Cranioplasty of Large Cranial Defect at an Early Stage After Decompressive Craniectomy Performed for Severe Head Trauma

Abstract

Large cranial defects resulting from decompressive craniectomy performed for refractory intracranial hypertension after head trauma is one of the indications for cranioplasty, and this procedure is commonly performed 3 months after craniectomy. However, the large cranial defect would lead to the kinds of complications early during the phase of these patients' recovery, which would go against rehabilitation. This study retrospectively reviewed 23 patients undergoing early cranioplasty (5-8 weeks after craniectomy) in the last 4 years with a detailed choice of patients, outcome of complications after head trauma and large craniectomy, as well as assessment of prognosis. The early outcome (1 month later) revealed most of the patients who had conscious disturbance before the cranioplasty recovered their consciousness and presented an improved neurologic function. The long-dated prognosis (18 months later) revealed that 17 patients were good (independent patients) in this series (74%), whereas four patients survived with a severe disability (17%) and two remained in a vegetative state (9%). No dead patients or intracranial infection after the procedure were found in this study. Most patients' complications were relieved after the cranioplasty with improvements of symptoms or image of computed tomography scan. In conclusion, we consider that with the appropriate choice of patients and materials, early cranioplasty for large cranial defects after decompressive craniectomy would be safe and helpful for the improvement of patients' neurologic function and prognosis. To our knowledge, this series may be the first detailed report in English about early cranioplasty after decompressive craniectomy. We are going to perform prospective and retrospective contrastive studies to further confirm the effects of this procedure on the patients with large cranial defects after decompressive craniectomy.

Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases

“…Most significant may be the fact that those patients treated early (0-48 days) or those treated late (≥ 137 days) did not have a significantly increased risk. This finding, along with the reports by Carvi et al 6 and Liang et al, 37 may negate previous dictum suggesting cranioplasty needing to be performed during a certain time point postcraniectomy. Again, this conclusion is limited and requires further analysis in a prospective study.…”

“…56 However, because this study included only patients with penetrating head injuries, the results may not apply to patients who have undergone decompressive craniectomy in the setting of nonpenetrating injury. Recently Carvi et al 6 and Liang et al 37 have suggested that cranioplasty following decompressive craniectomy for blunt injury can be performed sooner than previously suggested. The possible advantages of performing cranioplasty in a more timely fashion may include easier dissection of tissue planes, as well as prevention of negative postcraniectomy sequelae including posttraumatic hydrocephalus, 8 syndrome of the trephined, 31,46 or other neurological complications.…”

“…27,66 Once patients undergo decompressive craniectomy, those who survive are obligated to undergo a second procedure for surgical cranial reconstruction, that is, cranioplasty. Much of the modern literature regarding cranioplasty following decompressive craniectomy is based on case series that emphasize the technical aspects of the procedure such as the use of materials, 2,3,9,10,12,14,26,30,33,35,[50][51][52]54,55,60,63,68,70,71 the use of techniques to store the bone flap prior to reconstruction, 16,19,24,25,43,48,49,72 the timing of surgical intervention, 6,37 or other specific modifications to either the craniectomy or cranioplasty procedure, which may influence the cranioplasty. 20,28,34,36,38,41,47,67 There are relatively few modern-day large clinical series describing the clinical outcomes and perioperative complications of cranioplasties in the setting of nonpenetrating traumatic brain injury and large vessel infarction.…”

Complications following cranioplasty: incidence and predictors in 348 cases

“…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.…”

Complications of decompressive craniectomy for traumatic brain injury

“…98,99 However, Liang et al 46 have recently shown that titanium mesh cranioplasty can be performed as early as 5-8 weeks after decompressive craniectomy without untoward infectious complications.…”