Outcomes of cranioplasty following decompressive craniectomy in the pediatric population

Rocque, Brandon G.; Amancherla, Kaushik; Lew, Sean M.; Lam, Sandi

doi:10.3171/2013.4.peds12605

Cited by 83 publications

(74 citation statements)

References 24 publications

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“…Also, time between craniectomy and cranioplasty did not have a significant effect on complication rate. 13 The results came from studies in the pediatric population but were consistent with our study. In contrast to our study, Zhou et al reported that the outcome of a single-stage operation combining VP shunt placement and cranioplasty did not significantly differ from that for two separate operations.…”

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confidence: 80%

Evaluation of simultaneous cranioplasty and ventriculoperitoneal shunt procedures

Heo

Park²,

Cho³

et al. 2014

JNS

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Decompressive craniectomy is a life-saving procedure used in the treatment of medically refractory intracranial hypertension in patients suffering from traumatic brain injury, cerebral infarction, subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH). 1,8,9,14 Indications for cranioplasty are usually protective and cosmetic. Cranioplasty has also been reported to facilitate neurological recovery 3,15 and improve cerebral blood flow, CSF hydrodynamics, and metabolic activity after a decompressive craniectomy.2-7 Some patients with severe brain swelling treated with decompressive craniectomy may develop communicating hydrocephalus, with or without persistent brain bulging. Consequently, these patients also require a ventriculoperitoneal (VP) shunt to relieve the hydrocephalus.There is no consensus as to the timing of the cranioplasty and VP shunt placement in patients who require both operations. A large cranial defect could lead to turbulence in CSF circulation hydrodynamics and cerebral blood perfusion due to exposure to atmospheric pressure, followed by hydrocephalus. 4-7 Cranioplasty and VP shunts each affect CSF circulation, but exactly how each operation affects it is as yet unknown. Thus, undergoing both operations at the same time may cause complications due to unexpected CSF circulation changes. In this study, we assessed the results of undergoing cranioplasty and VP shunting at the same time in patients with cranial defects and hydrocephalus. We hypothesized that the outcomes after simultaneous cranioplasty and VP shunting may be worse than those when the operations are performed at different times. Object. Some patients with severe brain swelling treated with decompressive craniectomy may develop hydrocephalus. Consequently, these patients require cranioplasty and a ventriculoperitoneal (VP) shunt to relieve the hydrocephalus. However, there is no consensus as to the timing of the cranioplasty and VP shunt placement in patients requiring both. The authors assessed the results of performing cranioplasty and VP shunt placement at the same time in patients with cranial defects and hydrocephalus.Methods. A retrospective review was performed of 51 patients who had undergone cranioplasty and VP shunt operations after decompressive craniectomy for refractory intracranial hypertension between 2003 and 2012 at the authors' institution. Patient characteristics, data on whether the operations were performed simultaneously, brain bulging, hydrocephalus, cranial defect size, and complications were analyzed.Results. The overall complication rate was 43% (22 of 51 patients). In 32 cases, cranioplasty and VP shunt placement were performed at the same time. Complications included subdural hematoma, subdural fluid collection, and infection. The group undergoing cranioplasty and VP shunt placement at the same time had higher complication rates than the group undergoing the procedures at different times (56% vs 21%, respectively). The severity of complications was also greater in the former group. Patients with...

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confidence: 80%

Evaluation of simultaneous cranioplasty and ventriculoperitoneal shunt procedures

Heo

Park²,

Cho³

et al. 2014

JNS

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“…Most surgeons prefer the previously stored cranial bone flap for the initial cranioplasty attempt due to its biocompatibility, perfect shape and possible osteo-inductive effects. However, the autologous graft is no more applicative when a revision cranioplasty is required (15,29). In case of a failed cranioplasty, surgeon faces with giving a decision between far-site autologous grafts, allografts or synthetic implant materials.…”

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confidence: 99%

“…Bone turnover is relatively higher in pediatric age, thus the spontaneous bone resorption is mostly the leading reason for revisions (29 There is not a consensus on surgical strategy for revision cranioplasty. When indicated, the timing of the surgery also remains a debate especially for patients with infected bone flap and skin.…”

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Management of failed cranioplasty

Sarı

Tönge²,

Bölükbaşı³

et al. 2015

Turkish Neurosurgery

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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...

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“…13,32,33 Decompressive craniectomy carries a complication risk of 37%-50%, 5,13,32,79 and patients undergoing a cranioplasty for the repair of a craniectomy defect face an additional 16%-34% complication risk. 3,9,14,23,24,46,57,65,75 One caveat regarding the DECRA trial is that only patients without any significant mass lesions were enrolled. 13 Some studies seem to suggest that a craniectomy may improve outcome when used for the treatment of elevated ICP associated with a mass lesion.…”

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Dynamic telescopic craniotomy: a cadaveric study of a novel device and technique

Khanna

Ferrara²

2016

JNS

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OBJECT The authors assessed the feasibility of the dynamic decompressive craniotomy technique using a novel cranial fixation plate with a telescopic component. Following a craniotomy in human cadaver skulls, the telescopic plates were placed to cover the bur holes. The plates allow constrained outward movement of the bone flap upon an increase in intracranial pressure (ICP) and also prevent the bone flap from sinking once the ICP normalizes. The authors compared the extent of postcraniotomy ICP control after an abrupt increase in intracranial volume using the dynamic craniotomy technique versus the standard craniotomy or hinge craniotomy techniques. METHODS Fixation of the bone flap after craniotomy was performed in 5 cadaver skulls using 3 techniques: 1) dynamic telescopic craniotomy, 2) hinge craniotomy, and 3) standard craniotomy with fixed plates. The ability of each technique to allow for expansion during intracranial hypertension was evaluated by progressively increasing intracranial volume. Biomechanical evaluation of the telescopic plates with load-bearing tests was also undertaken. RESULTS Both the dynamic craniotomy and the hinge craniotomy techniques provided significant control of ICP during increases in intracranial volume as compared with the standard craniotomy technique. With the standard craniotomy, ICP increased from a mean of 11.4 to 100.1 mm Hg with the addition of 120 ml of intracranial volume. However, with the dynamic craniotomy, the addition of 120 ml of intracranial volume increased the ICP from a mean of 2.8 to 13.4 mm Hg, maintaining ICP within the normal range as compared with the standard craniotomy (p = 0.04). The dynamic craniotomy was also superior in controlling ICP as compared with the hinge craniotomy, providing expansion for an additional 40 ml of intracranial volume while maintaining ICP within a normal range (p = 0.008). Biomechanical load-bearing tests for the dynamic telescopic plates revealed rigid restriction of bone-flap sinking as compared with standard fixation plates and clamps. CONCLUSIONS The dynamic telescopic craniotomy technique with the novel cranial fixation plate provides superior control of ICP after an abrupt increase in intracranial volume as compared with the standard craniotomy and hinge craniotomy techniques.

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Outcomes of cranioplasty following decompressive craniectomy in the pediatric population

Cited by 83 publications

References 24 publications

Evaluation of simultaneous cranioplasty and ventriculoperitoneal shunt procedures

Evaluation of simultaneous cranioplasty and ventriculoperitoneal shunt procedures

Management of failed cranioplasty

Dynamic telescopic craniotomy: a cadaveric study of a novel device and technique

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