Recent Updates on Controversies in Decompressive Craniectomy and Cranioplasty: Physiological Effect, Indication, Complication, and Management

Malignant Cerebral Edema After Cranioplasty: A Case Report and Literature Insights

BACKGROUND Decompressive craniectomy is a common life-saving intervention in the setting of elevated intracranial pressure. Cranioplasty restores the calvarium and intracranial physiology once swelling recedes. Cranioplasty is often thought of as a low-risk intervention. However, numerous reports indicate that malignant cerebral edema (MCE) is an often-fatal complication of an otherwise uneventful cranioplasty. A careful review of the literature is needed to better understand this devastating condition. CASE REPORT A 41-year-old man presented after suffering a gunshot wound to the right frontal lobe. Upon initial evaluation, the patient had grossly visible brain matter, left-sided hemiparesis with a Glascow Coma Score (GCS) of 11, and vital signs concerning for elevated intracranial pressure. Computed tomography (CT) showed right-sided intraparenchymal and subarachnoid hemorrhage with a 5 mm leftward midline shift. The patient was taken to the operating room (OR) for right fronto-parietal craniectomy. Over the next 3 months, he recovered steadily and underwent PEEK cranioplasty on post-operative day 83. Pre-operative CT showed sunken skin flap syndrome with an 8-mm midline shift. Following an uneventful cranioplasty, he failed to regain consciousness. Examination revealed absent brainstem reflexes. CT showed global diffuse cerebral edema. The patient was declared brain dead. CONCLUSIONS Continued research is needed to better understand the pathophysiology of malignant cerebral edema so that future incidences may be prevented. A combination of negative-pressure suction drainage, sunken skin flap syndrome, and delayed time to cranioplasty likely play a significant role in the evolution of MCE. We urge neurosurgeons to consider the likelihood of MCE and adapt surgical planning accordingly.

A Retrospective Study on Subgaleal Fluid Collection After Titanium Mesh and Polyetheretherketone Cranioplasty

OBJECTIVE

Cranioplasty is a common neurosurgical procedure aimed at providing structural protection to cerebral tissues and enhancing neurological function. The choice of implant material, particularly polyetheretherketone (PEEK) and titanium mesh, significantly influences postoperative outcomes, including the incidence of subgaleal fluid collections (SFC). This study investigates the incidence of SFC associated with PEEK and titanium mesh in cranioplasty, identifying risk factors and implications for clinical practice.

METHODS

A retrospective analysis was conducted on 70 patients who underwent cranioplasty. The incidence of SFC, postoperative complications, and demographic data were collected and analyzed. Statistical comparisons were made between the 2 implant materials.

RESULTS

The incidence of SFC was significantly higher in the PEEK group (46.2%) compared to the titanium mesh group (20.5%) (P = 0.023). PEEK was identified as an independent risk factor for SFC. Additionally, approximately 60% of postoperative epidural hematoma cases presented with SFC, highlighting the importance of meticulous hemostasis during surgery. The overall reoperation rate was 5.7%, consistent with existing literature. Although diabetes mellitus did not show a statistically significant association with SFC (P = 0.064), its potential impact on postoperative complications warrants further investigation.

CONCLUSIONS

The selection of implant materials in cranioplasty significantly affects postoperative outcomes, with PEEK associated with a higher incidence of SFC. Careful material selection, particularly in patients with comorbidities, and meticulous surgical techniques are essential to improve patient outcomes. Future research should focus on the biological interactions between implant materials and cranial tissues to refine guidelines for clinical practice.

Astrocytoma Mimicking Herpetic Meningoencephalitis: The Role of Non-Invasive Multimodal Monitoring in Neurointensivism

Neuromonitoring is a critical tool for emergency rooms and intensive care units to promptly identify and treat brain injuries. The case report of a patient with status epilepticus necessitating orotracheal intubation and intravenous lorazepam administration is presented. A pattern of epileptiform activity was detected in the left temporal region, and intravenous Acyclovir was administered based on the diagnostic hypothesis of herpetic meningoencephalitis. The neurointensivist opted for multimodal non-invasive bedside neuromonitoring due to the complexity of the patient's condition. A Brain4care (B4C) non-invasive intracranial compliance monitor was utilized alongside the assessment of an optic nerve sheath diameter (ONSD) and transcranial Doppler (TCD). Based on the collected data, a diagnosis of intracranial hypertension (ICH) was made and a treatment plan was developed. After the neurosurgery team's evaluation, a stereotaxic biopsy of the temporal lesion revealed a grade 2 diffuse astrocytoma, and an urgent total resection was performed. Research suggests that monitoring patients in a dedicated neurologic intensive care unit (Neuro ICU) can lead to improved outcomes and shorter hospital stays. In addition to being useful for patients with a primary brain injury, neuromonitoring may also be advantageous for those at risk of cerebral hemodynamic impairment. Lastly, it is essential to note that neuromonitoring technologies are non-invasive, less expensive, safe, and bedside-accessible approaches with significant diagnostic and monitoring potential for patients at risk of brain abnormalities. Multimodal neuromonitoring is a vital tool in critical care units for the identification and management of acute brain trauma as well as for patients at risk of cerebral hemodynamic impairment.