Cranioplasty for patients with disorders of consciousness

Abstract

Background: Cranioplasty (CP) is necessary for patients with disorders of consciousness (DOC) and skull defects. However, due to the complexity of these conditions, the surgical indications are conservative, and there are few published reports. This study aimed to assess the outcomes and complications of CP in patients with DOC, and to optimize the management of transcalvarial herniation (TCH) and hydrocephalus.Methods: A total of 87 patients with DOC who underwent CP at our center between December 2016 and April 2019 were selected. The patients were divided into traumatic brain injury (TBI) and non-TBI groups, and the complications, outcomes, and costs were compared. Factors associated with prognosis and surgical complications were identified using multivariate logistic regression analysis.Results: Postoperative complications occurred in 18 patients (20.7%). The complication rate was higher in the TBI group than in the non-TBI group (P=0.031). Preoperative ventriculoperitoneal shunt (VPS) was identified as a risk factor for incision complication (P=0.032), and non-traumatic cause tended to be a protective factor against postoperative hydrocephalus (P=0.055). One year after CP, 25 patients (28.7%) regained full consciousness [Extended Glasgow Outcome Scale (GOSE) ≥3] and 10 patients (11.5%) achieved partial self-care (GOSE =4). Multivariate analyses revealed that minimally conscious state (MCS) vs. vegetative state/unresponsive wakefulness syndrome (VS/UWS) (P=0.000) and early CP (P=0.023) were potential indicators for the recovery of consciousness.Conclusions: Our findings suggest that CP is safe in patients with DOC and may be beneficial for the recovery of consciousness. Early surgery and surgery for MCS provide better results. Timely CP in patients with TCH can help to reduce preoperative VPS, control incision complications, and detect and intervene in potential hydrocephalus.

When the practice does not meet the theory: results from an Italian survey on the clinical and pathway management of inpatients with decompressive craniectomy or cranioplasty admitted to rehabilitation

“… 21 , 33 However, VPS before DC may be associated with VPS hyper drainage, and VPS before or contemporary to CP may be associated with an increased risk of neurosurgical complications. 38 In our series, our interviewees reported that VPS was performed before CP in 15.9% of cases, a value similar to that (13.8%) reported by Dang et al 38 Also, our survey reported severe complications in 50% of the cases, thus explaining the strong disagreement with large ES between the ICC statement indicating the opportunity to perform VPS after CP in the case of hydrocephalus and the neurorehabilitation physicians’ perception of the actual practice. Considering this evidence, in patients with DC in whom the development of HC is suspected, CP should be performed as soon as possible in the absence of contraindications.…”

Can Cranioplasty Be Considered a Tool to Improve Cognitive Recovery Following Traumatic Brain Injury? A 5-Years Retrospective Study

“…Indeed, early CP was found to improve cognitive function by restoring CSF hydrodynamics, intracranial compliance, and cerebral blood flow when neurocognitive changes are at their peak [26]. However, when is the right timing to perform CP is still controversial because it variably affects functional recovery and is also a risk factor for infections and other complications [32,33]. Archavlis et al [34], in a 10-year retrospective study on a cohort of 200 patients, observed that patients who performed CP within 7 weeks from the decompressive craniectomy had an improvement of 78% (measured by the GCS) versus the 46% observed in patients who underwent cranioplasty after 7-12 weeks and only 12% after 12 weeks.…”

Deep brain stimulation improves electroencephalogram functional connectivity of patients with minimally conscious state

“…5 , 8 Some patients with MCS may even gradually regain consciousness and motor functions after effective rehabilitation and eventually return to society. 9 …”

“…They are more responsive to stimuli, such as auditory stimuli and electrical stimulation, 6,7 show greater activation of cortical metabolic rates, and are more likely to regain consciousness with natural recovery or rehabilitation due to preservation of their brain function 5,8 . Some patients with MCS may even gradually regain consciousness and motor functions after effective rehabilitation and eventually return to society 9 …”

“…5,8 Some patients with MCS may even gradually regain consciousness and motor functions after effective rehabilitation and eventually return to society. 9 Neuromodulatory interventions have been used in the treatment of patients with DOC. [10][11][12] Transcranial direct current stimulation (tDCS), repeated transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS), spinal cord electrical stimulation (SCS), and vagal nerve stimulation were shown to improve the consciousness level of these patients.…”