Bone flap resorption: Risk factors for the development of a long-term complication following cranioplasty after decompressive craniectomy.
ABSTRACT Aseptic bone flap resorption (BFR) is a known long-term complication after cranioplasty (CP). We analyzed our institutional data in order to identify risk factors for BFR. From October 1999 to April 2012, 254 patients underwent CP after decompressive craniectomy (DC) at our institution and had a long-term follow-up period of more than 1 year after CP (range 12-146 months). Overall, BFR occurred in 10 of 254 patients as long-term complication after CP (4%). BFR developed more often in patients aged ≤ 18 years (p=0.008), in patients who previously underwent DC due to traumatic brain injury (p=0.04), and in patients with multiple fractures within the reinserted bone flap (p=0.002). Furthermore, BFR developed significantly more often in patients who underwent cranioplasty ≤ 2 months after DC (p=0.008), as well as in patients with wound healing disturbance or abscess as an early complication after the CP procedure (p=0.01). The multivariate analysis of the present data identified the presence of multiple fractures within the bone flap (p=0.002, OR 10.3, 95% CI 2.4-43.8), wound infection after CP (p=0.003, OR 12.3, 95% CI 2.3-65.3), and cranioplasty performed ≤ 2 months after DC (p=0.01, OR 6.3, 95% CI 1.5-26.3) as independent risk factors for the development of BFR after CP in a large series with long term follow-up. This might influence future surgical decision making, especially in patients fulfilling high risk criteria for developing BFR.
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ABSTRACT: Aim of the study was a comparison of cranioplasty using the Tutoplast technology for autogenic bone processing and conventional polymethylmethacrylate (PMMA) calvarial re- construction. A retrospective analysis was carried out in a consecutive series of 61 plastic reconstructions for skull defects, the largest measuring more than 12 cm. Cranioplasty was either performed with PMMA or with the patient's own bone graft which had been recycled using the Tutoplast process. 36 patients with a mean age of 44 (range 10-68) years underwent freehand PMMA cranioplasty following craniectomy for increased intracranial pressure (19 patients, 52.8%), infection (15 patients, 41.7%), or traumatic bone destruction (2 patients, 5.6%). Bilateral procedures were performed in 10 patients (27.8%). Mean follow-up was 44 months. Four patients (11.1%) died, 14 (38.9%) remained severely disabled, and 18 (50%) made a satisfactory recovery. Two patients (5.6%) had PMMA-related complications and required removal. 26 patients exhibited at least satisfactory cosmetic results (83.9%), in 5 patients the results were not satisfactory (16.1%) and in 5 the results are unknown. Twenty-five patients with a mean age of 42 (range 2-68) years received Tutoplast processed autografts following craniectomy for elevated intracranial pressure. Bilateral procedures were performed in 3 patients (12%). Mean follow-up was 15 months. One patient (4%) died, 18 (72%) remained severely disabled, and 6 (24%) made a satisfactory recovery. All patients had satisfactory cosmetic results, but 2 patients (8.3%) required removal at a later stage, one due to infection (4.2%) and one for bone resorption (4.2%). In the 18 patients with follow-up >0.5 years significant resorption occurred in all 5 children and adolescents (100%) and in two adult patients (15.4%). Cosmetic results were more satisfactory with Tutoplast processed autografts, and the operating time for unilateral surgery was shorter. Complication rates were similar. Resorption occurred in all children and adolescents, but was rare in adults. Thus, Tutoplast processed autogenic bone grafts can be a reasonable alternative to other methods of cranioplasty in adult patients with large craniotomy defects. Cranioplasty in children and adolescents remains an unsolved problem.Zentralblatt für Neurochirurgie 12/2007; 68(4):182-9. · 0.63 Impact Factor
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ABSTRACT: INDICATIONS FOR SURGERY: An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patient's Glasgow Coma Scale (GCS) score. All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring. A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg. TIMING: In patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible. METHODS: If surgical evacuation of an acute SDH in a comatose patient (GCS < 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.Neurosurgery 04/2006; 58(3 Suppl):S16-24; discussion Si-iv. · 2.53 Impact Factor
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ABSTRACT: Malignant infarction of the middle cerebral artery (MCA) is associated with an 80% mortality rate. Non-randomised studies have suggested that decompressive surgery reduces this mortality without increasing the number of severely disabled survivors. To obtain sufficient data as soon as possible to reliably estimate the effects of decompressive surgery, results from three European randomised controlled trials (DECIMAL, DESTINY, HAMLET) were pooled. The trials were ongoing when the pooled analysis was planned. Individual data for patients aged between 18 years and 60 years, with space-occupying MCA infarction, included in one of the three trials, and treated within 48 h after stroke onset were pooled for analysis. The protocol was designed prospectively when the trials were still recruiting patients and outcomes were defined without knowledge of the results of the individual trials. The primary outcome measure was the score on the modified Rankin scale (mRS) at 1 year dichotomised between favourable (0-4) and unfavourable (5 and death) outcome. Secondary outcome measures included case fatality rate at 1 year and a dichotomisation of the mRS between 0-3 and 4 to death. Data analysis was done by an independent data monitoring committee. 93 patients were included in the pooled analysis. More patients in the decompressive-surgery group than in the control group had an mRS<or=4 (75%vs 24%; pooled absolute risk reduction 51% [95% CI 34-69]), an mRS<or=3 (43%vs 21%; 23% [5-41]), and survived (78%vs 29%; 50% [33-67]), indicating numbers needed to treat of two for survival with mRS<or=4, four for survival with mRS<or=3, and two for survival irrespective of functional outcome. The effect of surgery was highly consistent across the three trials. In patients with malignant MCA infarction, decompressive surgery undertaken within 48 h of stroke onset reduces mortality and increases the number of patients with a favourable functional outcome. The decision to perform decompressive surgery should, however, be made on an individual basis in every patient.The Lancet Neurology 03/2007; 6(3):215-22. · 23.92 Impact Factor