Management of failed cranioplasty

Abstract

ABSTRACTa convalescence period (17). This cranioplasty procedure intends to achieve two goals; one is the cosmetic improvement and the other is the functional improvement (31). Cranioplasty is one of the world's most ancient surgical procedures. The earliest known case has been identified in Peru, where a skull was unearthed with a thin gold plate covering the trepanation hole. Various autografts, allografts and xenografts have been used over the years in attempt to restore cranial vault following trepanation or trauma (3).Decompressive craniectomy has potential complications which effect long-term outcome (18,36). A very important but mostly unconsidered complication is the neurological dysfunction that can occur due to the absence of bone flap and distortion of the brain under retracted scalp. This may lead █ InTRODuCTIOn D ecompressive craniectomy (DC) has been previously described for the acute management of traumatic brain injury (1), ischemic stroke (30), subarachnoid hemorrhage (16), intracranial infections (7), dural sinus thrombosis (12), inflammatory conditions (4) and tumors (2) to decrease intracranial pressure when life-threatening. Vital importance of DC in neurological emergencies has been well understood and established over the past two decades (10,19). Although this procedure is a very helpful tool in management of acute patients, may also lead to further requirement for reconstruction and complications.Patients survived from the above mentioned acute neurologic states require reconstruction of the cranial vault following AIM: Failed cranioplasty attempts may lead to numerous complications in a broad spectrum including cosmetic problems, infection, neurological deterioration and even death. Selection of the most appropriate surgical technique for second and further surgical attempts for these patients still remains a debate. We aimed to share our experience and technical pitfalls on management of failed cranioplasty, particularly for patients with large cranial defects. MATERIAL and METhODS:A retrospective data analysis of cranioplasty cases in our series was performed including the time period between 2002 and 2012. Patients required recurrent cranioplasty were analyzed in detail. RESuLTS:Totally, 101 patients underwent cranioplasty for bony defect. Of 101 patients, eleven required a revision surgery due to infection or spontaneous resorption of the bone flap. All patients underwent revision cranioplasty with pre-surgical plaster cast mold technique modified from previous studies and/or tissue expansion technique. Polymethyl-metacrylate (PMMA) was used as substitute for reconstructions. Mean follow-up was 36 months. Two out of eleven cases (18.1%) developed major complications, which led to further revision. At the end, a satisfactory reconstruction was achieved for all patients.COnCLuSIOn: Our modified molded plaster cast technique is a safe and cost-effective approach for the revision of failed cranioplasty. We believe that the tissue expanding techniques have also great contribution to achi...

The comparison of autologous bone, methyl-methacrylate, porous polyethylene, and titanium mesh in cranioplasty

“…Cranioplasty revision and complication rates are quite high compared to other surgeries in neurosurgery practice. Cranioplasty revision rates in the literature range from 5% to 26% (9). Our study revealed this rate (16.5%) as compatible with the literature.…”

Never say never again: A bone graft infection due to a hornet sting, thirty-nine years after cranioplasty

“…[ 3 11 15 25 34 ] The execution of a swab test of the purulent discharge and the harvest of some intraoperative specimens are strictly recommended for further bacteriological studies, even if in a small percentage of the whole cases they can be inconclusive, showing no bacterial overgrowth. [ 26 ] In our case, the bacterial culture was positive for Staphylococcus aureus , both on the swab test and on the intraoperative specimens, in accordance with the literature data. [ 15 ] Due to variety of bacterial agents in such this kind of infection, our patient begun a medical therapy with vancomycin and cefepime before he underwent surgical operation and microbiological exam of intraoperative specimens.…”

“…Graft infection rate ranges from 5.8% to 16%,[ 15 16 33 ] and in most cases, it implicates additional surgical procedures with the revision of the former CP. [ 14 26 ]…”

“…There is still not a consensus on the timing and the surgical strategy in treating infected CP. [ 26 ] In this challenging scenario, as it is still not possible to find either definite risk factors of earlier CP infections or reliable predictors of the later ones, which often are even unpredictable, a graft infection has to be considered as a diagnostic option, in case of a congruity between patient's clinical presentation, laboratory findings, and neuroimaging, also after several decades.…”

“…[ 25 ] Their rate ranges from 5.8% to 16%,[ 15 16 33 ] and in most cases it implicates additional surgical procedures and the revision of the former CP. [ 14 26 ] Although their high incidence, the majority of surgical site infections is seen between 3 months and 10 months after CP,[ 2 5 20 ] instead late infections are extremely rare. [ 8 22 ] We report an exceptional case of graft infection seen 39 years after primary CP in a male patient with an unremarkable clinical history and uneventful graft permanence.…”