Cranioplasty Infections—Adding Insult to Injury

Abstract

ranioplasty infections represent a dreaded complication in patientswho have generally already experienced a serious, C usually traumatic event. Craniectomies are frequently performed in an effort to decrease the intracranial hypertension that accompanies a massive cerebral infarct or a serious head injury. Patients considered candidates for a decompressive craniectomy (DC) after a traumatic brain injury (TBI) are those younger in agewith reactive pupils with a good Glasgow Coma Scale score. In contrast, patients with bilateral fixed and dilated pupils or with brain stem involvement, which can include Duret hemorrhages, are usually excluded fromsurgical consideration.A recentCochraneReviewon theutility ofDCconcluded that therewasnoevidence tosupport the routine use of DC to improve mortality and quality of life in braininjured adults with high intracranial pressure (8). Overall, DC does not improve the outcome in good prognosis adult patients but can convert mortality to severe disability in poor prognosis patients. There are 2 ongoing randomized controlled trials of decompressive craniectomy (RescueICP and DECRA) that will hopefully provide further conclusions on the efficacy of DC in adults. Bilateral hemicraniectomy for TBI carries 67% mortality and provides benefit primarily to very young adults (10). In addition, DC may improve survival and neurological outcomes in pediatric patients with raised intracranial pressure froma TBI forwhomothermedical treatments had failed. The results in the pediatric population are based on 1 randomized controlled trial in 27 children.