The impact of timing of cranioplasty in patients with large cranial defects after decompressive hemicraniectomy

Archavlis, Eleftherios; Nievas, Mario Carvi y

doi:10.1007/s00701-012-1333-1

Cited by 103 publications

(50 citation statements)

References 30 publications

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“…There is no study however, that examines the effect of timing on the clinical outcome of patients. In accordance with the available literature, timing does not influence complications, but there might be an advantage for early reinsertion (<3 months), especially with respect to the risk for infections [51,52,53,54,55,56]. Recently published studies reported an approximate overall complication rate of up to 35% [51,52].…”

Section: Surgical Treatmentsupporting

confidence: 61%

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

Zweckberger¹,

Jüettler

Bösel

et al. 2014

Cerebrovasc Dis

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Background: Space-occupying malignant stroke of the middle cerebral artery (MCA) is associated with a high mortality rate of up to 80% under conservative treatment. Although there is convincing evidence that decompression craniectomy can significantly reduce mortality rate and improve neurological outcome in young patients (<60 years), many surgeons are still hesitant to recommend hemicraniectomy for stroke patients. Summary: This review addresses some major issues that appear to be an obstacle to decompression craniectomy, in particular, indicating surgery for patients >60 years or with infarcts of the dominant hemisphere. Furthermore, it emphasizes technical issues such as timing and size of the craniectomy, additional temporal lobectomy, and resection of the temporal muscle, as well as duraplasty and cranioplasty. According to the current literature, decompression craniectomy in older patients can increase survival without most severe disabilities, although, most survivors need assistance in most bodily needs. Involvement of the dominant hemisphere results in aphasia that might partly recover in younger patients, although, considering the neuropsychological deficits caused by infarctions of the nondominant hemisphere, involvement of the dominant hemisphere does not pose as a contraindication for decompression craniectomy. Furthermore, there is convincing evidence that surgery should be performed within 48 h after the onset of symptoms and the size of the craniectomy should be at least 12 cm as a minimum. An additional lobectomy or the resection of the temporal muscle, however, can only be part of individual treatment options. Conceding the weak evidence, it is recommended to close the dura by some form of a duraplasty avoiding cerebrospinal fluid leakages or scarring between the cortex and the scalp leading to injuries during reimplantation of the bone-flap. Complications associated with decompression surgery (hemorrhages, infections, ‘sinking skin-flap syndrome', cerebrospinal fluid leakages, hydrocephalus, seizures), with the infarction itself, or with those that occur during the ICU course (cardiac and pulmonary complications) appear acceptable and are mostly treatable, especially considering the fatal course of conservative treatment. Key Message: This review summarizes the current state of the literature about decompression craniectomy of patients with malignant stroke addressing, in particular, critical surgical issues, and thus, help surgeons to make decisions confidently for/or against performing surgery.

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Section: Surgical Treatmentsupporting

confidence: 61%

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

Zweckberger¹,

Jüettler

Bösel

et al. 2014

Cerebrovasc Dis

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“…Once the neurological and medical states of the patient have been stabilized, bone grafting is performed for esthetic, but also therapeutic, reasons and is associated with postoperative neurological improvement. 1,3,[7][8][9][11][12][13]16,22,24,27 Compared with other neurosurgical interventions, the complication rate of cranioplasty after decompressive craniectomy is surprisingly high, with a reoperation rate for wound infection, rebleeding, and wound-healing problems of up to 36.5%. 23,26 Long-term complications after autograft implantation have become an increasing concern in recent years.…”

Section: Discussionmentioning

confidence: 99%

Cranioplasty after decompressive craniectomy: is there a rationale for an initial artificial bone-substitute implant? A single-center experience after 631 procedures

Schwarz¹,

Dünisch²,

Walter³

et al. 2016

JNS

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OBJECT The complication rate for cranioplasty after decompressive craniectomy is higher than that after other neurosurgical procedures; aseptic bone resorption is the major long-term problem. Patients frequently need additional operations to remove necrotic bone and replace it with an artificial bone substitute. Initial implantation of a bone substitute may be an option for selected patients who are at risk for bone resorption, but this cohort has not yet been clearly defined. The authors’ goals were to identify risk factors for aseptic bone flap necrosis and define which patients may benefit more from an initial bone-substitute implant than from autograft after craniectomy. METHODS The authors retrospectively analyzed 631 cranioplasty procedures (503 with autograft, 128 with bone substitute) by using a stepwise multivariable logistic regression model and discrimination analysis. RESULTS There was a significantly higher risk for reoperation after placement of autograft than after placement of bone substitute; aseptic bone necrosis (n = 108) was the major problem (OR 2.48 [95% CI1.11–5.51]). Fragmentation of the flap into 2 or more fragments, younger age (OR 0.97 [95% CI 0.95–0.98]; p < 0.001), and shunt-dependent hydrocephalus (OR 1.73 [95% CI1.02–2.92]; p = 0.04) were independent risk factors for bone necrosis. According to discrimination analysis, patients younger than 30 years old and older patients with a fragmented flap had the highest risk of developing bone necrosis. CONCLUSIONS Development of bone flap necrosis is the main concern in long-term follow-up after cranioplasty with autograft. Patients younger than 30 years old and older patients with a fragmented flap may be candidates for an initial artificial bone substitute rather than autograft.

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“…The main reasons of large cranial defects after decompressive craniectomy include brain injury, cerebral infarction, subarachnoid hemorrhage and ICH (Table 1). Archavlis [4] grouped research date into three groups: <7 weeks, 7-12 weeks, and >13 weeks. Because both the first two groups are under 3 months, we combined the first two groups into one group to compare with the other group.…”

Section: Search Strategymentioning

confidence: 99%

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

Niu

et al. 2015

Clinical Neurology and Neurosurgery

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The impact of timing of cranioplasty in patients with large cranial defects after decompressive hemicraniectomy

Cited by 103 publications

References 30 publications

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review

Cranioplasty after decompressive craniectomy: is there a rationale for an initial artificial bone-substitute implant? A single-center experience after 631 procedures

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

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