Unexpected complications immediately after cranioplasty

Abstract

CaseAn 84‐year‐old man with subarachnoid hemorrhage underwent craniotomy and clipping with external decompression. Perfusion magnetic resonance imaging showed subclinical sinking skin flap syndrome, and he underwent cranioplasty on postoperative day 58. No problems occurred during the operation, but cerebral edema and hemorrhage were recognized on immediate postoperative computed tomography. Edema continued to progress, but edema and bleeding eventually improved without additional surgery.OutcomeNeurological symptoms improved to presurgical baseline and stabilized.ConclusionCauses of cerebral edema and hemorrhage immediately after cranioplasty include reperfusion, reduction of automatic adjustment function, sinking skin flap syndrome, negative pressure due to s.c. drain, venous stasis, vascular damage following restoration of midline shift, and allergic reaction. Although cranioplasty itself is a relatively minor surgery, the fatality rate for this complication is high. Most complications are due to infection, convulsions, or epidural hematoma, but brain edema and hemorrhage also occur. It is necessary to elucidate the etiology before corrective surgery.

Massive Brain Swelling after Cranioplasty: A Case Report

“…Wang et al 18 reported for the first time that ipsilateral intracranial vasculopathy is a risk factor for malignant cerebral swelling after cranioplasty. Kato et al 19 support the hypothesis that cerebral swelling after cranioplasty is probably due to the reduction of autoregulation, reperfusion, venous stasis, negative pressure due to a subgaleal suction drain, vascular damage following the restoration of midline shift, sinking skin flap syndrome, and allergic reaction. We believed that the following factors might have played a role in our patient:…”

Analysis of clinical efficiency and early postoperative complications after cranioplasty

“…This condition counts amongst the less frequent postoperative complications and is most likely explainable as the consequence of a reperfusion injury (11,42). As already mentioned, autoregulatory mechanisms of the intracranial space are impaired during the post-craniectomy period, often associated with a cerebral hypoperfusion and sinking skin fl ap syndrome (8,11,12). After a longer period, during which the brain was almost directly exposed to atmospheric pressure, the pressure was rapidly alleviated after a cranial vault reconstruction.…”

“…A restoration of cranial vault has a potential to normalize cerebrospinal fl uid circulation and to avoid the need for shunt procedure due to hydrocephalus, factor associated with a worse neurological outcome (13,15,16). Also, it has been described, that in patients after craniectomy, a decreased perfusion and metabo-lism with an associated possible neurological dysfunction occur, often accompanied by "sinking skin fl ap" (7,8,11,12,17). Besides of this, oedema and penetration of cerebrospinal fl uid into post-contusion foci with a subsequent worsening of motor functions was described as "motor trephine syndrome".…”

“…Several mostly subjective disorders following craniectomy describe a long known "syndrome of the trephined" (8,9). It is important, that especially an early cranioplasty has a potential to reverse these symptoms and improve metabolism, perfusion and dysfunction of the affected brain tissue (7,8,(10)(11)(12). Associated motor and cognitive improvements were reported in several studies assessing the outcome of patients undergoing cranioplasty (17)(18)(19)(20)(21)(22).…”

“…Also, hypoperfusion and a decreased metabolism associated with cranial defects were observed in both decompressed and contralateral hemisphere (7) accompanied by various forms of neurological dysfunction, typically linked to diagnoses such as "syndrome of trephined", "sinking skin fl ap syndrome" or "motor trephine syndrome" (8)(9)(10). Such conditions might be later restored by the means of cranial reconstruction, which is associated with an improved cerebral perfusion, oxygenation, and metabolism as well as with normalization of the cerebrospinal fl uid circulation (11)(12)(13).…”