Cranioplasty Following Decompressive Craniectomy

Abstract

Cranioplasty (CP) after decompressive craniectomy (DC) for trauma is a neurosurgical procedure that aims to restore esthesis, improve cerebrospinal fluid (CSF) dynamics, and provide cerebral protection. In turn, this can facilitate neurological rehabilitation and potentially enhance neurological recovery. However, CP can be associated with significant morbidity. Multiple aspects of CP must be considered to optimize its outcomes. Those aspects range from the intricacies of the surgical dissection/reconstruction during the procedure of CP, the types of materials used for the reconstruction, as well as the timing of the CP in relation to the DC. This article is a narrative mini-review that discusses the current evidence base and suggests that no consensus has been reached about several issues, such as an agreement on the best material for use in CP, the appropriate timing of CP after DC, and the optimal management of hydrocephalus in patients who need cranial reconstruction. Moreover, the protocol-driven standards of care for traumatic brain injury (TBI) patients in high-resource settings are virtually out of reach for low-income countries, including those pertaining to CP. Thus, there is a need to design appropriate prospective studies to provide context-specific solid recommendations regarding this topic.

Ventriculoperitoneal shunt occlusion and cranioplasty

“…In this context, patients submitted to DC may need cranioplasty and VPS after the subacute stage. 1,8,12 Diagnostic of hydrocephalus in people who have had hemicraniectomy surgical procedures done is necessarily subjective, since criteria based on measuring intracranial pressure or details on ventricular structure are generally not reliable in the scenario of an open cranial vault. However, the almost universal disposition towards the progressive accumulation of CSF in these individuals, frequently manifested as an increase in extra-axial gatherings over the hemispheric convexity, indicates an incapacity for adequately balancing the production of CSF by draining the venous sinuses.…”

“…This can make them predisposed for the necessity of a previous shunt, as described in this case study. 8,10,12,14 In the patients who have gone through craniectomy and whose hydrocephalus is persistent, the literature's point of view is still controversial as to the management of and the adequate time for applying shunt and cranioplasty. Recent data suggest that patients submitted for cranioplasty procedures and VPS by stages can benefit from less complicated results when compared to patients who go through the two procedures at the same time.…”

“…Some authors will defend the shunt for managing hydrocephalus and cranioplasty at a later stage. 3,6,8,9 Cranioplasty in patients with VPS may be challenging, mainly in those patients presenting a sunken flap due to the shunt. In patients with the sunken flap, there is a technical difficulty at the time of operating during the separation of the cutaneous layer, dura mater and encephalic tissue.…”

“…In the case described, what was chosen was the closing of the VPS in order to permit parenchymal expansion after the cranioplasty procedure. 3,8,10,12,14 As in the majority of hydrocephalus cases, after decompressive craniectomy there is a spontaneous resolution with cranioplasty. VPS occlusion was maintained after cranioplasty, and a rigorous postoperative observation was conducted with regard to expansion inside the brain and the necessity for a shunt.…”

“…No worsening in the patient's condition was observed. 3,8,9 The literature is yet to offer a standard for managing cranioplasty in patients with previous shunt and sunken skin flap. In spite of the success in the case related, there is no relevant sample or previous works available to compare such a case.…”