The results of this study suggest that long operative times (> 120 min), craniectomy with temporalis muscle resection, the presence of preoperative subgaleal fluid collection, and postoperative wound disruption may be risk factors for graft infection after cranioplasty. Surgical techniques should be developed to reduce operative time and to avoid temporalis muscle resection when possible. In addition, meticulous dural closure aimed at reducing the formation of subgaleal fluid collection is important for the prevention of graft infections after cranioplasty.

No abstract

The authors report two cases of stent fracture and restenosis after placement of a drug-eluting device in the vertebral artery (VA) origin, and describe management of restenosis with the stent-in-stent technique. Two women, one 62 and the other 67 years of age, underwent stent placement in the VA origin to treat symptomatic and angiographically significant stenosis in this vessel. Sirolimus-eluting coronary stents (Cypher) were used in both cases. Four months after placement of the devices, the symptoms recurred. Follow-up angiography performed 5 months after insertion of the devices revealed a transverse stent fracture with separation of the fragments and severe in-stent restenosis in both cases. The restenoses were treated with reinsertion of coronary stents (Cypher and Jostent FlexMaster) by using the stent-in-stent technique. After stent reinsertion, the patients exhibited relief of symptoms. This paper is the first report of fracture in a drug-eluting stent and restenosis after stent placement in the VA origin. Restenosis caused by such a fracture can be managed successfully by performing the stent-in-stent maneuver. The physical properties of metallic devices, stent strut geometry, and anatomical peculiarities of the subclavian artery may be associated with stent fractures. Earlier follow-up angiography studies (within 6 months) are warranted.

The authors report on a case of intravascular ultrasonography (IVUS)-guided stent angioplasty for iatrogenic extracranial vertebral artery (VA) dissection in a 49-year-old man after coil embolization for an unruptured aneurysm of the right posterior inferior cerebellar artery. Insignificant dissections occurred during the procedure. Postoperatively, the patient experienced gradually worsening posterior neck pain and headache, and follow-up angiography 8 months after the coil embolization revealed expansion of the dissection. The patient underwent stent angioplasty with IVUS guidance and his symptoms improved. To the authors' knowledge, this is the first report of IVUS-guided stent angioplasty of an extracranial VA dissection. It was safe and feasible to treat extracranial VA dissections with stent placement under IVUS guidance. Intravascular environments are in real time with IVUS, and this technique is useful in the confirmation of a true lumen and evaluation of appropriate stent apposition. More clinical experience with this technique is necessary and mandatory, and devices with smaller diameters with improved trackability are essential for further introduction of IVUS into the field of endovascular neurosurgery.