Cranioplasty Research Articles

Factors affecting incidence of epilepsy after cranioplasty

Objective To investigate the factors affecting the incidence of epilepsy after cranioplasty. Methods A retrospective case control study was conducted on the clinical data of 171 patients with skull defect who underwent cranioplasty between January 2012 and December 2015. There were 126 males and 45 females, with an average age of 50.9 years (range, 16-78 years). The patients were divided into epileptic seizure group (61 cases) and non epileptic seizure group (110 cases). The gender, age, defect cause, defect location, defect duration, perioperative antiepileptic drug use, skull defect regional depression volume (Vd), skull defect regional integrity volume (Vf), skull defect regional depression rate (Pd) of two groups were recorded. Univariate analysis and multivariate logistic regression analysis were used to identify the independent risk factor of epilepsy after cranioplasty. Results All patients were followed up for 54 months averagely (range, 18-90 months). Sixty-one patients (35.7%) had epilepsy after cranioplasty. Univariate analysis suggested that age, defect cause, defect location, defect duration, perioperative antiepileptic drug use, and Vf were not associated with epilepsy after cranioplasty (all P>0.05); while gender, Vd, and Pd was associated with epilepsy after cranioplasty (P<0.05). Multivariate logistic regression analysis demonstrated that Pd (OR=0.024, 95%CI 0.001-0.502, P<0.05) was independent predictor of epilepsy after cranioplasty. Conclusion Pd is an independent risk factor for epilepsy after cranioplasty and depression degree could significantly affect its incidence. Key words: Epilepsy; Craniocerebral trauma; Cranioplasty

Early or late cranioplasty following decompressive craniotomy for traumatic brain injury: A systematic review and meta-analysis.

ObjectiveTo evaluate the effectiveness of early (<3 months) cranioplasty (CP) and late CP (>3 months) on post-operative complications in patients receiving decompressive craniotomy (DC) for traumatic brain injury (TBI).MethodsThe Cochrane Library, PubMed and EMBASE databases were systematically searched for studies published prior to May 21, 2017. A meta-analysis examined post-operative overall complication rates, infection rates, subdural fluid collection and operating times according to early and late CP.ResultsOf the initial 1675 references, five studies, all cohort, involving a total of 413 patients, were selected for the review. There was no difference between early and late CP in post-operative overall complication rate (RR=0.68, 95%CI [0.36, 1.29]) and the post-operative infection rate (RR=0.50, 95%CI [0.20, 1.24]) in patients receiving DC for TBI. However, there was a significant difference in post-operative subdural effusion (RR=0.24, 95%CI [0.07, 0.78]) and mean operative time (mean difference = −33.02 min, 95%CI [−48.19, −17.84]) both in favour of early CP.ConclusionsNo differences were found between early and late CP in post-operative overall complications and procedural related infections in patients receiving DC for TBI, but early CP reduced the complication of subdural effusion and the mean operating time. These findings need to be confirmed by large, randomised controlled trials.

Aseptic Bone Flap Resorption after Cranioplasty with Autologous Bone: Incidence, Risk Factors, and Clinical Implications

Aseptic bone flap resorption (ABFR) is a known complication of cranioplasty (CP) with an autologous bone flap. The incidence of ABFR has been reported to be as high as 34.2% in the literature; however, it is underestimated in clinical fields. We retrospectively reviewed 13 years of clinical cases of patients who underwent CP after decompressive craniectomy (DC) to investigate the incidence and risk factors of ABFR. Ninety-one patients who underwent DC and CP in Guro Hospital, Korea University Medical Center, were enrolled. ABFR was defined using serial brain computed tomography. To identify possible risk factors for ABFR, univariate and multivariate Cox regression and receiver operating characteristic curve analyses were performed. Of the 91 patients enrolled, ABFR was diagnosed in 32 patients (35.1%). Bone flap size, existence of a shunting system, and the DC-CP interval were significant in the univariate analysis. Bone flap size was statistically significant in the multivariate analysis (P= 0.0189). The cutoff points of the DC-CP interval and bone flap size were 44 days and 110 cm2, respectively. The incidence of ABFR was remarkably high. Bone flap size, the existence of a shunting system, and the DC-CP interval were shown to be potential risk factors of ABFR after CP.

Preoperative lumbar drainage placement for surgical cranioplasty

ObjectiveIntraoperative reduction of cerebrospinal fluid may be required in patients undergoing cranioplasty (CP) surgery, especially in the presence of bulging cranial defects. Direct cannulation of the frontal horn of the lateral ventricle is associated with risks such as intracerebral haemorrhage or postoperative leakage of cerebrospinal fluid. Here we report our initial experiences with preoperative lumbar drain (LD) placement for cranioplasty surgery in patients with bulging cranial defects. MethodThe medical records of patients who were treated with LD prior to CP surgery at our institution were retrospectively analysed. Pre-, intra- and postoperative modalities, complications and outcome parameters are described. ResultsA total of 14 patients (mean age 46 years) were included in this analysis. The majority of patients had received decompressive craniectomy due to space-occupying cerebral infarction (64.3%) and traumatic brain injury (14.3%). CP was performed unilaterally with autologous bone graft in 93% of cases. No complications occurred during lumbar drainage placement and the grafts were implanted without the need of dural opening and ventricle puncture. LDs were maintained for an average of 17 ± 15 h (range, 1–48 h). There were no LD related complications in the further course. ConclusionOur initial experiences demonstrate that preoperative LD placement facilitates CP in patients with bulging cranial defects requiring surgical cranioplasty. Intraoperative puncture of ventricles for reducing cerebrospinal fluid is avoided and therefore, the risk of intracerebral haemorrhage and brain damage is reduced. Further studies are needed to evaluate the advantages of this technique as an alternative to conventional methods of intraoperative CSF reduction.

Cognitive and Functional Outcomes of Early Versus Delayed Cranioplasty after Decompressive Craniectomy

Abstract Introduction Delay in doing cranioplasty (CP) after decompressive craniectomy (DC) may cause motor, cognitive, and language deficits. Studies show doing CP before developing such symptoms helps in improving the outcome. CP improves cerebrospinal fluid (CSF) dynamics and cerebral blood flow, which may lead to better cognitive and functional outcome. Objective The aim of the study was to assess cognitive and functional outcomes of early versus delayed cranioplasty (DCP) after DC. Methodology This was a prospective observational study on 42 patients aged over 16 years and up to 70 years, who had undergone CP after DC for severe traumatic brain injury in in-patient and outpatient department of neurosurgery at a tertiary care hospital in Bhubaneswar, Odisha, India from the period of March 01, 2016 to December 31, 2017. Cognitive and functional outcomes were compared in early and DCP groups in preoperative and follow-up period at 1 month, 3 months, and 6 months. Early cranioplasty (ECP) was within 2 months, and DCP was beyond 2 months. Results Total sample size under this study was 42; 21 in ECP and 21 in DCP group. Mean age was 41.40 ± 15.95 years. The age distribution was quite young with 38.1% in 30 to 49 age group and had very high proportion of males (85.7%). This analysis revealed that both the ECP and DCP groups have resulted in significant improvement in mini-mental state examination (MMSE) and Glasgow Outcome Scale Extended (GOSE) score after CP. But in the ECP group, there has been steady and significant improvement in MMSE and GOSE score at different follow-ups starting from postoperative 1 month in MMSE score and from 3 months up to 6 months in GOSE score. Conclusion Neurosurgeon should evaluate and carefully monitor each individual case and take up CP as early as possible with suitable indication.

A Large Multicenter Retrospective Research on Embedded Cranioplasty and Covered Cranioplasty.

Cranioplasty (CP) can be either embedded or covered, according to the implants used. However, determining which one is better in treating cranial defects is difficult. This study aimed to compare the clinical outcomes and complications of embedded CP and covered CP. A multicenter retrospective study was undertaken with patients who underwent CP with polyetheretherketone (PEEK) implants and titanium implants between January 2014 and March 2017. The medical records of these patients were reviewed retrospectively and analyzed statistically. There were 185 patients, including 75 patients (40.5%) who underwent embedded CP with PEEK implants (PEEK group) and 110 patients (59.5%) who underwent covered CP using titanium mesh (titanium group), in this study. Compared with the titanium group, the incidence of overall complications (P= 0.03), postoperative new seizures (P= 0.01), postoperative implant exposure (P= 0.03), and reoperation (P= 0.01) was significantly lower in PEEK group. The rate of brain function improvement (P= 0.01) after CP and satisfaction with CP (P= 0.01) in patients in the PEEK group were higher than that in the titanium group. Our results show that embedded CP with PEEK has a distinct advantage in brain function improvement and fewer postoperative complications compared with covered CP with titanium mesh. However, the high cost of PEEK is an obvious drawback. This study can help both neurosurgeons and patients in choosing a better therapeutic method to achieve the most satisfactory outcome in treating cranial defects.

Initial Dead Space and Multiplicity of Bone Flap as Strong Risk Factors for Bone Flap Resorption after Cranioplasty for Traumatic Brain Injury.

ObjectiveBone flap resorption (BFR) is a complication of cranioplasty (CP) that increases the risk of brain damage and can cause cosmetic defects. In this study, the risk factors for BFR were examined to improve the prognosis of patients after CP for traumatic brain injury (TBI).MethodsThis study was conducted in 80 patients with TBI who underwent decompressive craniectomy and CP with an autologous bone graft between August 2006 and August 2017. BFR was defined as a >0.1 ratio of the difference between the initial bone flap area and the last bone flap area to the craniectomy size and a <0.5 ratio of the last bone flap thickness to the bone thickness of the contralateral region on computed tomography scans and plain skull radiographs. The patients were divided into the BFR and non-BFR groups, and medical data were compared between the two groups.ResultsAmong the 80 patients, 22 (27.5%) were diagnosed as having BFR after CP. The earliest cases of BFR occurred at 57 days after CP, and the latest BFR cases occurred at 3,677 days after CP. Using multivariate logistic regression analyses, the initial dead space size (odds ratio [OR], 1.002; 95% confidence interval [CI], 1.001–1.004; p=0.006) and multiplicity of the bone flap (OR, 3.058; 95% CI, 1.021–9.164; p=0.046) were found to be risk factors for BFR.ConclusionThe risk factors for BFR in this study were the initial dead space size and multiplicity of the bone flap.

Clinical application of triangular parabolic PEEK mesh with hole button produced by combining CAD, FEM and 3DP into cranioplasty

Background: Cranioplasty (CP) helps to restore the integrity of the skull and the stability of the inner brain structure, to greatly improve the aesthetic and to reduce the concerns caused by the weakening of the brain’s protection. However, how to achieve less complications while maintain a high aesthetic effect of CP has always been the pursuits of the neurosurgeons, manufactures and researchers. Objectives: Using Computer-Aided Design (CAD), Finite Element Methods (FEM) and 3D printing (3DP) to produce a customized triangular parabolic polyetheretherketone (PEEK) mesh for patients with skull defect who need Cranioplasty. Patients and Methods: A patient whose left frontal-temporal-parietal temporal skull had defects, need CP, and a customized triangular parabolic polyetheretherketone (PEEK) mesh with hole button prepared by CAD, FEM and 3DP is proposed for CP. After cycled individualized design and mechanical comparison analysis, the implant is formed by 3DP. Results: A triangular parabolic PEEK mesh with 5-hole button produced by CAD and A vertical 2000 N static force was applied in the central area of a 7 mm diameter of implants, then the maximum stress of 5-lock-botton mesh (triangular paraboloid mesh with lock button model σ=5.7228e6; defective bone σ=4.1904e6) and maximum strain of 5-lock-botton mesh (triangular paraboloid mesh with lock button model=9.053e-7; defective bone e=1.9363e-7) was obtained by stress-strain analysis, the corresponding stress nephogram and stress ribbon image showing that the concentrated force distribution is relatively uniform. Conclusion: Triangular parabolic PEEK mesh with hole button had a high biomechanical performance and aesthetic effect for CP.

Validation of a Novel Clinical Score: The Rostock Functional and Cosmetic Cranioplasty Score.

With a rising number of cranioplasty (CP) procedures and an increasing percentage of patients with a good clinical outcome and prolonged survival after CP, looking at the functional and aesthetic outcome of these patients becomes more and more important. The aim of our study was to evaluate a novel score, combining functional and cosmetics aspects after CP, created at our institution: the Rostock Functional and Cosmetic Cranioplasty (RFCC-) Score. A total of 27 patients were enrolled, representing all indications for a secondary CP after decompressive craniectomy or extended temporal trephination with a complete separation of the temporalis muscle. Besides the clinical evaluation, five different already established clinical rating systems were tested and compared with our score. For reasons of objectivity, the score was also tested against the patient's own rating. Our findings showed that the RFCC-Score, derived from a health professional, is superior to other scoring systems, which only display a facet of the functional state of the patient. Our score is objective and independent of a disposition for a depression of the patient. It can be obtained without the need of a verbal communication, making it applicable for nearly all patients after CP. The score is time-saving, clearly arranged, and reliable, which are inevitable requirements for the comparing and evaluation of different surgical techniques and associated complications of CP.

How Early Can We Perform Cranioplasty for Traumatic Brain injury After Decompressive Craniectomy? A Retrospective Multicenter Study.

Decompressive craniectomy (DC) is used to treat intractable intracranial hypertension after severe traumatic brain injury (TBI). Cranioplasty (CP) is typically performed weeks or months later. However, the optimal timing for CP is unknown. We aimed to determine the earliest possible time point for CP. We retrospectively reviewed brain computed tomography images from 159 patients who underwent CP after DC for TBI at 3 hospitals. We determined the earliest possible day for CP by reviewing the resolution of intracranial pressure in serial brain computed tomography images between DC and CP. The early CP group was defined as the group within the earliest possible timing of CP; other cases constituted the late CP group. We compared complications and the Glasgow Outcome Scale scores at 6 months between groups. The mean initial Glasgow Coma Scale score was 8.33 ± 3.46. The time interval between DC and CP was 94.75 ± 143.98 days. The earliest possible timing for CP was determined to be 34.60 ± 34.36 days after DC. The incidence of complications did not differ significantly between groups, except for ventriculomegaly, which occurred more frequently in the late CP group (P= 0.026). Predictors of good outcome were revision because of infection, preoperative epidural hematoma, early cranioplasty, and no ventriculomegaly after DC. CP can be performed at around 34 days after DC for TBI. Ventriculomegaly occurred less frequently and the 6-month Glasgow Outcome Scale score was better in the early CP group than in the late CP group.

Cranioplasty Using Autoclaved Autologous Skull Bone Flaps Preserved at Ambient Temperature.

Context:Decompressive craniectomy followed by cranioplasty (CP) uses autologous craniectomy flaps or synthetic materials like titanium. Sterilization and preservation methods for the autologous bone flaps continue to be the surgeon's choice.Aim:This study aimed to assess the short-term as well as long-term clinical outcomes of CP using autoclaved autologous bone grafts.Settings and Design:This retrospective observational study was performed on patients admitted in a tertiary care teaching neurosurgery department.Patients and Methods:Seventy-two patients who underwent CP with autoclaved autologous skull flaps preserved under ambient conditions with strict aseptic precautions were included in the study.Statistical Analysis Used:Frequencies and percentages of the various characteristics before and after the surgery were tabulated. Continuous variables were summarized as means and standard deviations.Results:The primary CP had a satisfactory clinical outcome in 62 cases (86.11%). Osteomyelitis was observed in four patients (5.56%) nearly 2 months after the surgery. Radiologically significant bone resorption was noted in a single patient (1.39%) after 1 year. Five patients (6.94%) developed bone fragmentation or fracture, and the mean time taken for this was about 36 months. In all these ten cases, secondary CP was successfully done using a prefabricated, patient-specific titanium mesh.Conclusions:The efficacy and safety of the studied craniectomy flaps used for cranial reconstruction showed a good patient outcome. Further retrospective studies with larger cohorts and prospective case–control studies are essential so as to issue standard guidelines for sterilization and preservation of autologous bone flaps.

Risk of Complications with Simultaneous Cranioplasty and Placement of Ventriculoperitoneal Shunt.

The development of hydrocephalus (HCP) necessitating placement of a ventriculoperitoneal shunt (VPS) after decompressive hemicraniectomy occurs at a rate of approximately 5%-15%. The ideal approach for addressing both HCP and a cranial defect remains unclear, and whether concomitant VPS and cranioplasty (CP) increases the risk of complications is uncertain. This is a retrospective cohort study of adult patients who underwent CP and VPS placement for any indication at Harborview Medical Center, Seattle between March 2004 and November 2014 with at least 30 days of follow-up. The primary variable of interest was the timing of CP relative to VPS placement. The outcomes of interest were CP- and VPS-related infections, early (within 1 year of placement) VPS obstruction, and a composite of any of these complications in a single patient. The rate of composite outcomes was 15% in the subgroup of patients with simultaneous CP and VPS placement, compared with 29% in the subgroup of patients in whom CP and VPS placement were performed separately, a non-statistically significant difference (P= 0.24). Similarly, there was no statistically significant difference between the subgroups in any of the 3 individual outcomes of interest, which remained after accounting for potential covariates in a multivariate regression model. In our study population, there was no difference between simultaneous and separate CP and VPS placement with respect to CP infection, VPS infection, and VPS mechanical failure/obstruction. There is equipoise in the current literature regarding the safety of performing these 2 common procedures simultaneously, with studies of similar size and design finding variable degrees of safety of this practice.

Clinical observation on the early replantation of autologous periosteum-preserved skull flap

Objective To investigate the feasibility of preservation of the skull flap covered with periosteum in vivo and early cranioplasty in patients with decompressive craniectomy. Methods Sixty-seven patients underwent autologous cranioplasty using periosteum-covered skull flap preserved subcutaneously after decompressive craniectomy from January 2012 to December 2015 at Neurosurgery Department of Rizhao People's Hospital. Their data were retrospectively reviewed. Cranioplasty was conducted within 4-8 weeks after decompression for all patients. Part of the skull flap tissue was obtained in cranioplasty for identification of the bone activity by pathological examination. At follow-up, all patients received CT scan and 34 patients underwent SPECT to assess the healing and survival of skull flap. Results The size of skull flap in the 67 patients with cranioplasty remained the same as that at the time of decompression. Bones were not destructed, focal dead bone was not observed by the pathological examination. The postoperative follow-up lasted 1-2 years and CT scans revealed that the healing rate was 0%, 62.7% (42/67), and (67/67), 100% (53/53) at 1, 6, 12, 24 months after cranioplasty. No skull resorption was reported. Bone survival and good blood supply of the skull flap were demonstrated by SPECT. During the follow-up period, 1 (1.5%) patient had small subcutaneous hematoma, 4 (6.0%) patients developed subcutaneous effusion, and no intracranial or subcutaneous infection was observed. Conclusion Biological activities of skull flap in patients with decompressive craniectomy could remain well through subcutaneous preservation with periosteum, which might be useful for facilitating the good outcome of cranioplasty. Key words: Decompressive craniectomy; Periosteum; Transplantation, autologous; Cranioplasty; Preservation in vivo

Analysis of myocardial fibrosis in children with hypertrophic cardiomyopathy: A report from the pediatric cardiomyopathy registry

Patient safety aspects and the residents' role in spine surgery within a structured training program have recently been investigated. The current work deals with residency training safety aspects for cranioplasty (CP), a standard neurosurgical cranial procedure.Retrospective 2-center study comparing consecutive patients undergoing CP by a supervised neurosurgery resident (teaching cases) with a consecutive series of patients operated on by a board-certified faculty neurosurgeon (nonteaching cases). The primary end point was occurrence of a postoperative complication. Secondary end points were severity (Ibañez degree) of postoperative complications, surgical site infections requiring CP removal and patients' clinical outcome measured with the modified Rankin Scale.A total of 240 CPs (137 teaching [57.1%] and 103 nonteaching [42.9%] cases) were analyzed. The mean teaching case operation time was longer (129.2 vs. 115.8 minutes; P < 0.001), and there was no difference in the estimated blood loss (mean 243.3 vs. 223.1 mL; P = 0.444). Supervised residents were as likely as board-certified faculty neurosurgeons to have a postoperative complication (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.42–1.39; P = 0.385) and the severity was comparable (Pearson χ2 = 7.62; P = 0.106). Teaching cases were as likely as nonteaching cases to experience a surgical site infection requiring CP removal (OR, 1.66; 95% CI, 0.69–4.04; P = 0.261). Also, the likelihood for postoperative improvement on the modified Rankin Scale was similar for patients in both groups (OR, 1.11; 95% CI, 0.62–2.00; P = 0.719).A relatively simple cranial procedure, such as CP, can be safely performed by a supervised neurosurgery resident without increasing complications or compromising patients' outcomes.

Discussion: Spring-Assisted Cranioplasty for the Correction of Nonsyndromic Scaphocephaly: A Quantitative Analysis of 100 Consecutive Cases.

Discussion: Spring-Assisted Cranioplasty for the Correction of Nonsyndromic Scaphocephaly: A Quantitative Analysis of 100 Consecutive Cases.

Factors Affecting Optimal Time of Cranioplasty: Brain Sunken Ratio.

ObjectiveAfter a rigorous management of increased intracranial pressure by decompressive craniectomy (DC), cranioplasty (CP) is usually carried out for functional and cosmetic purposes. However, the optimal timing of CP remains controversial. Our study aims to analyze the relationship between the optimal timing of CP and the post-operative complications.MethodsFrom January 2013 to December 2015, ninety patients who underwent CP in a single institution were analyzed. We set the independent variables as follows: 1) patient characteristics; 2) the time interval between the DC and CP; 3) operation time; 4) anesthesia time; and 5) pre-operative computed tomography (CT) findings such as a degree of sunken brain by ratio of A (the median length from scalp to midline) to B (the length from midline to inner table of skull at this level). The dependent variables of this study are the event of post-operative complications.ResultsThe overall complication rate was 33.3%. There was no statistical significance in the time interval between the DC and CP in the groups with and without complications of CP (p=0.632). However, there was a significant statistical difference in the degree of sunken brain by ratio (A/B) between the two groups (p<0.001).ConclusionFrom this study, we conclude that it is better to determine the optimal timing of CP by the pre-operative CT finding than by the time interval between the DC and CP. Hereby, we suggest a potentially useful determinant of optimal timing of CP.

Comparison of Complications Following Cranioplasty Using a Sterilized Autologous Bone Flap or Polymethyl Methacrylate.

ObjectiveThe aims of current study are to compare complications following cranioplasty (CP) using either sterilized autologous bone or polymethyl methacrylate (PMMA), and to identify the risk factors for two of the most common complications: bone flap resorption (BFR) and surgical site infection (SSI).MethodsBetween January 2004 and December 2013, 127 patients underwent CP and were followed at least 12 months. Variables, including sex, age, initial diagnosis, time interval between decompressive craniectomy (DC) and CP, operation time, size of bone flap, and presence of ventriculo-peritoneal shunt, were analyzed to identify the risk factors for BFR and SSI.ResultsA total of 97 (76.4%) patients underwent CP using PMMA (Group I) and 30 (23.6%) underwent CP using autologous bone (Group II). SSI occurred in 8 (8.2%) patients in Group I, and in 2 (6.7%) in Group II; there was no statistically significant difference between the groups (p=1.00). No statistically significant risk factors for SSI were found in either group. In Group I, there was no reported case of BFR. In Group II patients, BFR developed in 18 (60.0%) patients at the time of CP (Type 1 BFR), and at 12-month follow up (Type 2 BFR) in 4 (13.3%) patients. No statistically significant risk factors for BFR were found in Group II.ConclusionCP using sterilized autologous bone result in a significant rate of BFR. PMMA, however, is a safe alloplastic material for CP, as it has low complication rate.

Analysis of the treatment strategies and surgical complications of hydrocephalus after decompressive craniectomy

Objectives To investigate the reasonable operation time and operation approaches of the hydrocephalus treatment after decompressive craniectomy and to count its complication characteristics. Methods From January 2009 to February 2015, the clinical data of 54 patients treated with cranioplasty and ventricular peritoneal (V-P) shunt at the same time (n=21) or different time (n=33) at the Department of Neurosurgery, Shandong Jiaotong Hospital and the Emergency Surgery, Qilu Hospital of Shandong University were analyzed retrospectively. The operation time of both procedures and the operation related complications were analyzed and discussed. Results The surgical complication rate was 32% (17/54). The occurrence rates of complications of cranioplasty and V-P shunt groups over the same period were higher than those of the staging operation group (57% vs. 15%; P<0.05). The incidence of postoperative infection of the synchronous operation group was significantly higher than that of the staging operation group (P<0.02). The incidence of postoperative complication in patients with flap bulging was higher than that in patients with flap depression (40% vs. 16%, P<0.05). There were no statistical significance in the effects of successively order, skull defect area, and degree of hydrocephalus on complications of the cranioplasty and V-P shunt between the 2 groups, however, 13 patients did not treated with V-P shunt because of their hydrocephalus were improved significantly after the first cranioplasty. Conclusions Because of its lower incidence of complications, the staging cranioplasty and V-P shunt might be more beneficial to the treatment of patients, especially for those with obvious flap bulging. Because the order of 2 procedures did not have any effect on postoperative complications and no need to perform V-P shunt after partial cranioplasty, therefore, it was recommended that patients without flap bulging should conduct cranioplasty first. Key words: Decompression, Surgery; Hydrocephalus; Neurosurgical procedures; Postoperative complications

Cranioplasty in neurosurgery: is there a way to reduce complications?

Cranioplasty (CPL) is a surgical procedure that has still a high rate of complications, although it is commonly considered an easy and routine operation. In the literature, cranioplasty complications may rise up to 41% of cases, and the most frequently reported are infections, autologous bone flap resorption, and hematomas. Although possible, poor cosmetic results are rarely mentioned. We retrospectively analyzed the cases of 313 patients who underwent 377 surgical procedures for cranioplasty and reoperations for complications between 2008 and 2014. In other 2 patients we performed a new surgical procedure for the prosthesis fracture. Pediatric patients (aging from 5 to 17 years) have been included in this series in order to compare the complication rate between adult and pediatric populations. The clinical-radiological follow-up of these 313 patients lasted between 1 and 6 years. Overall complications for cranioplasty were seen in 38 (12.14%) out of the 313 patients. However, complications requiring surgical therapy were seen in 28 patients who underwent 64 new surgical procedures. Adult male patients represented the majority of the group with cranioplasty complications. In the pediatric group we have not observed any complication requiring more than a clinical observation. Infections and autologous bone resorption were the most frequent complications reported in this series; however, we observed a poor cosmetic result as a concomitant but separate complication in more than 26% of our 313 patients. In this paper we present an overview of all the possible complications of cranioplasty reported in the literature, comparing them with those observed in our series. We also discuss critically the most evident causes of complications, suggesting, when possible, solutions to avoid or limit them.

Timing, Outcome, and Complications of Cranioplasty after Decompressive Hemicraniectomy in Patients Suffering from Traumatic Brain Injury or Malignant Brain Infarction: A Retrospective Single-Center Study

Objective: Cranioplasty (CP) as established skull integrity restoring procedure is often performed after decompressive hemicraniectomy (DHC) in patients suffering from refractory ICP elevation caused by traumatic brain injury (TBI) or malignant brain infarction (MBI). However timing of CP and associated postoperative complications (e.g., hematoma, infections and hydrocephalus) are controversial discussed as well as the usage of cranioplastic material.