Preservation of bone flap after craniotomy infection

Pseudomeningocele Following Posterior Cranial Fossa Surgery Significantly Increases the Risk of Intracranial Infection: A 10-Year Retrospective Analysis

Background: Posterior fossa craniotomy is commonly performed for various pathologies. However, intra-cranial infection following craniotomy causes morbidity. Pseudomeningocele is one of the main complications following posterior fossa operation. This study aimed to test the hypothesis that the risk of intra-cranial infection is increased in patients who undergo posterior fossa craniotomy with pseudomeningocele compared with those without pseudomeningocele. Methods: We retrospectively analyzed the data of patients undergoing posterior fossa craniotomy for the management of neurological pathologies at our institute from 2011 to 2020. A total of 308 craniotomies were included, and the primary outcome of interest was the occurrence of intra-cranial infection. Standard statistical methods were used to explore associations between several parameters, including pseudomeningocele, intra-cranial infection, and wound leak. Results: Of the 308 craniotomies, 41 (13.3%) developed intra-cranial infection and 59 (19.2%) involved pseudomeningocele. Of cases involving pseudomeningocele, 27 (45.8%) developed an intra-cranial infection compared with only 14 of 249 without pseudomeningocele (5.6%; p < 0.001). In the multi-variable analysis, pseudomeningocele was associated with intra-cranial infection (odds ratio [OR] 8.56; 95% confidence interval [CI] 3.145-23.299; p < 0.001) and wound leak (OR 91.339; 95% CI 10.437-799.364; p < 0.001). Conclusion: The findings indicate that patients undergoing posterior fossa craniotomy are at a greater risk of intra-cranial infection if there is pseudomeningocele after the operation.

Surgical strategies in acute subdural hematoma: a meta-analysis of decompressive craniectomy vs. craniotomy

OBJECTIVE

Acute subdural hematoma (ASDH) stands as a significant contributor to morbidity after severe traumatic brain injuries (TBI). The primary treatment approach for patients experiencing progressive neurological deficits or notable mass effects is the surgical removal of the hematoma, which can be achieved through craniotomy (CO) or decompressive craniectomy (DC). Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy.

MATERIALS AND METHODS

We conducted a comprehensive literature review, utilizing prominent online databases and manually searching references related to craniotomy and craniectomy for subdural hematoma evacuation up to November 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes.

RESULTS

We included a total of 11 comparative studies in our analysis, encompassing 4269 patients, with 2979 undergoing craniotomy and 1290 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale (GCS) during their initial presentation. Following surgery, the DC group exhibited a significantly reduced rate of residual subdural (P = 0.009). Additionally, the likelihood of a poor outcome during follow-up was lower in the CO group. Likewise, the mortality rate was lower in the CO group compared to the craniectomy group (OR 0.63, 95% CI 0.41-0.98, I2 = 84%, P = 0.04).

CONCLUSION

Our study found that CO was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome while DC was associated with less likelihood of residual subdural hematoma. Upon further investigation of patient characteristics who underwent into either of these interventions, it was very clear that patients in DC cohort have more serious and low pre-op characteristics than the CO group. Nonetheless, brain herniation and advanced age act as independent factor for predicting the outcome irrespective of the intervention.

Risk of postoperative scalp necrosis in the occipital artery region after posterior cranial fossa surgery

Ischemia-induced postoperative scalp necrosis in the superficial temporal artery (STA) region is known to occur after STA-middle cerebral artery anastomoses. However, no reports have evaluated the risk of postoperative scalp necrosis in the occipital artery (OA) region. This study examined the surgical procedures that pose a risk for postoperative scalp necrosis in the OA region following posterior cranial fossa surgery. Patients who underwent initial posterior fossa craniotomy at our institution from 2015 to 2022 were included. Clinical information was collected using medical records. Regarding surgical procedures, we evaluated the incision design and whether a supramuscular scalp flap was prepared. The supramuscular scalp flap was defined as a scalp flap dissected from the sternocleidomastoid and/or splenius capitis muscles. A total of 392 patients were included. Postoperative scalp necrosis occurred in 19 patients (4.8%). There were 296 patients with supramuscular scalp flaps, and supramuscular scalp flaps prepared in all 19 patients with postoperative necrosis. Comparing incision designs among patients with supramuscular scalp flap, a hockey stick-shaped scalp incision caused postoperative necrosis in 14 of 73 patients (19.1%), and the odds of postoperative scalp necrosis were higher with the hockey stick shape than with the retro-auricular C shape (adjusted odds ratio: 12.2, 95% confidence interval: 3.86-38.3, p = 0.00002). In all the cases, ischemia was considered to be the cause of postoperative necrosis. The incidence of postoperative necrosis is particularly high when a hockey stick-shaped scalp incision is combined with a supramuscular scalp flap.

Comparison of Infection Rates Following Immediate and Delayed Cranioplasty for Postcraniotomy Surgical Site Infections: Results of a Meta-Analysis

Postoperative surgical site infections (SSIs) in neurosurgery are rare. However, they pose a formidable challenge to the treating neurosurgeon and substantially worsen patient outcomes. These infections require prompt intervention in the form of débridement, including removal of craniotomy bone. Reconstruction of the craniotomy defect can be performed along with the débridement or can be performed at a later time. Although there have been concerns about performing cranioplasty at the same time as débridement, recent studies have advocated performance of cranioplasty at the same time as the débridement, as it avoids the morbidity associated with having a craniectomy defect and avoids the need for another surgical procedure. We conducted a literature review and meta-analysis to examine the data on immediate cranioplasties and delayed cranioplasties performed for postcraniotomy SSIs. We analyzed 15 articles with a total of 353 patients. Our analysis revealed that the pooled proportion of treatment failure was 10.4% (95% confidence interval [CI] 5.9%-17.8%) when an immediate cranioplasty was done and 16.1% (95% CI 7.2%-32.1%) when delayed cranioplasty was done. The pooled proportion of treatment failure was 12% (95% CI 5.9%-22.9%) when the same bone was used for cranioplasty and was 8% (95% CI 3%-20%) when prosthetic material such as titanium was used for cranial vault reconstruction. Thus, the rate of treatment failure was less when an immediate single-stage cranioplasty was done compared with a delayed cranioplasty following SSIs.

Early versus delayed debridement for surgical site infection after oncological neurosurgery

Background:

There are no guidelines on the management of surgical site infection (SSI) in neurosurgery. This study sought to analyze whether early debridement improved survival compared to antibiotic therapy alone in patients with postcraniotomy infections after oncological neurosurgeries.

Methods:

We retrospectively reviewed patient records from 2011 to 2019 to identify patients that had been reoperated for the debridement of SSI after brain tumor resection. If SSI was suspected but not clinically evident, the diagnosis was confirmed by cerebrospinal fluid (CSF) analysis or contrast-based imaging examinations. Immediately after diagnosis, broad-spectrum antibiotics were started for all patients.

Results:

Out of 81 SSI cases, 57 underwent debridement. Two patients were reoperated 3 times, and three had two surgeries, resulting in a total of 64 procedures. The number of days between SSI diagnosis and surgical intervention did not influence mortality in both univariate and multivariable analyses (Hazard ratio [HR] 1.03, 95% CI 0.93–1.13). Early debridement (<24 h) did not influence rates of antibiotic prescription at discharge (P = 0.53) or hospital length of stay (LOS) (P = 0.16). Higher neutrophil-lymphocyte ratios (NLRs) were associated with the lower survival (HR 1.05, 95% Confidence interval [CI] 1.01–1.08). Multiple cutoffs were tested and values above 3.5 are more significantly associated with worse outcomes (HR 2.2; 95%CI 1.1–4.2).

Conclusion:

Early debridement does not seem to influence the survival, rates of antibiotic at discharge, or hospital LOS of patients presenting with SSI after neurosurgery for intracranial tumors. High NLRs are strong predictors of worse prognosis in this population.

Outcome of Patients with Surgical Site Infection after Craniotomy

Background: The management of surgical site infection (SSI) after craniotomy remains challenging with few existing recommendations. Patients and Methods: We reviewed the medical files of patients who underwent surgery between 2009 and 2018 to manage infection after craniotomy at our tertiary hospital. The Cox proportional hazards model and the Renyi test were used to investigate the association between relapse or all-cause mortality and selected variables. We compared infections with and without intra-cranial involvement using the Fisher test and the Wilcoxon rank sum test. Results: Seventy-seven episodes of infection were identified in 58 patients. The proportion of relapse was estimated to be 32.2% (± standard deviation [SD] 6.9) at five years. Intra-cranial infection was present in 15.6% of the cases (n = 12). Bone flap was removed in the majority of cases (93.5%) and the overall median duration of antibiotic therapy was six weeks (interquartile range [IQR] 6-12 weeks). Staphylococcus aureus was associated with a higher risk of relapse (p = 0.037). The administration of parenteral antibiotic agents (p = 0.012) and bone flap removal (p = 0.0051) were correlated with less relapse. In contrast, immunosuppressive drug use and radiotherapy were correlated with a higher risk of relapse (p = 0.014 and p = 0.031, respectively) and a higher all-cause mortality (p = 0.0093 and p < 0.0001, respectively). We found no difference between infections with and without intra-cranial involvement. Conclusions: Bone flap removal and parenteral antibiotic agents remain important in the management of SSI after craniotomy and were associated with less relapse in our study. More studies are needed to better determine the optimal treatment of this infection.

Bifrontal Osteoplastic Flap: An Option to Decrease Infection in Bifrontal Craniotomies with Skull Base Osteotomies

Infection can be a common complication following bifrontal craniotomy with skull base osteotomies given the potential violation of sinuses and entry into the nasal structures. Our objective was to examine our series of patients who underwent a bifrontal craniotomy with skull base osteotomies and describe the infection rate. We propose the bifrontal osteoplastic flap as an adjunct to infection prevention. A retrospective single-center study of a patient database was performed. Twenty patients were identified. Fifty-five percent were male. The mean age was 55.7 ± 13.9 years. The most common indications for surgery were esthesioneuroblastomas (35%) and anterior skull base meningiomas (30%). Six patients (30%) developed an infection, 1 patient (5%) developed a CSF leak, and no patients developed a mucocele. All 6 infected cases had nasal pathology with intracranial extension, they all received chemoradiation post-operatively and were all combined cases with otorhinolaryngology. Eighty-three percent of these patients required a craniectomy and all of them required long-term IV antibiotics. Infection is not uncommon after a bifrontal craniotomy with skull base osteotomies and the use of the bifrontal osteoplastic flap in cases where the risk of infection is high, i.e., esthesioneuroblastomas surgery, may help reduce said risk and lead to better patient outcomes.

Bone flap management strategies for postcraniotomy surgical site infection

Background:

Surgical site infection (SSI) after a craniotomy is traditionally treated with wound debridement and disposal of the bone flap, followed by intravenous antibiotics. The goal of this study is to evaluate the safety of replacing the bone flap or performing immediate titanium cranioplasty.

Methods:

All craniotomies at single center between 2008 and 2020 were examined to identify 35 patients with postoperative SSI. Patients were grouped by bone flap management: craniectomy (22 patients), bone flap replacement (seven patients), and titanium cranioplasty (six patients). Retrospective chart review was performed to identify patient age, gender, index surgery indication and duration, diffusion restriction on MRI, presence of gross purulence, bacteria cultured, sinus involvement, implants used during surgery, and antibiotic prophylaxis/ treatment. These variables were compared to future infection recurrence and wound breakdown.

Results:

There was no significant difference in infection recurrence or future wound breakdown among the three bone flap management groups (P = 0.21, P = 0.25). None of the variables investigated had any significant relation to infection recurrence when all patients were included in the analysis. However, when only the bone flap replacement group was analyzed, there was significantly higher infection recurrence when there was frank purulence present (P = 0.048).

Conclusion:

Replacing the bone flap or performing an immediate titanium cranioplasty is safe alternatives to discarding the bone flap after postoperative craniotomy SSI. When there is gross purulence present, caution should be used in replacing the bone flap, as infection recurrence is significantly higher in this subgroup of patients.

Post-craniotomy fever and its associated factors in patients with traumatic brain injury

BACKGROUND

Fever frequently occurs in patients with traumatic brain injury and can cause secondary damage to the brain. Critical care nurses play essential roles in assessing and managing fever in these patients.

AIM

The study aimed to (a) examine the fever causes in and condition of neurosurgical patients with traumatic brain injury in intensive care, (b) identify the factors associated with fever, and (c) determine the effects of fever on hospital stay and prognosis.

STUDY DESIGN

This study is a retrospective observational design.

METHODS

Data were collected through chart reviews of 93 traumatic brain injury patients admitted to a teaching hospital's intensive care unit for postoperative care. Fever was defined as at least one episode of body temperature >38°C.

RESULTS

Of the 93 patients, 76 developed a fever within 1-week post-craniotomy. Of these, 49 were infection-related and 27 were unexplained. Results of logistic regression showed that the preoperative Glasgow coma scale score (ß = -.323; P = .013) and length of intubation (ß = .480; P = .005) were the key predictors of unexplained post-craniotomy fever, and these two variables (ß = -.494; P < .001 and ß = .479; P = .006, respectively) were also the key predictors of infection-related fever.

CONCLUSION

A significant portion of patients developed a fever during the first post-craniotomy week. Patients with a lower pre-craniotomy Glasgow coma scale score and a longer intubation length were at a greater risk for both infection-related fever and unexplained fever. Patients with fever had a bad outcome score.

RELEVANCE TO CLINICAL PRACTICE

Critical care nurses should closely monitor traumatic brain injury patients' body temperatures and employ evidence-based infection prevention and control measures to minimize their infection risks. Respiratory care and intensive care unit Liberation Bundle should be reinforced to liberate these patients from mechanical ventilation and its associated complications.

Surgical Site Infections after glioblastoma surgery: results of a multicentric retrospective study

BACKGROUND

The effects of surgical site infections (SSI) after glioblastoma surgery on patient outcomes are understudied. The aim of this retrospective multicenter study was to evaluate the impact of SSI on the survival of glioblastoma patients.

METHODS

Data from SSI cases after glioblastoma surgeries between 2009 and 2016 were collected from 14 French neurosurgical centers. Collected data included patient demographics, previous medical history, risk factors, details of the surgical procedure, radiotherapy/chemotherapy, infection characteristics, and infection management. Similar data were collected from gender- and age-paired control individuals.

RESULTS

We used the medical records of 77 SSI patients and 58 control individuals. 13 were excluded. Our analyses included data from 64 SSI cases and 58 non-infected glioblastoma patients. Infections occurred after surgery for primary tumors in 38 cases (group I) and after surgery for a recurrent tumor in 26 cases (group II). Median survival was 381, 633, and 547 days in patients of group I, group II, and the control group, respectively. Patients in group I had significantly shorter survival compared to the other two groups (p < 0.05). The one-year survival rate of patients who developed infections after surgery for primary tumors was 50%. Additionally, we found that SSIs led to postoperative treatment discontinuation in 30% of the patients.

DISCUSSION

Our findings highlighted the severity of SSIs after glioblastoma surgery, as they significantly affect patient survival. The establishment of preventive measures, as well as guidelines for the management of SSIs, is of high clinical importance.

Salvage of an exposed cranial prosthetic implant using a transposition flap with an indwelling antibiotic irrigation system

Cranial implant removal is recommended if implants become exposed owing to scalp necrosis after cranioplasty. However, it carries the risk of extensive bleeding, and the resultant cranial defects can cause both aesthetic and functional problems. We present a case of a scalp defect exposing a cranial prosthetic implant that was reconstructed with a local flap and salvaged using an indwelling antibiotic irrigation system. A 73-year-old man presented with scalp necrosis after undergoing cranioplasty due to intracranial hemorrhage. The cranial implant was exposed through the scalp defect. Methicillin-resistant Staphylococcus aureus was detected in the culture from the open wound. After debridement of the necrotic tissue and burring of the superficial layer of the implant, a transposition flap was used to cover the defect and an indwelling antibiotic irrigation system was installed. Continuous irrigation with vancomycin was conducted for 5 days, and intravenous vancomycin was continued for 4 weeks. The flap was in good condition at 4 months postoperatively, with no infection. The convex contour of the scalp was well maintained. The patient’s neurological status was stable. Exposed cranial implants can be salvaged with continuous antibiotic irrigation as an alternative to implant removal; thus, the risk of bleeding and possible disfigurement may be avoided.

Gram-negative Cranial Bone Flap Infection Treated with Continuous Gentamicin Irrigation: A Case Report

A 57-year-old male presented with severely altered mental status in the setting of diabetic ketoacidosis. Neuroimaging revealed two intracranial masses. Days following surgical resection of an olfactory groove meningioma, the patient developed Serratia marcescens bacteremia along with an enlarging epidural and subgaleal fluid collection. Subgaleal fluid aspiration was also positive. The patient later returned to the operating room for wound washout where purulent collections were discovered in the subgaleal, epidural, and left subdural spaces. The wound was evacuated and the bone flap was thoroughly cleansed with betadine and soaked in peroxide prior to replacement. Four drains were placed (two subgaleal and two epidural) with two serving as inlets and two as outlets. Continuous irrigation of the subgaleal and epidural spaces with gentamicin solution was performed for five days. The bone flap was successfully salvaged and the patient was discharged from inpatient rehab three weeks following washout.

Successful Strategies for Dealing With Infected, Custom-Made Hydroxyapatite Cranioplasty

When a cranioplasty implant becomes infected, standard operating procedure dictates its removal and the initiation of a long course of antibiotic therapy. However, removing such a prosthesis can have a series of adverse consequences, including delayed cognitive and motor recovery, lack of brain tissue protection, unsightly deformity, and the need for two additional surgical procedures, not to mention the additional costs involved. To maintain the advantages of cranioplasty, we opted for a conservative approach (levofloxacin and rifampicin every 24 hours for 8 weeks) in a 68-year-old woman whose custom-made porous hydroxyapatite implant, fitted following aneurysm clipping, had become infected. The tissues overlying the implant were curettaged, and the patient's clinical condition, blood markers, and infection course were continuously monitored (local monitoring was performed by single-photon emission computed tomography [SPECT]/computed tomography [CT after intravenous administration of Tc-labeled antigranulocyte antibody). Blood tests and SPECT/CT evidenced a progressive reduction in phlogosis indices and infection locus, even 1 month after antibiotic therapy was commenced, and at 2 years from cranioplasty, the same tests and clinical examination were negative. At 6-year follow-up, clinical assessment revealed nothing out of the ordinary.Hence, specific cases (hydroxyapatite prosthesis, intact dura, cranial CT and magnetic resonance imaging negative for empyema, well-vascularized scalp, antibiotic-responsive bacteria) of infected cranial implant can be treated using a conservative approach consisting of appropriate antibiotic therapy, accompanied by local debridement where necessary, and assiduous monitoring of phlogosis indices and local verification via labeled-leukocyte scintigraphy. Our report, which was compiled after a long-term follow-up period, shows that this conservative procedure appears to be a viable option in cases of infected, custom-made hydroxyapatite cranioplasty, provided that some basic rules concerning clinical and instrumental standards are adhered to, as clearly stated in our report.

Post-operative complications of craniotomy and craniectomy

Craniotomy and craniectomy are widely performed emergent neurosurgical procedures and are the prescribed treatment for a variety of conditions from trauma to cancer. It is vital for the emergency radiologist to be aware of expected neuroimaging findings in post-craniotomy and craniectomy patients in order to avoid false positives. It is just as necessary to be familiar with postsurgical complications in these patients to avoid delay in lifesaving treatment. This article will review the commonly encountered normal and abnormal findings in post-craniotomy and craniectomy patients. The expected postoperative CT and MRI appearance of these procedures are discussed, followed by complications. These include hemorrhage, tension pneumocephalus, wound/soft tissue infection, bone flap infection and extradural abscesses. Complications specifically related to craniectomies include extracranial herniation, external brain tamponade, paradoxical herniation, and trephine syndrome.

Bone flap salvage in acute surgical site infection after craniotomy for tumor resection

Craniotomy surgical site infections are an inherent risk and dreaded complication for the elective brain tumor patient. Sequelae can include delays in resumption in adjuvant treatments for multiple surgeries if staged cranioplasty is pursued. Here, the authors review their experience in operative debridement of surgical site infections with single-stage reimplantation of the salvaged craniotomy bone flap. A prospectively maintained database of a single surgeon's neuro-oncology patients from 2009 to 2017 (JRF) was queried to identify 11 patients with surgical site infection after craniotomy for tumor resection. All patients underwent a protocol of aggressive operative debridement including drilling the bone edges and intraoperative flap sterilization with single-stage reimplantation, followed by tailored-antibiotic therapy. Ten of the 11 patients with frankly contaminated bone flaps from surgical site infection were able to be salvaged in a single-stage procedure. Five of these patients underwent adjuvant chemotherapy and/or radiation without secondary complication. There was one treatment failure in a delayed fashion which required additional surgery for craniectomy; however, this occurred after adjuvant treatment was administered. Surgical debridement and bone flap salvage is safe and cost-effective in managing acute surgical site infections after craniotomy for tumors. Additionally, this practice is likely beneficial in expediting the resumption of cancer therapy.

Fundamental Basis of Scalp Layering Techniques to Protect Against Wound Infection: A Comparative Study Between Conventional and In-to-Out Dissection of the Superficial Temporal Artery

BACKGROUND

Superficial temporal artery (STA) to middle cerebral artery (MCA) bypass is associated with several surgical problems. Despite the vascular patency and hemodynamic changes after the anastomosis, wound problems can be a major surgical complication.

METHODS

In a review of 41 surgical cases of STA-MCA bypass for moyamoya disease or cerebral occlusive vascular disease, we compared the conventional (out-to-in) dissection method for STA (n = 23) with the in-to-out (ITO) dissection method (n = 18) and evaluated the surgical results with respect to wound problems.

RESULTS

The incidence of skin maceration was significantly higher in the conventional dissection group than the ITO dissection group (34.8% vs. 5.5%; P < 0.01). Skin necrosis also showed a higher incidence in the conventional dissection group (39.1%) than the ITO group (22.2%).

CONCLUSIONS

These data suggest that the simple layering technique of the ITO dissection method can protect against contamination from bacteria and reduce postoperative surgical wound problems. Sealing of the galea aponeurotica (first protective barrier), including fibrous septa and loose areolar tissues, including the periosteal layer (second protective barrier), is an important factor to decrease the rate of scalp wound infection.

Repair of a Complicated Calvarial Defect: Reconstruction of an Infected Wound With rhBMP-2

BACKGROUND

Management of the previously infected craniofacial defect remains a significant clinical challenge, posing obstacles such as wound healing complications, lack of donor site availability, and predisposition to failure of the repair. Optimal therapy would reconstruct like with like, without donor site morbidity. The purpose of this study was to compare the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2)-mediated bone regeneration with the current standard of autologous bone graft for repair of previously infected calvarial defects.

METHODS

Nineteen adult New Zealand white rabbits underwent subtotal calvariectomy. Bone flaps were inoculated with Staphylococcus aureus and replanted. After 1 week of infection, bone flaps were removed, and wounds were debrided, followed by 10 days of antibiotic treatment. After 6 weeks, animals underwent scar debridement followed by definitive reconstruction in 1 of 4 groups: empty control (n = 3), vehicle control (buffer solution on absorbable collagen sponge [ACS], n = 3), autologous bone graft (n = 3), or rhBMP-2 repair (rhBMP-2/ACS, n = 10). Animals underwent computed tomography imaging at 0, 2, 4, and 6 weeks postoperatively, followed by euthanization and histological analysis. Percent healing was determined by 3-dimensional analysis. A (time × group) 2-way analysis of variance was performed on healing versus treatment group and postoperative time.

RESULTS

At 6 weeks postoperatively, rhBMP-2/ACS and autologous bone graft resulted in 93% and 68% healing, respectively, whereas the empty and vehicle control treatment resulted in 27% and 26% healing (P < 0.001). Histologically, compared to autologous bone graft, bone in the rhBMP-2/ACS group was more cellular and more consistently continuous with wound margins.

CONCLUSIONS

The rhBMP-2 therapy is effective in achieving radiographic coverage of previously infected calvarial defects.

Operative wound-related complications after cranial revascularization surgeries

OBJECT

Intracranial revascularization surgeries are an effective treatment for moyamoya disease and other intracranial vascular obliterative diseases. However, in some cases, wound-related complications develop after surgery. Although the incidence of wound complication is supposed to be higher than that with a usual craniotomy, this complication has rarely been the focus of studies in the literature that report the outcomes of revascularization surgeries. Here, the relationship between intracranial revascularization surgeries and their complications is statistically assessed.

METHODS

Between October 2004 and February 2010, 71 patients were treated using cerebral revascularization surgeries on 98 sides of the head. The relationship between wound complications and operative technique was retrospectively assessed. Multivariate logistic regression analysis was performed to identify the risk factors of wound complication, including operative technique, age, sex, diabetes mellitus (DM), hypertension, hyperlipidemia, and smoking history.

RESULTS

In total, there were 21 (21.4%) operative wound complications. Of these 21 complications, there were 14 (66.7%) minor complications and 7 (33.3%) major complications. No statistically significant relationship was found between wound complications and any surgical procedure. A trend toward severer complications was demonstrated for the procedures that used both STA branches (“double” procedures) in comparison with the procedures that used only 1 STA branch (“single” procedures, p = 0.016, Cochran-Armitage trend test). Multivariate logistic regression analysis also revealed that double procedures demonstrated a significantly higher incidence of wound complications than single procedures (OR 3.087, p = 0.048). DM was found to be a risk factor for wound complication (OR 9.42, p = 0.02), but age, sex, hypertension, and hyperlipidemia were not associated with the incidence of complications. Even though the blood supply to the scalp is abundant due to 5 arteriovenous systems, sometimes cutaneous necrosis develops after intracranial revascularization surgeries. The galeal blood supply is thought to be crucial for preventing wound-related complications. Special care is also thought to be required for DM patients.

CONCLUSIONS

Revascularization surgeries seemed to demonstrate a higher risk of wound-related complications. Double-type procedures, which use both branches of the STA, and a history of DM were found to be risk factors for wound-related complications. Attention should be paid to the design of the galeal incision and vessel harvest line. Also, special attention should be paid to patients with DM.

Management of infections complicating the orbitocranial approaches: Report of two cases and review of literature

BACKGROUND

The orbitocranial approaches are now indispensible for treating lesions of the skull base, providing access to lesions in the anterior and middle cranial fossae, as well as the upper clivus and anterior brainstem. The management of infectious complications of the orbitocranial approaches, however, has evaded the literature.

CASE DESCRIPTION

We present two cases of patients who underwent orbitocranial approach whose clinical course was complicated by wound infection and osteomyelitis. One patient was treated with antibiotics and then had a custom implant placed for cranioplasty. The other case was managed with removal of bone and wire-mesh cranioplasty.

CONCLUSION

Management of orbitocraniotomy infections can be difficult due to the complex geometry of the flap and to cosmetic considerations. Once the infection involves the bone, the bone can be replaced after cleaning or discarded and a cranioplasty performed. Cranioplasty can be performed with wire-mesh or a custom implant made by computer-assisted modeling.

Complications of cranioplasty using a bone flap sterilised by autoclaving following decompressive craniectomy

BACKGROUND

Increasing use of decompressive craniectomies has led to a corresponding number of cranioplasties performed to replace the subsequent bone defect created. We aimed to evaluate the morbidity associated with cranioplasty using an autologous bone flap sterilised in an autoclave.

METHODS

We retrospectively analysed data from 149 patients who underwent cranioplasty following decompressive craniectomy during the time period January 1998 to December 2012. Autologous bone flaps were sterilised in an autoclave and stored in a refrigerator at a temperature of 8 degrees above zero until cranioplasty was performed. Complications were registered and patient data were analysed in order to identify risk factors for surgical site infection and bone flap resorption after cranioplasty. Only the patients with a follow-up period of >24 months were included in the analysis of bone flap resorption (110 patients).

RESULTS

Surgical side infection occurred in only five patients (3.3%), whereas bone flap resorption developed in 22 patients (20%). The multivariate analysis of the presented data identified the operating time of >120 min (p = 0.0277; OR, 16.877; 95% CI, 1.364-208.906) and the presence of diabetes mellitus (p = 0.0016; OR, 54.261; 95% CI, 4.529-650.083) as independent risk factors of development of infection and the presence of ventriculo-peritoneal (VP) shunt (p < 0.0001; OR, 35.564; 95% CI, 9.962-126.960) as independent risk factor of development of the bone flap resorption.

CONCLUSIONS

Reimplantation of the autoclaved autologous bone flap following decompressive craniectomy is a simple and cheep alternative to other techniques and is available to any institution that provides autoclaving sterilisation services. This method is associated with a low rate of surgical site infection, but with a significant rate of the bone flap resorption.

Are patients open to elective re-sampling of their glioblastoma? A new way of assessing treatment innovations

BACKGROUND

This is a qualitative study designed to examine patient acceptability of re-sampling surgery for glioblastoma multiforme (GBM) electively post-therapy or at asymptomatic relapse.

METHODS

Thirty patients were selected using the convenience sampling method and interviewed. Patients were presented with hypothetical scenarios including a scenario in which the surgery was offered to them routinely and a scenario in which the surgery was in a clinical trial.

RESULTS

The results of the study suggest that about two thirds of the patients offered the surgery on a routine basis would be interested, and half of the patients would agree to the surgery as part of a clinical trial. Several overarching themes emerged, some of which include: patients expressed ethical concerns about offering financial incentives or compensation to the patients or surgeons involved in the study; patients were concerned about appropriate communication and full disclosure about the procedures involved, the legalities of tumor ownership and the use of the tumor post-surgery; patients may feel alone or vulnerable when they are approached about the surgery; patients and their families expressed immense trust in their surgeon and indicated that this trust is a major determinant of their agreeing to surgery.

CONCLUSION

The overall positive response to re-sampling surgery suggests that this procedure, if designed with all the ethical concerns attended to, would be welcomed by most patients. This approach of asking patients beforehand if a treatment innovation is acceptable would appear to be more practical and ethically desirable than previous practice.

Microbial contamination assessment of cryostored autogenous cranial bone flaps: should bone biopsies or swabs be performed?

BACKGROUND

Autogenous cranioplasty infection requiring bone flap removal is under-recognised as a major complication causing significant morbidity. Microbial contamination of stored bone flaps may be a significant contributing factor. Current infection control practices and storage procedures vary. It is not known whether 'superficial' swabs or bone cultures provide a more accurate assessment.

METHOD

Twenty-five skull flaps that were cryo-stored for more than 6 months were studied. Two swab samples (superficial and deep) and a bone biopsy sample were taken from each skull flap sample and cultured. Half blood agar and half chocolate agar plates were inoculated with the swabs for anaerobic and aerobic cultures respectively. The bone biopsy samples were cultured in brain-heart broth and subcultured similar to the swabs for 5 days.

RESULTS

Incidence of microbial contamination was 20 % in the bone flaps studied. One swab culture and five bone biopsy cultures were positive for bacterial growth, all of which contained Propionibacterium acnes (p = 0.014). Positive cultures were from bone flaps stored less than 18 months, whereas no growth was obtained from bone flaps that were stored longer (p = 0.014).

CONCLUSIONS

Bone biopsy culture is a more sensitive technique of assessing microbial contamination of cryo-stored autogenous bone flaps than swab cultures. The clinical implications of in vitro demonstration of microbial contamination require further study.

The incidence of infection for adults undergoing supra-tentorial craniotomy for tumours without hair removal

AIMS & OBJECTIVES

The aim of the study was to look at the infection rate in adults undergoing craniotomies without hair removal and compare the results with the usual practice of pre-operative shaving/clipping.

MATERIALS & METHODS

One-hundred consecutive adult patients who had elective supra-tentorial craniotomy for tumour were studied prospectively. A uniform policy of performing surgery without hair removal was adopted. Patients were followed up prospectively to look for surgical site infection. The rate of infection was determined and the results were compared with the published data on similar procedures where hair removal was carried out before surgery.

RESULTS

A total of three patients developed surgical-site infection. One infection occurred in the glioma and two in the meningioma subgroup. The rate of infection is comparable to the published figures where pre-operative hair removal was performed routinely.

CONCLUSIONS

Cranial surgery with hair left in place does not pre-dispose to an increased infection risk for adults undergoing tumour surgery.

Immediate titanium cranioplasty after debridement and craniectomy for postcraniotomy surgical site infection

BACKGROUND

For postcraniotomy surgical site infection (SSI) involving the bone, typical management involves craniectomy, debridement, and delayed cranioplasty. Disadvantages to delayed cranioplasty include cosmetic deformity, vulnerability of unprotected brain, and risks and costs associated with an additional operation. Many authors have attempted bone flap salvage by using various techniques.

OBJECTIVE

We evaluate our experience with immediate titanium mesh cranioplasty at the time of craniectomy and debridement.

METHODS

We retrospectively reviewed SSIs in patients that underwent craniotomy for treatment of a brain tumor. These patients were treated with craniectomy, debridement, and immediate titanium mesh cranioplasty followed by antibiotics. The primary outcome was recurrent infection.

RESULTS

Twelve patients met the inclusion criteria. Risk factors for infection included preoperative radiation therapy (33%), prior craniotomy (33%), and postoperative CSF leak (25%). Median follow-up was 14 months. Ten (83%) patients had long-term resolution without recurrent infection. One patient required additional surgical debridement for persistent infection with successful placement of new titanium mesh. Another patient developed recurrent infection but opted for hospice care because of tumor progression.

CONCLUSION

This series demonstrates the safety and feasibility of performing immediate titanium cranioplasty at the time of craniectomy and debridement in patients with postcraniotomy infections. This has been shown in patients with risk factors for poor wound healing. Immediate cranioplasty avoids the drawbacks, risks, and costs of delayed cranioplasty.

Immediate titanium mesh cranioplasty for treatment of postcraniotomy infections

OBJECTIVE

Postcraniotomy infections have generally been treated by debridement of infected tissues, disposal of the bone flap, and delayed cranioplasty several months later to repair the resulting skull defect. Debridement followed by retention of the bone flap has also been advocated. Here we propose an alternative operative strategy for the treatment of postcraniotomy infections.

METHODS

Two patients presenting with clinical and radiographic signs and symptoms of postcraniotomy infections were treated by debridement, bone flap disposal, and immediate titanium mesh cranioplasty. The patients were subsequently administered antibiotics, and their clinical courses were followed.

RESULTS

The patients treated in this fashion did not have recurrence of their infections during 3-year follow-up periods.

CONCLUSIONS

Surgical debridement, bone flap disposal, and immediate titanium mesh cranioplasty may be a suitable option for the treatment of postcraniotomy infections. This treatment strategy facilitates the eradication of infectious sources and obviates the risks and costs associated with a second surgical procedure.