.1 ± 10.8 months after craniectomy for neurotrauma (38%). The average reported craniectomy is 88.3 ± 34.4 cm and usually exists with a "sunken skin flap" (93%). Symptoms most commonly include motor, cognitive, and language deficits (57%, 41%, 28%, respectively), with improvement after cranioplasty within 3.8 ± 3.9 days. Functional independence with activities of daily living is achieved by 54.9% of patients after 2.9 ± 3.4 months of rehabilitation. However, evaluation of SoT is inconsistent, with only 53% of reports documenting objective studies. DISCUSSION SoT is a variable phenomenon associated with a prolonged time to cranioplasty. Due to current weaknesses in objectivity, we hypothesize that SoT is often underdiagnosed and recommend a multifaceted approach for consistent evaluation. CONCLUSION SoT is a serious complication that lacks exact characterization and deserves future investigation. Improved understanding and recognition have important implications for early intervention and patient outcomes. ABBREVIATIONS ADLs, activities of daily livingCBF, cerebral blood flowSoT, syndrome of the trephinedVP, ventriculoperitoneal.
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Affiliation(s)
- Kimberly Ashayeri
- *Albert Einstein College of Medicine, New York, New York; ‡Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; §Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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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: 19] [Impact Index Per Article: 2.4] [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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Pierson M, Birinyi PV, Bhimireddy S, Coppens JR. Analysis of Decompressive Craniectomies with Subsequent Cranioplasties in the Presence of Collagen Matrix Dural Substitute and Polytetrafluoroethylene as an Adhesion Preventative Material. World Neurosurg 2015; 86:153-60. [PMID: 26433096 DOI: 10.1016/j.wneu.2015.09.078] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 09/21/2015] [Accepted: 09/23/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Decompressive craniectomy is an established treatment for malignant intracranial hypertension. Cranioplasty is performed once cerebral swelling has resolved. Complications include infection, postoperative fluid collections, hematoma, reoperation, and seizures. Our experience using a double layer technique during craniectomy with a collagen matrix onlay dural substitute and expanded polytetrafluoroethylene for antiadhesive properties during cranioplasty was reviewed. METHODS This is a retrospective chart review of 39 consecutive patients who underwent craniectomy with placement of collagen matrix dural onlay and expanded polytetrafluoroethylene and subsequent cranioplasty. Demographic data, size of craniectomy defect, estimated blood loss, operative time, time between operations, presence of dural tackups, and postoperative complications were analyzed. RESULTS Mean operative time was 132 minutes and estimated blood loss was 112 mL. Overall complication rate was 25.6% and no mortality was encountered. Nine patients had postoperative fluid collections measuring ≥ 10 mm in thickness and/or 5 mm of midline shift. Two patients required reoperation for these collections. Two patients developed infections requiring bone flap removal. Three patients developed seizures after cranioplasty. Five patients required shunt placement for hydrocephalus. CONCLUSIONS Our dual layer closure technique at time of decompressive craniectomy carries a similar reduction in operative time and estimated blood loss when compared with cranioplasty series with other antiadhesives present. The technique described enables easy dissection of the musculocutaneous flap from the dural plane during cranioplasty and increases the safety of the operation.
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Affiliation(s)
- Matt Pierson
- Department of Neurological Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA.
| | - Paul V Birinyi
- Department of Neurological Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Sujit Bhimireddy
- Department of Neurological Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Jeroen R Coppens
- Department of Neurological Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
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Griessenauer CJ, He L, Salem M, Chua M, Ogilvy CS, Thomas AJ. Epidural Bovine Pericardium Facilitates Dissection During Cranioplasty: A Technical Note. World Neurosurg 2015; 84:2059-63. [PMID: 26283487 DOI: 10.1016/j.wneu.2015.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 08/02/2015] [Accepted: 08/03/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVE Adhesions and scarring of the subcutaneous tissue to the dura mater or dural substitute often complicate cranioplasty. We present our experience with epidural bovine pericardium as a barrier membrane to minimize adhesions and facilitate separation of tissue layers. METHODS A cohort of patients who underwent decompressive craniectomy and subsequent cranioplasty at a major academic institution in the United States from August 2007 to October 2013 and had epidural bovine pericardium placed as a barrier membrane was retrospectively reviewed. Medical records and imaging studies were reviewed for a number of variables including presence of adhesions, infection, contusions, and operative complications. RESULTS Twenty-nine patients (male-to-female = 1:1.1; mean age 45 ± 14.7 years) who underwent decompressive craniectomy with placement of epidural bovine pericardium with subsequent cranioplasty were identified. The median interval between craniectomy and cranioplasty was 64 days, and autologous bone was used for cranioplasty in 86.2% of cases. The average size of cranial defect was 71.2 ± 28.5 cm(2). At the time of cranioplasty, no or minimal adhesions were found between the subcutaneous tissue and the epidural bovine pericardium. There were 2 (6.9%) infections, 2 (6.9%) patients had contusion after the cranioplasty, and no patient had a complication after cranioplasty that required reoperation. CONCLUSIONS Epidural bovine pericardium at the time of decompressive craniectomy facilitates dissection at the time of cranioplasty and is not associated with any additional risks.
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Affiliation(s)
- Christoph J Griessenauer
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lucy He
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle Chua
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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