External cranioplasty for the syndrome of the trephined – Case report

Sarti, Talita Helena Martins; Paz, Daniel; Diniz, Juliete Melo; Kim, Isaque Hyung Tong; Rodrigues, Thiago; Cavalheiro, Sérgio; Suriano, Ítalo Capraro

doi:10.1016/j.inat.2020.101065

Cited by 3 publications

(4 citation statements)

References 8 publications

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“…A large skull defect creates an intracranial and atmospheric pressure imbalance with secondary metabolic alterations, as well as hydrodynamic and cerebral blood flow changes. 4,15 Our customized external cranioplasty provides a safe, noninvasive option for restoring intracranial physiology in challenging cases when it is not possible to perform definitive cranioplasty. This technique aims to restore the equilibrium between intracranial and atmospheric pressure imbalance and is, thus, expected to improve the patient's symptoms.…”

Section: Discussionmentioning

confidence: 99%

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Customized External Cranioplasty for Management of Syndrome of Trephined in Nonsurgical Candidates

Ghinda

Stewart²,

Totis

et al. 2023

Operative Neurosurgery

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BACKGROUND: Craniectomies represent a lifesaving neurosurgical procedure for many severe neurological conditions, such as traumatic brain injury. Syndrome of trephined (SoT) is an important complication of decompressive craniectomy, and cranial reconstruction is the definitive treatment. However, many patients cannot undergo surgical intervention because of neurological status, healing of the primary surgical wound, or the presence of concurrent infection, which may prevent cranioplasty. OBJECTIVE: To offer a customized external cranioplasty option for managing skull deformities for patients who could not undergo surgical intervention for definitive cranioplasty. METHODS: We describe the design and clinical application of an external cranioplasty for a patient with a medical history of intractable epilepsy, for which she underwent multiple right cerebral resections with a large resultant skull defect and SoT. RESULTS: The patient had resolution of symptoms and restoration of a symmetrical skull contour with no complication at 17 months. CONCLUSION: Customized external cranioplasty can improve symptoms associated with SoT for patients who cannot undergo a definitive cranioplasty. In addition, inset monitoring options, such as electroencephalography or telemetric intracranial pressure sensors, could be incorporated in the future for comprehensive monitoring of the patient's neurological condition.

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Section: Discussionmentioning

confidence: 99%

“…13 There is currently no protocol to prevent the clinical and radiological deterioration attributed to SoT, and there are only case reports of plaster molded to the patient's head for the management of severe, life-threatening SoT. 14,15 In this technical note, we report a novel noninvasive technique to manage and potentially prevent SoT.…”

mentioning

confidence: 99%

Customized External Cranioplasty for Management of Syndrome of Trephined in Nonsurgical Candidates

Ghinda

Stewart²,

Totis

et al. 2023

Operative Neurosurgery

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“…These include custom-made helmets, the placement of external metal plates using transcortical screws, and customized three-dimensional–printed external plates. 4 , 10 , 11 The plaster cast and wound VAC address the crucial issue of time and reduce the technical components and materials required, allowing neurosurgical teams to utilize a simple, easy-to-use device for addressing SSFS symptoms.…”

Section: Discussionmentioning

confidence: 99%

“…A widespread misconception is that the concavity of the skin flap and subsequent brain compression arise because of exposure to atmospheric pressure. [4][5][6] However, this is unequivocally refuted in Hakim's thesis, which asserts that it is directly related to changes in cerebrospinal fluid (CSF) pressure. 7 Furthermore, removing a patient's bone flap has been shown to cause in cerebral metabolism, CSF flow dynamics, and cerebral hemodynamics.…”

mentioning

confidence: 99%

Vacuum-assisted scalp repositioning: a novel temporizing approach to acute sinking skin flap syndrome. Illustrative cases

Courville,

Marquez,

Homma

et al. 2023

Journal of Neurosurgery: Case Lessons

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BACKGROUND This report describes the use of a novel approach to address acute sinking skin flap syndrome (SSFS), a postcraniectomy complication arising from brain dysfunction beneath the skull defect. The authors present a case series of two patients, emphasizing the prospective application of an external plaster cast in tandem with a vacuum-assisted closure (VAC) device (wound VAC) to promptly reposition the scalp and relieve brain compression. OBSERVATIONS Following intervention, one patient showed immediate neurological improvement, with complete resolution of symptoms within hours. Conversely, the second patient developed nonconvulsive status epilepticus. Computed tomography scans postintervention validated the successful scalp repositioning and mass effect resolution in both instances. This temporary approach proved successful in one patient with moderate symptoms, serving as a bridge to cranioplasty. LESSONS The integration of an external plaster cast and wound VAC offers a cost-effective and prompt solution for patients with acute SSFS pending cranioplasty. Appropriate patient selection and heightened caution for those with severe symptoms should be exercised.

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3D printed customised external cranial plate in a patient with syndrome of trephined: ‘a case report’

et al. 2021

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Background Syndrome of the trephined is a well-recognised phenomenon that occurs in patients following a craniectomy. It is associated with several symptoms, including headaches, motor impairments, cognitive disorders and reduced consciousness. Treatment for the syndrome usually involves replacing the skull defect. Case Study A 71-year-old male underwent a left-sided craniectomy after being diagnosed with biopsy-confirmed invasive squamous cell carcinoma with associated skull erosion. Subsequently, he developed a severe case of syndrome of the trephined (SoT,) resulting in having to lie flat to prevent the motor component of the Glasgow Coma Score (GCS) falling from M5/6 (E3/4 Vt M5/6) to M1 (E3/4 Vt M1) on sitting to 30 degrees. Unfortunately, due to ongoing chest sepsis and physical frailty, he was unable to undergo a cranioplasty. Therefore, to aid in clinical stabilisation, the treating physicians and clinical engineering teams designed and manufactured a prosthesis on-site, allowing rapid patient treatment. The prosthesis led to the patient being able to sit up to 30 degrees without the motor component of the GCS falling from M6 to M1 (E4 VT M6). Conclusion Clinical improvements were demonstrated with definitive neurological improvement after applying the external cranial plate in clinical outcome measures and radiographically. Furthermore, we have shown that rapid prototyping technology provides a flexible solution to synthesise bespoke medical prostheses with the correct expertise and regulatory framework.

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External cranioplasty for the syndrome of the trephined – Case report

Cited by 3 publications

References 8 publications

Customized External Cranioplasty for Management of Syndrome of Trephined in Nonsurgical Candidates

Customized External Cranioplasty for Management of Syndrome of Trephined in Nonsurgical Candidates

Vacuum-assisted scalp repositioning: a novel temporizing approach to acute sinking skin flap syndrome. Illustrative cases

3D printed customised external cranial plate in a patient with syndrome of trephined: ‘a case report’

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