Evaluation of simultaneous cranioplasty and ventriculoperitoneal shunt procedures

Abstract

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...

Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy: Staged Surgery Is Associated with Fewer Postoperative Complications

“…Furthermore, we previously reported that the presence of VPS at the time of CP is associated with a higher postoperative complication rate (18). A recent publication stated that simultaneous CP and VPS procedures have a higher postoperative complication rate when compared with patients with a median time interval of >2 months between both procedures (14). In the present series, the median time between CP and VPS procedures in patients with staged procedures was likewise approximately 2 months.…”

Complications Associated with Decompressive Craniectomy: A Systematic Review

“…The majority of reports of deep complications came from studies of patients who underwent DC and cranioplasty for numerous indications, and thus data could not be stratified. In these cases [108, 110, 129, 131, 133, 137, 138, 143–146], deep complications were observed in 3.8 % (52/1361) of patients.…”

Early cranioplasty vs. late cranioplasty for the treatment of cranial defect: A systematic review

“…We believe that the preventive effect of normal intracranial pressure dynamics for hydrocephalus still needs further research. To the patients who underwent DC and require placement of a VP shunt, some researchers hold that the combined CP and programmable shunts implantation surgery will be a helpful choice [29,40] On the contrary, Heo reported that patients undergoing cranioplasty and VP shunt placement at the same time had higher complication rates, especially those with severe brain bulging recently [18]. Meanwhile, extra-axial fluid collections following DC have also been observed in a variety of patient populations, which have traditionally been thought to represent extra-axial signs of hydrocephalus.…”

“…Decompressive craniotomy (DC) -a surgical procedure that involves the removal of part of the skull to accommodate brain swelling -has been used for many years in the management of patients with brain edema and/or intracranial hypertension due to subarachnoid hemorrhage, traumatic brain injury, cerebral infarction, intracerebral hemorrhage (ICH), and other causes [1,11,18,20]. Since more patients survive because of the DC surgery, the number of subsequent cranioplasty (CP) procedures is increasing.…”