Cranioplasty following decompressive craniectomy: minor surgical complexity but still high periprocedural complication rates

Shiban, Ehab; Lange, Nicole; Hauser, Antonia; Jörger, Ann-Kathrin; Wagner, Arthur; Meyer, Bernhard; Lehmberg, Jens

doi:10.1007/s10143-018-1038-x

Cited by 19 publications

(13 citation statements)

References 24 publications

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“…We reviewed the long-term complication rate of patients undergoing cranioplasty (CP) following decompressive craniectomy (DC) by analyzing a 13-year, single-center, consecutive patient cohort. CP-related complications occurred in 23%, similar to many published studies of comparably sized cohorts [25][26][27][28][29][30]. The presence of symptomatic disturbance in CSF flow prior to CP and acute subdural hematoma as etiology of DC were associated with higher complication rates.…”

Section: Discussionsupporting

confidence: 78%

Complications in cranioplasty after decompressive craniectomy: timing of the intervention

et al. 2020

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Objective To prevent complications following decompressive craniectomy (DC), such as sinking skin flap syndrome, studies suggested early cranioplasty (CP). However, several groups reported higher complication rates in early CP. We studied the clinical characteristics associated with complications in patients undergoing CP, with special emphasis on timing. Methods A single-center observational cohort study was performed, including all patients undergoing CP from 2006 to 2018, to identify predictors of complications. Results 145 patients underwent CP: complications occurred in 33 (23%): 18 (12%) epi/subdural hemorrhage, 10 (7%) bone flap infection, 4 (3%) hygroma requiring drainage, and 1 (1%) post-CP hydrocephalus. On univariate analysis, acute subdural hematoma as etiology of DC, symptomatic cerebrospinal fluid (CSF) flow disturbance (hydrocephalus) prior to CP, and CP within three months after DC were associated with higher complication rates. On multivariate analysis, only acute subdural hematoma as etiology of DC (OR 7.5; 95% CI 1.9-29.5) and symptomatic CSF flow disturbance prior to CP (OR 2.9; 95% CI 1.1-7.9) were associated with higher complication rates. CP performed within three months after DC was not (OR 1.4; 95% CI 0.5-3.9). Pre-CP symptomatic CSF flow disturbance was the only variable associated with the occurrence of epi/ subdural hemorrhage. (OR 3.8; 95% CI 1.6-9.0) Conclusion Cranioplasty has high complication rates, 23% in our cohort. Contrary to recent systematic reviews, early CP was associated with more complications (41%), explained by the higher incidence of pre-CP CSF flow disturbance and acute subdural hematoma as etiology of DC. CP in such patients should therefore be performed with highest caution.

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Section: Discussionsupporting

confidence: 78%

Complications in cranioplasty after decompressive craniectomy: timing of the intervention

et al. 2020

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“…Elective cranioplasty is — in general — associated with higher complication rates than other elective neurosurgical procedures [ 24 ]. In a comparable 3D printing-guided cranioplasty case series, Schön et al also reported a relatively high early reoperation rate in three out of 16 patients (18.75%) because of epidural or subdural postoperative haematomas [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

The “springform” technique in cranioplasty: custom made 3D-printed templates for intraoperative modelling of polymethylmethacrylate cranial implants

et al. 2021

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Background Manual moulding of cranioplasty implants after craniectomy is feasible, but does not always yield satisfying cosmetic results. In contrast, 3D printing can provide precise templates for intraoperative moulding of polymethylmethacrylate (PMMA) implants in cranioplasty. Here, we present a novel and easily implementable 3D printing workflow to produce patient-specific, sterilisable templates for PMMA implant moulding in cranioplastic neurosurgery. Methods 3D printable templates of patients with large skull defects before and after craniectomy were designed virtually from cranial CT scans. Both templates — a mould to reconstruct the outer skull shape and a ring representing the craniectomy defect margins — were printed on a desktop 3D printer with biocompatible photopolymer resins and sterilised after curing. Implant moulding and implantation were then performed intraoperatively using the templates. Clinical and radiological data were retrospectively analysed. Results Sixteen PMMA implants were performed on 14 consecutive patients within a time span of 10 months. The median defect size was 83.4 cm2 (range 57.8–120.1 cm2). Median age was 51 (range 21–80) years, and median operating time was 82.5 (range 52–152) min. No intraoperative complications occurred; PMMA moulding was uneventful and all implants fitted well into craniectomy defects. Excellent skull reconstruction could be confirmed in all postoperative computed tomography (CT) scans. In three (21.4%) patients with distinct risk factors for postoperative haematoma, revision surgery for epidural haematoma had to be performed. No surgery-related mortality or new and permanent neurologic deficits were recorded. Conclusion Our novel 3D printing-aided moulding workflow for elective cranioplasty with patient-specific PMMA implants proved to be an easily implementable alternative to solely manual implant moulding. The “springform” principle, focusing on reconstruction of the precraniectomy skull shape and perfect closure of the craniectomy defect, was feasible and showed excellent cosmetic results. The proposed method combines the precision and cosmetic advantages of computer-aided design (CAD) implants with the cost-effectiveness of manually moulded PMMA implants.

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“…Moreover, sTBI complications are still common. The best approach to help these patients could be the application of decompressive craniectomy 22 with dural augmentation 23 . It has the advantages of full decompression, providing more and larger intracranial buffer space for brain tissue under high pressure, reducing ICP, rebuilding cerebral blood flow perfusion, and controlling secondary brain damage.…”

Section: Discussionmentioning

confidence: 99%

“…Although some studies have shown that DC can substantially reduce ICP in patients with severe brain injury, the incidence of complications, including cerebral infarction, remains high. Similarly, morbidity and mortality are still as high as 50–70% 6 , 23 . Thus, reducing the incidence of intraoperative and postoperative complications remains a major challenge.…”

Section: Discussionmentioning

confidence: 99%

Controlled decompression alleviates early brain injury in rabbit intracranial hypertension model by regulating apoptosis/necroptosis

et al. 2021

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Purpose To evaluate the effects of controlled decompression and rapid decompression, explore the potential mechanism, provide the theoretical basis for the clinical application, and explore the new cell death method in intracranial hypertension. Methods Acute intracranial hypertension was triggered in rabbits by epidural balloon compression. New Zealand white rabbits were randomly put into the sham group, the controlled decompression group, and the rapid decompression group. Brain water content, etc., was used to evaluate early brain injury. Western blotting and double immunofluorescence staining were used to detect necroptosis and apoptosis. Results Brain edema, neurological dysfunction, and brain injury appeared after traumatic brain injury (TBI). Compared with rapid decompression, brain water content was significantly decreased, neurological scores were improved by controlled decompression treatment. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining and Nissl staining showed neuron death decreased in the controlled decompression group. Compared with rapid decompression, it was also found that apoptosis-related protein caspase-3/ tumor necrosis factor (TNF)-a was reduced markedly in the brain cortex and serum, and the expression levels of necroptosis-related protein, receptor-interacting protein 1 (RIP1)/receptor-interacting protein 1 (RIP3) reduced significantly in the controlled decompression group. Conclusions Controlled decompression can effectively reduce neuronal damage and cerebral edema after craniocerebral injury and, thus, protect the brain tissue by alleviating necroptosis and apoptosis.

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Cranioplasty following decompressive craniectomy: minor surgical complexity but still high periprocedural complication rates

Cited by 19 publications

References 24 publications

Complications in cranioplasty after decompressive craniectomy: timing of the intervention

Complications in cranioplasty after decompressive craniectomy: timing of the intervention

The “springform” technique in cranioplasty: custom made 3D-printed templates for intraoperative modelling of polymethylmethacrylate cranial implants

Controlled decompression alleviates early brain injury in rabbit intracranial hypertension model by regulating apoptosis/necroptosis

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