Cranioplasty: morbidity and failure

Honeybul, Stephen; Ho, Kwok M.

doi:10.1080/02688697.2016.1187259

Cited by 67 publications

(57 citation statements)

References 40 publications

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“…10 A frequently observed long-term complication of AC is bone flap resorption (BFR), an aseptic, osteolytic process leading to significant disintegration of the reimplanted bone in up to 54.4% of pediatric patients 4,21,25 and up to 30.4% of patients in mixed cohorts. 5,8,9,17,22,35 BFR can lead to visible and palpable, aesthetically disfiguring defects, and in its advanced form it results in a loss of the bony coverage of the brain. Revision surgery with implantation of a synthetic bone flap is required in severe cases of BFR.…”

Section: Clinical Articlementioning

confidence: 99%

ACE-inhibitors: a preventive measure for bone flap resorption after autologous cranioplasty?

Schütz¹,

Murek

Stieglitz

et al. 2019

Journal of Neurosurgery

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OBJECTIVEDecompressive craniectomy (DC) is an established treatment for refractory intracranial hypertension. It is usually followed by autologous cranioplasty (AC), the reinsertion of a patient’s explanted bone flap. A frequent long-term complication of AC is bone flap resorption (BFR), which results in disfigurement as well as loss of the protective covering of the brain. This study investigates risk factors for BFR after AC, including medical conditions and antihypertensive drug therapies, with a focus on angiotensin-converting enzyme inhibitors (ACEIs), which have been associated with a beneficial effect on bone healing and bone preservation in orthopedic, osteoporosis, and endocrinology research.METHODSIn this single-center, retrospective study 183 consecutive cases were evaluated for bone flap resorption after AC. Information on patient demographics, medical conditions, antihypertensive therapy, and BFR—defined as an indication for revision surgery established by a neurosurgeon based on clinical or radiographic assessments—was collected. A Kaplan-Meier analysis of time from AC to diagnosis of BFR was performed, and factors associated with BFR were investigated using the log-rank test and Cox regression.RESULTSA total of 158 patients were considered eligible for inclusion in the data analysis. The median follow-up time for this group was 2.2 years (95% CI 1.9–2.5 years). BFR occurred in 47 patients (29.7%), with a median time to event of 3.7 years (95% CI 3.3–4.1 years). An ACEI prescription was recorded in 57 cases (36.1%). Univariate Kaplan-Meier analysis and the log-rank test revealed that ACEI therapy (2-year event free probability [EFP] 83.8% ± 6.1% standard error vs 63.9% ± 5.6%, p = 0.02) and ventriculoperitoneal (VP) shunt treatment (2-year EFP 86.9% ± 7.1% vs 66% ± 5.0%, p = 0.024) were associated with a lower probability of BFR. Multiple Cox regression analysis showed ACEI therapy (HR 0.29, p = 0.012), VP shunt treatment (HR 0.278, p = 0.009), and male sex (HR 0.500, p = 0.040) to be associated with a lower risk for BFR, whereas bone fragmentation (HR 1.92, p = 0.031) was associated with a higher risk for BFR.CONCLUSIONSHypertensive patients treated with ACEIs demonstrate a lower rate of BFR than patients treated with other hypertensive medications and nonhypertensive patients. Our results are in line with previous reports on the positive influence of ACEIs on bone healing and preservation. Further analysis of the association between ACEI treatment and BFR development is needed and will be evaluated in a multicenter prospective trial.

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Section: Clinical Articlementioning

confidence: 99%

ACE-inhibitors: a preventive measure for bone flap resorption after autologous cranioplasty?

Schütz¹,

Murek

Stieglitz

et al. 2019

Journal of Neurosurgery

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“…Complications after cranioplasty were reported in approximately a third of the cases. [2][3][4] Massive brain swelling occurring after cranioplasty is a rare complication associated with high mortality, but is increasingly reported; the underlying cause remains unclear. [5][6][7][8][9][10][11] In this study, we report a case of fatal brain swelling after cranioplasty and discuss the possible mechanisms underlying this complication.…”

Section: Introductionmentioning

confidence: 99%

Massive Brain Swelling after Cranioplasty: A Case Report

Zhang

Pan

et al. 2019

J Neurol Surg A Cent Eur Neurosurg

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Background Cranioplasty is a common procedure in neurosurgery. It is usually performed following decompressive craniectomy (DC). However, complications may occur after the operation, such as massive brain swelling. Up to now, far too little attention has been given to this severe complication. We report one case of fatal cerebral swelling after cranioplasty and analyze the possible mechanism of this complication. Case Description The patient was a 40-year-old man who had a severe right basal ganglia cerebral hemorrhage and underwent DC ∼ 2 months before. One day before scheduled cranioplasty, a lumbar cerebrospinal fluid drainage was placed. The cranioplasty itself was uneventful. However, he gradually fell into a coma, and his right pupil was moderately dilated 20 hours after the surgery. A brain computed tomography (CT) scan indicated massive right cerebral edema with compressed right midbrain. The patient did not regain consciousness, and he remained quadriplegic. Conclusion It is necessary to increase awareness of complications of cranioplasty in high-risk patients. The lessons learned from this case include avoiding excessive drainage of cerebrospinal fluid. Patients with low-density lesions in the brain need to be treated with caution. Once the CT scan shows massive cerebral swelling, the patient has a poor prognosis.

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“…If on one hand CP may lead to notable improvements (Sancisi et al, ; Stiver, Wintermark, & Manley, ), on the other hand it may increase the possibility of infections, the risk of hydrocephalus (especially when performed later), and the possibility of developing the “trephined” syndrome (Stiver, Wintermark, & Manley, ), especially when operation time exceeding 90 min (Cho & Kang, ). Indeed, although the mortality rate after cranioplasty is rather low, research suggests that 1 out of 3 people has overall complications (Zanaty et al, ), especially seizures and infection (Honeybul & Ho, ). Timing of cranioplasty is therefore crucial even though the literature is divided.…”

Section: Introductionmentioning

confidence: 99%

Timing for cranioplasty to improve neurological outcome: A systematic review

et al. 2018

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IntroductionCranioplasty is a surgical technique applied for the reconstruction of the skullcap removed during decompressive craniectomy (DC). Cranioplasty improves rehabilitation from a motor and cognitive perspective. However, it may increase the possibility of postoperative complications, such as seizures and infections. Timing of cranioplasty is therefore crucial even though literature is controversial. In this study, we compared motor and cognitive effects of early cranioplasty after DC and assess the optimal timing to perform it.MethodsA literature research was conducted in PubMed, Web of Science, and Cochrane Library databases. We selected studies including at least one of the following test: Mini‐Mental State Examination, Rey Auditory Verbal Learning Test immediate and 30‐min delayed recall, Digit Span Test, Glasgow Coma Scale, Glasgow Outcome Scale, Coma Recovery Scale‐Revised, Level of Cognitive Functioning Scale, Functional Independence Measure, and Barthel Index.ResultsSix articles and two systematic reviews were included in the present study. Analysis of changes in pre‐ and postcranioplasty scores showed that an early procedure (within 90 days from decompressive craniectomy) is more effective in improving motor functions (standardized mean difference [SMD] = 0.51 [0.05; 0.97], p‐value = 0.03), whereas an early procedure did not significantly improve neither MMSE score (SMD = 0.06 [−0.49; 0.61], p‐value = 0.83) nor memory functions (SMD = −0.63 [−0.97; −0.28], p‐value < 0.001). No statistical significance emerged when we compared studies according to the timing from DC.ConclusionsIt is believed that cranioplasty performed from 3 to 6 months after DC may significantly improve both motor and cognitive recovery.

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Cranioplasty: morbidity and failure

Abstract: One key finding in this study is the reduction in infection rate that can occur when a single senior clinician performs the procedure and there is strict adherence to aseptic technique. This may result in a significant reduction in morbidity.

Cited by 67 publications

References 40 publications

ACE-inhibitors: a preventive measure for bone flap resorption after autologous cranioplasty?

ACE-inhibitors: a preventive measure for bone flap resorption after autologous cranioplasty?

Massive Brain Swelling after Cranioplasty: A Case Report

Timing for cranioplasty to improve neurological outcome: A systematic review

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