An Improved One-Stage Operation of Cranioplasty and Ventriculoperitoneal Shunt in Patient with Hydrocephalus and Large Cranial Defect

Staged or simultaneous operations for ventriculoperitoneal shunt and cranioplasty: Evidence from a meta-analysis

OBJECTIVE

To date, there is no consensus on the surgery strategies of cranioplasty (CP) and ventriculoperitoneal shunt (VPS) placement. This meta-analysis aimed to investigate the safety of staged and simultaneous operation in patients with comorbid cranial defects with hydrocephalus to inform future surgery protocols.

METHODS

A meta-analysis of PubMed, Ovid, Web of Science, and Cochrane Library databases from the inception dates to February 8, 2023 adherent to PRISMA guidelines was conducted. The pooled analyses were conducted using RevMan 5.3 software. The outcomes included postoperative infection, reoperation, shunt obstruction, hematoma, and subdural effusion.

RESULTS

Of the 956 studies initially retrieved, 10 articles encompassing 515 patients were included. Among the total patients, 193 (37.48%) and 322 (62.52%), respectively, underwent simultaneous and staged surgeries. The finding of pooled analysis indicated that staged surgery was associated with lower rate of subdural effusion (14% in the simultaneous groups vs. 5.4% in the staged groups; OR = 2.39, 95% CI: 1.04-5.49, p = 0.04). However, there were no significant differences in overall infection (OR = 1.92, 95% CI: 0.74-4.97, p = 0.18), central nervous system infection (OR = 1.50, 95% CI: 0.68-3.31, p = 0.31), cranioplasty infection (OR = 1.58, 95% CI: 0.50-5.00, p = 0.44), shunt infection (OR = 1.30, 95% CI: 0.38-4.52, p = 0.67), reoperation (OR = 1.51, 95% CI: 0.38-6.00, p = 0.55), shunt obstruction (OR = 0.73, 95% CI: 0.25-2.16, p = 0.57), epidural hematoma (OR = 2.20, 95% CI: 0.62-7.86, p = 0.22), subdural hematoma (OR = 1.20, 95% CI: 0.10-14.19, p = 0.88), and intracranial hematoma (OR = 1.31, 95% CI: 0.42-4.07, p = 0.64). Moreover, subgroup analysis failed to yield new insights.

CONCLUSIONS

Staged surgery is associated with a lower rate of postoperative subdural effusion. However, from the evidence of sensitivity analysis, this result is not stable. Therefore, our conclusion should be viewed with caution, and neurosurgeons in practice should make individualized decisions based on each patient's condition and cerebrospinal fluid tap test.

Breaking Barriers in Cranioplasty: 3D Printing in Low and Middle-Income Settings-Insights from Zenica, Bosnia and Herzegovina

Background and Objectives: Cranial defects pose significant challenges in low and middle-income countries (LIMCs), necessitating innovative and cost-effective craniofacial reconstruction strategies. The purpose of this study was to present the Bosnia and Herzegovina model, showcasing the potential of a multidisciplinary team and 3D-based technologies, particularly PMMA implants, to address cranial defects in a resource-limited setting. Materials and Methods: An observational, non-experimental prospective investigation involved three cases of cranioplasty at the Department of Neurosurgery, Cantonal Hospital Zenica, Bosnia and Herzegovina, between 2019 and 2023. The technical process included 3D imaging and modeling with MIMICS software (version 10.01), 3D printing of the prototype, mold construction and intraoperative modification for precise implant fitting. Results: The Bosnia and Herzegovina model demonstrated successful outcomes in cranioplasty, with PMMA implants proving cost-effective and efficient in addressing cranial defects. Intraoperative modification contributed to reduced costs and potential complications, while the multidisciplinary approach and 3D-based technologies facilitated accurate reconstruction. Conclusions: The Bosnia and Herzegovina model showcases a cost-effective and efficient approach for craniofacial reconstruction in LIMICs. Collaborative efforts, 3D-based technologies, and PMMA implants contribute to successful outcomes. Further research is needed to validate sustained benefits and enhance craniofacial reconstruction strategies in resource-constrained settings.

Correlation between cerebrospinal fluid abnormalities before ventriculoperitoneal shunt and postoperative intracranial infection in adult patients with hydrocephalus: A clinical study

Objective

To identify the relationship between preoperative cerebrospinal fluid (CSF) leukocyte, chloride, glucose, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase, lactic acid and protein levels and ventriculoperitoneal shunt infection.

Methods

Records of 671 consecutive adult patients who underwent ventriculoperitoneal shunt surgery for the treatment of hydrocephalus at Zhujiang Hospital affiliated with Southern Medical University from January 2011 to March 2022 were reviewed. The patients were divided into infection and non-infection groups based on the presence of postoperative infection. For all patients, we analyzed age; sex; primary disease; preoperative CSF leukocyte, chloride, glucose, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase, lactic acid and protein levels; postoperative temperature; and postoperative infection.

Results

A total of 397 patients were included, 28 (7.05%) of whom had an infection within 6 months of the operation and the remaining had no infection. There was no significant difference in age, sex, primary disease, leukocyte, chloride ion, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase and protein levels in CSF between infection group and non-infection group (p > 0.05). The postoperative infection rate of patients with CSF glucose < 2.8 mmol/L (x ² = 11.650, p = 0.001) and CSF lactic acid >2.8 mmol/L (x ² = 12.455, p < 0.001) was higher than that of patients with CSF glucose level ≥2.8 mmol/L and CSF lactic acid level in the range of (1-2.8) mmol/L, respectively, with statistical difference. Compared with the non-infection group, the level of CSF glucose (t = 4.113, p < 0.001) was significantly lower, and the level of CSF lactic acid (t = 6.651, p < 0.001) was significantly higher in the infection group. Multivariate logistic regression analysis showed that preoperative cerebrospinal fluid glucose < 2.8 mmol/L (OR = 3.911, 95% CI: 1.653~9.253, p = 0.002) and cerebrospinal fluid lactate >2.8 mmol/L (OR = 4.712, 95% CI: 1.892~11.734, p = 0.001) are risk factors for infection after ventriculoperitoneal shunt. ROC analysis revealed that the area under the curve (AUC) for CSF glucose and lactic acid level were 0.602 (95% CI: 0.492-0.713) and 0.818 (95% CI: 0.738-0.898), respectively. The infection group had higher rates of fever and body temperature on postoperative day 3-7 (p < 0.05).

Conclusions

For adult hydrocephalus patients without clinical manifestations of intracranial infection but only with simple abnormality of cerebrospinal fluid, when the content of glucose in cerebrospinal fluid is < 2.8 mmol/L, and the content of lactic acid is >2.8 mmol/L, it is recommended to perform ventriculoperitoneal shunt after further improvement of cerebrospinal fluid indicators, otherwise, hasty operation will increase the postoperative infection rate. The postoperative fever rate of ventriculoperitoneal shunt surgery is high and the body temperature drops rapidly. If there is still fever after day 3 after surgery, whether there is intracranial infection should be considered.

Improved strategy for post-traumatic hydrocephalus following decompressive craniectomy: Experience of a single center

Background

Patients with head trauma may develop hydrocephalus after decompressive craniectomy. Many studies have referred one-stage cranioplasty (CP) and ventriculoperitoneal shunt (VPS) was applied to treat cranial defect with post-traumatic hydrocephalus (PTH), but the safety and efficiency of the procedure remain controversial.

Methods

This is a retrospective cohort study including 70 patients of PTH following decompressive craniectomy who underwent simultaneous (50) and separated (20) procedures of cranioplasty and VPS from March 2014 to March 2021 at the authors' institution with at least 30 days of follow-up. Patient characteristics, clinical findings, and complications were collected and analyzed.

Results

Fifty patients with PTH underwent improved simultaneous procedures and 20 patients underwent staged surgeries. Among the cases, the overall complication rate was 22.86%. Complications suffered by patients who underwent one-stage procedure of CP and VPS did not differ significantly, compared with patients in the group of staged procedures (22% vs. 25%, p = 0.763). The significant difference was not observed in the two groups, regarding the complications of subdural/epidural fluid collection (4%/6% vs. 0/2%, p = 1.000/1.000), epidural hemorrhage (6% vs. 4%, p = 0.942), dysfunction of shunting system (0 vs. 2%, p = 0.286), postoperative seizure (8% vs. 4%, p = 1.000), and reoperation case (0 vs. 2%, p = 0.286). No case of subdural hemorrhage, incision/intracranial/abdominal infection, shunting system dysfunction, or reoperation was observed in the group of simultaneous procedure. Complications including subdural/epidural fluid collection, subdural hemorrhage, and incision/intracranial infection were not shown in the case series of the staged procedure group.

Conclusion

The improved simultaneous procedure of cranioplasty and VPS is effective and safe to treat cranial defect and post-traumatic hydrocephalus with low risk of complications.

[Surgical treatment of patients with skull defects and cerebrospinal fluid flow disorders after previous decompressive craniectomy]

Decompressive craniectomy (DC) is performed for refractory intracranial hypertension following severe traumatic brain injury, vascular and oncological diseases. This fact increases the number of patients with extensive and giant skull defects. Cerebrospinal fluid (CSF) flow disorders after DC are often accompanied by ventriculomegaly. However, only some patients with ventriculomegaly have hydrocephalus and require CSF bypass procedures. Differentiation of post-traumatic hydrocephalus requiring surgical treatment and atrophic dilation of ventricular system «ex vacuo» caused by brain injury is still an important issue. Skull sealing as a way to normalize CSF circulation and eliminate hydrocephalus is also an open question. Currently, there is no unified approach to patients with extensive and giant cranial defects combined with post-traumatic hydrocephalus. There is no unified algorithm for sequence of reconstructive and CSF bypass operations in these patients. Literature data on risks of infectious complications for different surgical strategies are controversial.

Is simultaneous cranioplasty with cerebrospinal fluid shunts implantation as safe as staged procedures?

Objective

The combination of cranioplasty and ventriculoperitoneal shunt is a therapeutic strategy for patients with hydrocephalus after decompressive craniectomy (DC). However, the efficacies of simultaneous vs. staged surgery in reducing postoperative complications have not been conclusively determined. This was a meta-analysis of relevant studies to assess whether simultaneous surgery significantly reduces postoperative complication risks, compared to staged surgery.

Methods

We systematically searched PubMed, Embase, Cochrane, Web of science databases for studies (published by 11 May 2022) comparing patients undergoing concurrent and staged cranioplasty and ventriculoperitoneal shunt. Our main endpoints were; overall postoperative complications, postoperative bleeding, postoperative infection and reoperation. We assessed the pooled data using a random effects model to compare complication rates using odds ratios (ORs) and 95% confidence intervals (CIs).

Results

Of the 494 identified studies, 12 were included in our analysis (N = 651 participants). Compared to staged surgery, concurrent surgery increased the relative risk for overall complications (pooled OR: 2.00; 95% CI: 1.10–3.67), however, it did not increase the relative risks for postoperative bleeding, postoperative infection or reoperation. Subgroup analysis revealed that in the Asian population, concurrent surgery increased the relative risks for overall complications (staged vs. concurrent group: OR: 2.41, 95% CI: 1.51–3.83, I² = 0.0%) and postoperative infections (staged vs. concurrent group: OR: 2.35, 95% CI: 1.06–5.21, I² = 31.8%).

Conclusion

Compared to staged surgery, concurrent surgery increases the overall complication rates. However, differences between the two therapeutic approaches in terms of postoperative bleeding, postoperative infection, or reoperation are insignificant. Simultaneous surgery was associated with increased overall post-operative complications and post-operative infection rates in the Asian population.

A Clinical Study on Individualized Surgical Scheme of Hydrocephalus Complicated With Skull Defect

OBJECTIVE

This study intends to discuss the individualized selection of surgical scheme of hydrocephalus complicated with skull defect.

METHODS

A total of 141 patients with hydrocephalus complicated with skull defect in our hospital from January 2012 to December 2018 were the main subjects of this study. Among these 141 patients, 78 patients underwent shunt and skull repair surgery in our hospital. In the present study, according to the classification of bone window tension, and combined with factors that affect the operation, different surgical schemes were selected, namely, repair surgery in the first phase and shunt surgery in the second phase, or simultaneous surgery, or shunt surgery in the first phase and repair surgery in the second phase.

RESULTS

The results of the present study show that an individualized surgical scheme can allow for the operation of hydrocephalus complicated with skull defect, without increasing the risk of complications, such as shunt infection, epidural hematoma, etc.

CONCLUSIONS

The surgical scheme for hydrocephalus complicated with skull defect differs in clinic.

Clinical Study of Cranioplasty Combined With Ipsilateral Ventriculoperitoneal Shunt in the Treatment of Skull Defects With Hydrocephalus

OBJECTIVE

To explore the clinical effect and safety of cranioplasty combined with ipsilateral ventriculoperitoneal shunts in the treatment of skull defects with hydrocephalus.

METHODS

The clinical data of 78 patients with skull defects with hydrocephalus were analyzed retrospectively. All patients were treated with cranioplasty and ventriculoperitoneal shunts in 1 stage, including 35 cases of cranioplasty combined with ipsilateral ventriculoperitoneal shunts (ipsilateral operation group) and 43 cases of contralateral operations (contralateral operation group).

RESULTS

The incision length (28.97 ± 4.55 cm), operation time (139.00 ± 42.27 minutes), and intraoperative hemorrhage (174.57 ± 79.35 mL) in the ipsilateral operation group were significantly better than those in the contralateral operation group (respectively they were 37.15 ± 5.83 cm, 214.07 ± 34.35 minutes, and 257.21 ± 72.02 mL), and the difference was statistically significant (t = 6.786, 8.656, and 4.815, all P < 0.05). The degree of postoperative hydrocephalus was significantly improved in both groups, but there was no statistically significant difference in the degree of hydrocephalus between the 2 groups (P > 0.05). Among the postoperative complications, there was no statistically significant difference in infection, epilepsy, subdural effusion, titanium plate effusion, or excessive cerebrospinal fluid drainage between the 2 groups (P > 0.05), but the incidence of intracranial hemorrhage in the ipsilateral operation group (2.86%) was significantly lower than that in the contralateral operation group (20.93%, χ2 = 4.138, P = 0.042). The postoperative Glasgow Coma Scale scores of the 2 groups were improved compared with those before the operation (P < 0.05), and there was no statistically significant difference in the postoperative Glasgow Coma Scale scores (P > 0.05). At 6 months after surgery, there was no statistically significant difference in Glasgow Outcome Scale effectiveness between the 2 groups (χ2 = 0.005, P = 0.944).

CONCLUSIONS

Cranioplasty combined with ipsilateral ventriculoperitoneal shunt has the same therapeutic effect as a contralateral operation, but it has the advantage of a short operation time, less intraoperative trauma, less bleeding, and less risk of intracranial hemorrhage, which is suitable for clinical applications.

Consensus statement from the international consensus meeting on post-traumatic cranioplasty

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.

Simultaneous cranioplasty and ventriculoperitoneal shunt placement in patients with traumatic brain injury undergoing unilateral decompressive craniectomy

Hydrocephalus is a common complication after decompressive craniectomy (DC) in patients with traumatic brain injury (TBI). However, the strategy of managing TBI patients with a cranial defect and hydrocephalus remains controversial. Placement of a ventriculoperitoneal shunt (VPS) in patients with a cranial defect and hydrocephalus may aggravate sinking skin flap overlying the cranial defect and result in syndrome of sinking skin flap (SSSF) that causes neurological deterioration. A retrospective analysis of 49 TBI patients who developed hydrocephalus after unilateral DC was undertaken to investigate the safety of simultaneous cranioplasty and VPS placement, and the incidence of SSSF after VPS placement. Among these patients, 17 patients underwent simultaneous cranioplasty and VPS placement, and 32 patients underwent staged cranioplasty and VPS placement. The overall complication rate was 9.3% (3/32) in staged group and 29.4% (5/17) in simultaneous group, respectively. There was no statistically significance between two study groups regarding overall complication (p = 0.11) and reoperation rate (p = 0.47). Two patients with severe brain bulging in staged group developed SSSF after placement of a nonprogrammable VPS. Our study showed that simultaneous cranioplasty and VPS placement may be safe in TBI patients with a cranial defect and hydrocephalus. However, due to the contradictory results about the safety of simultaneous cranioplasty and VPS placement in the literatures, neurosurgeons should carefully consider whether patients are suitable for such treatment. In patients planning to undergo VPS placement first, a programmable shunt may be a better choice for the possibility of SSSF after shunt placement.

Comparison of Postoperative Surgical-Site Infection and Symptomatic Intracranial Hemorrhage between Staged and Simultaneous Cranioplasty with Ventriculoperitoneal Shunt Placement: A Meta-Analysis

Objective

Consensus about the sequence of cranioplasty and ventriculoperitoneal shunt placement to reduce postoperative complications has not been established. This meta-analysis investigated and collated further evidence to determine whether staged cranioplasty with ventriculoperitoneal shunt placement would significantly reduce the risk of postoperative surgical-site infection (SSI) and symptomatic intracranial hemorrhage.

Methods

Two independent reviewers identified articles and extracted the data of patients who underwent cranioplasty and ventriculoperitoneal shunt placement from PubMed, Embase, and Cochrane Central Register of Controlled Trials. A random effects model was used to compare the complication rates using odd ratios (ORs) and 95% confidence intervals (CIs). A meta-regression analysis for traumatic brain injury (TBI) was additionally performed.

Results

Data from 7 studies with 391 patients were consecutively included. The meta-analysis revealed that staged surgery was significantly associated with lower rates of SSI after decompressive craniectomy (staged group vs. simultaneous group: 6.2% vs. 23.7%, OR: 2.72, 95% CI: 1.46–5.06, I²=2.4%, p=0.407). Pooled analysis did not indicate a statistically significant difference between the 2 groups for symptomatic intracranial hemorrhage (staged group vs. simultaneous group: 10.4% vs. 23.0%, OR: 1.66, 95% CI: 0.74–3.73, I²=0.0%, p=0.407). The meta-regression analysis did not indicate any modifying effect of TBI on postoperative SSI development (p=0.987).

Conclusion

This meta-analysis indicated that staged surgery is significantly associated with a lower rate of postoperative SSI as compared with simultaneous surgery, but there is no difference in symptomatic intracranial hemorrhage. Additionally, there is no modifying effect of TBI on SSI.

Cranioplasty Following Decompressive Craniectomy

Cranioplasty (CP) after decompressive craniectomy (DC) for trauma is a neurosurgical procedure that aims to restore esthesis, improve cerebrospinal fluid (CSF) dynamics, and provide cerebral protection. In turn, this can facilitate neurological rehabilitation and potentially enhance neurological recovery. However, CP can be associated with significant morbidity. Multiple aspects of CP must be considered to optimize its outcomes. Those aspects range from the intricacies of the surgical dissection/reconstruction during the procedure of CP, the types of materials used for the reconstruction, as well as the timing of the CP in relation to the DC. This article is a narrative mini-review that discusses the current evidence base and suggests that no consensus has been reached about several issues, such as an agreement on the best material for use in CP, the appropriate timing of CP after DC, and the optimal management of hydrocephalus in patients who need cranial reconstruction. Moreover, the protocol-driven standards of care for traumatic brain injury (TBI) patients in high-resource settings are virtually out of reach for low-income countries, including those pertaining to CP. Thus, there is a need to design appropriate prospective studies to provide context-specific solid recommendations regarding this topic.

The Conundrum of Ventricular Dilatations Following Decompressive Craniectomy: Is Ventriculoperitoneal Shunt, The Only Panacea?

Introduction:

Ventriculomegaly and hydrocephalus (HCP) are sometimes a bewildering sequela of decompressive craniectomy (DC). The distinguishing criteria between both are less well defined. Majority of the studies quoted in the literature have defined HCP radiologically, rather than considering the clinical status of the patient. Accordingly, these patients have been treated with permanent cerebrospinal fluid (CSF) diversion procedures. We hypothesize that asymptomatic ventriculomegaly following DC should undergo aspiration with cranioplasty and be followed up regularly.

Materials and Methods:

All patients with post-DC who were scheduled for cranioplasty and satisfied the radiological criteria for HCP were included. These patients were categorized into two groups. Group 1 included ventriculomegaly with clinical signs attributable to HCP and Group 2 constituted ventriculomegaly but no clinical signs attributable to HCP. All patients in Group 1 underwent ventriculoperitoneal shunt followed by cranioplasty, whereas all patients in Group 2 underwent cranioplasty along with simultaneous ventriculostomy and temporary aspiration of the lateral ventricle. All patients were regularly followed as the outpatient basis.

Results:

There were 21 patients who developed ventriculomegaly following DC. There were 10 patients in Group 1 and 11 patients in Group 2. The average duration of follow-up was from 6 months to 2 years. Two patients in the shunt group - (group 1) had over drainage and required revision. One patient in aspiration group - (group 2) required permanent CSF diversion.

Conclusions:

Cranioplasty with aspiration is a viable option in selected group of patients in whom there is ventriculomegaly but no signs or symptoms attributable to HCP.

Massive Brain Swelling and Death After Cranioplasty: A Systematic Review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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