Cranioplasty After Postinjury Decompressive Craniectomy: Is Timing of the Essence?

Beauchamp, Kathryn M.; Kashuk, Jeffry L.; Moore, Ernest E.; Bolles, Gene; Rabb, Craig H.; Seinfeld, Joshua; Szentirmai, Oszkar; Sauaia, Angela

doi:10.1097/ta.0b013e3181e491c2

Cited by 148 publications

(112 citation statements)

References 19 publications

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“…Aseptic resorption of the reimplanted flap is considered a particular problem, having been described in up to 50% of patients, and although age, fragmentation, and shunt dependency have been postulated as possible risk factors, the causes remain unclear. [2][3][4][5]9,18,23,24 Another possible influence on bone flap necrosis is storage of the bone flaps. Some authors have reported a higher incidence of aseptic bone resorption with cryoconserved flaps than with bone flaps stored in abdominal subcutaneuous fat.…”

Section: Discussionmentioning

confidence: 99%

Cranioplasty after decompressive craniectomy: is there a rationale for an initial artificial bone-substitute implant? A single-center experience after 631 procedures

Schwarz¹,

Dünisch²,

Walter³

et al. 2016

JNS

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OBJECT The complication rate for cranioplasty after decompressive craniectomy is higher than that after other neurosurgical procedures; aseptic bone resorption is the major long-term problem. Patients frequently need additional operations to remove necrotic bone and replace it with an artificial bone substitute. Initial implantation of a bone substitute may be an option for selected patients who are at risk for bone resorption, but this cohort has not yet been clearly defined. The authors’ goals were to identify risk factors for aseptic bone flap necrosis and define which patients may benefit more from an initial bone-substitute implant than from autograft after craniectomy. METHODS The authors retrospectively analyzed 631 cranioplasty procedures (503 with autograft, 128 with bone substitute) by using a stepwise multivariable logistic regression model and discrimination analysis. RESULTS There was a significantly higher risk for reoperation after placement of autograft than after placement of bone substitute; aseptic bone necrosis (n = 108) was the major problem (OR 2.48 [95% CI1.11–5.51]). Fragmentation of the flap into 2 or more fragments, younger age (OR 0.97 [95% CI 0.95–0.98]; p < 0.001), and shunt-dependent hydrocephalus (OR 1.73 [95% CI1.02–2.92]; p = 0.04) were independent risk factors for bone necrosis. According to discrimination analysis, patients younger than 30 years old and older patients with a fragmented flap had the highest risk of developing bone necrosis. CONCLUSIONS Development of bone flap necrosis is the main concern in long-term follow-up after cranioplasty with autograft. Patients younger than 30 years old and older patients with a fragmented flap may be candidates for an initial artificial bone substitute rather than autograft.

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Section: Discussionmentioning

confidence: 99%

Cranioplasty after decompressive craniectomy: is there a rationale for an initial artificial bone-substitute implant? A single-center experience after 631 procedures

Schwarz¹,

Dünisch²,

Walter³

et al. 2016

JNS

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“…1). We defined EFC as low density fluid in the epidural space on brain CT scan Data from recent studies have indicated that cranioplasty following decompressive craniectomy was associated with a high complication rates, ranged from 16.4% to 34% 4,6,8,12) . However, these studies mainly analyzed on major complications including infection, hematoma formation, and bone flap resorption.…”

Section: Discussionmentioning

confidence: 99%

Epidural Fluid Collection after Cranioplasty : Fate and Predictive Factors

Lee

Kim

Kang

et al. 2011

J Korean Neurosurg Soc

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We conducted retrospective collection of demographic, clinical, and radiographic data in 59 patients who underwent a first cranioplasty following decompressive craniectomy during a period of 6 years, between January 2004 and December 2009. Patients underwent decompressive craniectomy for the control of increased intracranial pressure.The decision to undertake cranioplasty depended on the judgment of each individual surgeon. Although operative techniques of cranioplasty were different among neurosurgeons, bone flaps removed during the initial craniectomy were frozen and stored in bone bank. The previous scars were incised, and scalp flap was carefully detached from the underlying dura and brain. Any dural tears and defects were repaired. After achieving meticulous hemostasis in the epidural spaces with bipolar coagulation and hemostatic agents, circumferential and bone flap dural tack-up sutures were placed to reduce epidural dead space. The bone flap was replaced and fixed in place with microscrews and plates. In all patients, a closed epidural and subgaleal drainage system was left in place for 2 to 4 days. INTRODUCTIONDecompressive craniectomy is widely performed in patients suffering from medically refractory elevation of intracranial pressure and is known to improve clinical outcome 1,9,15) . The patients who survive after decompressive craniectomy need to undergo cranioplasty.The complications, including infection, hematoma, and bone graft resorption following cranioplasty have been well studied and considered as a significant cause of postoperative morbidity 6,8,11,12) . However, reports of epidural fluid collection (EFC) after cranioplasty are uncommon and limited to isolated case examples and small series 6,10) .In our neurosurgical practice, we treated patients who developed EFC following cranioplasty. We thus investigated the incidence of EFC and predictive factors associated with its development. Also, this study was focused on the presumptive mechanism of EFC de- Department of Neurosurgery, Eulji University School of Medicine, Nowon Eulji Hospital, Seoul, KoreaObjective : Infection and bone resorption are major complications of cranioplasty and have been well recognized. However, there are few clinical series describing the epidural fluid collection (EFC) as complication of cranioplasty. This study was planned to identify the predictive factors and fate of EFC after cranioplasty. Methods : We reviewed retrospectively the demographic, clinical, and radiographic data in 59 patients who underwent a first cranioplsty following decompressive craniectomy during a period of 6 years, from January 2004 to December 2009. We compared demographic, clinical, and radiographic factors between EFC group and no EFC group. The predictive factors associated with the development of EFC were assessed by logistic regression analysis. Results : Overall, 22 of 59 patients (37.3%) suffered from EFC following cranioplasty. EFC had disappeared (n=6, 31.8%) or regressed (n=6, 31.8%) over time on follow up brain computed tomogr...

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“…4,11 Some studies have shown that patients who had early cranioplasties had better functional outcomes, 3,5,46 whereas several others have shown that early cranioplasty (3-6 months) is associated with higher complication rates and worse outcomes, 3,4,[8][9][10]26,35,42 including hydrocephalus, increased intracranial pressure, and infection. Other studies have shown that late cranioplasty is associated with a higher risk of complications.…”

Section: Timing Infection and Hydrocephalusmentioning

confidence: 99%

Complications following cranioplasty: incidence and predictors in 348 cases

Zanaty

Chalouhi

Starke

et al. 2015

JNS

182

156

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C ranioplasty is more than a cosmetic repair of cranial defects; it is part of the rehabilitation process following a patient's neurological injury. Recent studies have shown that cranioplasty may improve the patient's psychological status, social performance, and neurocognitive functioning. 1,14,19,21 The factors that contribute to periprocedural complications, including patients' demographic information, comorbidities, surgical procedure, and under lying disease, need to be thoroughly evaluated. Previous studies that were intended to answer these questions were limited by their design or by their sample size. Our aim was to evaluate risk factors that predispose patients to an increased risk of cranioplasty complications. Recent evidence in the literature emphasizes patient-specific factors over surgery-specific factors as major predictors of cranioplasty complications. 47,51 It is also becoming evident that surgical treatment for cranioplasty complications is associated with additional surgical procedures. 17,46 In this study, we evaluated the association between patient-specific factors and complications folabbreviatioNs AED = antiepileptic drug; DHC = decompressive hemicraniectomy; DM = diabetes mellitus; SAH = subarachnoid hemorrhage; TBI = traumatic brain injury. obJect The factors that contribute to periprocedural complications following cranioplasty, including patient-specific and surgery-specific factors, need to be thoroughly assessed. The aim of this study was to evaluate risk factors that predispose patients to an increased risk of cranioplasty complications and death. methods The authors conducted a retrospective review of all patients at their institution who underwent cranioplasty following craniectomy for stroke, subarachnoid hemorrhage, epidural hematoma, subdural hematoma, and trauma between January 2000 and December 2011. The following predictors were tested: age, sex, race, diabetic status, hypertensive status, tobacco use, reason for craniectomy, urgency status of the craniectomy, graft material, and location of cranioplasty. The cranioplasty complications included reoperation for hematoma, hydrocephalus postcranioplasty, postcranioplasty seizures, and cranioplasty graft infection. A multivariate logistic regression analysis was performed. Confidence intervals were calculated as the 95% CI. results Three hundred forty-eight patients were included in the study. The overall complication rate was 31.32% (109 of 348). The mortality rate was 3.16%. Predictors of overall complications in multivariate analysis were hypertension (OR 1.92, CI 1.22-3.02), increasing age (OR 1.02, CI 1.00-1.04), and hemorrhagic stroke (OR 3.84,). Predictors of mortality in multivariate analysis were diabetes mellitus (OR 7.56, CI 1.56-36.58), seizures (OR 7.25, CI 1.238-42.79), bifrontal cranioplasty (OR 5.40,, and repeated surgery for hematoma evacuation (OR 13.00, CI 1.51-112.02). Multivariate analysis was also applied to identify the variables that affect the development of seizures, the need for reoperation for hem...

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Cranioplasty After Postinjury Decompressive Craniectomy: Is Timing of the Essence?

Cited by 148 publications

References 19 publications

Cranioplasty after decompressive craniectomy: is there a rationale for an initial artificial bone-substitute implant? A single-center experience after 631 procedures

Cranioplasty after decompressive craniectomy: is there a rationale for an initial artificial bone-substitute implant? A single-center experience after 631 procedures

Epidural Fluid Collection after Cranioplasty : Fate and Predictive Factors

Complications following cranioplasty: incidence and predictors in 348 cases

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