Interventional neurorehabilitation for promoting functional recovery post-craniotomy: a proof-of-concept.

The human brain is a highly plastic 'complex' network-it is highly resilient to damage and capable of self-reorganisation after a large perturbation. Clinically, neurological deficits secondary to iatrogenic injury have very few active treatments. New imaging and stimulation technologies, though, offer promising therapeutic avenues to accelerate post-operative recovery trajectories. In this study, we sought to establish the safety profile for 'interventional neurorehabilitation': connectome-based therapeutic brain stimulation to drive cortical reorganisation and promote functional recovery post-craniotomy. In n = 34 glioma patients who experienced post-operative motor or language deficits, we used connectomics to construct single-subject cortical networks. Based on their clinical and connectivity deficit, patients underwent network-specific transcranial magnetic stimulation (TMS) sessions daily over five consecutive days. Patients were then assessed for TMS-related side effects and improvements. 31/34 (91%) patients were successfully recruited and enrolled for TMS treatment within two weeks of glioma surgery. No seizures or serious complications occurred during TMS rehabilitation and 1-week post-stimulation. Transient headaches were reported in 4/31 patients but improved after a single session. No neurological worsening was observed while a clinically and statistically significant benefit was noted in 28/31 patients post-TMS. We present two clinical vignettes and a video demonstration of interventional neurorehabilitation. For the first time, we demonstrate the safety profile and ability to recruit, enroll, and complete TMS acutely post-craniotomy in a high seizure risk population. Given the lack of randomisation and controls in this study, prospective randomised sham-controlled stimulation trials are now warranted to establish the efficacy of interventional neurorehabilitation following craniotomy.

Custom Fabrication of a 3-Dimensionally Printed Helmet for Improved Socialization and Subjective Self-Assessment in a Case of Acquired Cranial Defect: A Case Presentation.

Traumatic injury and subsequent residual cosmetic deformity are subject of intense scrutiny for their effects on objective health measures assessing patient morbidity and mortality. Although these remain principal concerns of all members of the treatment team, of less immediate yet lasting importance to the patient are the social costs of such disfigurement. Subjective feelings of unease and embarrassment can hinder social reintegration and encourage deteriorating psychosocial health. The following presents a case of one such individual who sustained traumatic brain injury and associated pneumocephalus and osteomyelitis requiring surgical debridement with bifrontal craniectomy and lobotomy. Postoperative management was cosmetically improved by the application of a custom-fabricated, 3-dimensionally printed helmet used in place of generic over-the-counter hardware, and the associated improvement reported in patient satisfaction is reported. LEVEL OF EVIDENCE: V.

Treatment of postsurgical temporal hollowing with high-density porous polyethylene.

Temporal hollowing is most frequently an acquired defect and can be caused by a volumetric deficiency of bone, soft tissue, or both. Given high-density porous polyethylene's ease of use, customizability, long-term strength and resiliency, and successful application in other areas of the craniofacial skeleton, the authors have used it as the first-line material for reconstruction of temporal hollowing. Herein, we present 4 illustrative cases demonstrating this technique and further describe subtypes of the temporal defect with appropriate means of reconstruction. The cases were reviewed for comorbidities, intraoperative details, and the postoperative course. There were no complications, and all patients were pleased with their final result. High-density porous polyethylene is a safe, well-studied, and easily handled biomaterial that is useful for the treatment of temporal hollowing.

Is there a therapeutic role for cranioplasty?

Cranioplasty is often undertaken as a joint neurosurgical and maxillofacial procedure. The principal aims remain to improve cosmesis and to protect the underlying brain. We report two cases of cranioplasty with subsequent improvement in neurological function and discuss the possible therapeutic role of cranioplasty.

Do patients have any special medical or rehabilitation difficulties after a craniectomy for malignant cerebral infarction during their hospitalization in a physical medicine and rehabilitation department?

OBJECTIVES: To observe whether medical complications, the evolution of neurological disorders and dependence and/or the discharge destinations are different for patients treated by craniectomy for malignant cerebral infarction in the middle cerebral artery compared to patients treated medically for severe or malignant cerebral infarction in the same cerebral territory, during their hospitalization in a physical medicine and rehabilitation department. PATIENTS AND METHODS: This retrospective study compared patients treated by craniectomy for malignant cerebral infarction in the middle cerebral artery and patients treated medically for severe or malignant cerebral infarction in the same cerebral territory. Patients were paired according to age, lesion side and hospitalization period. RESULTS: Twelve patients treated by craniectomy (age 43+/-10.44) were paired with 12 patients treated medically (age 49+/-7.66). The two groups were comparable in terms of general undesirable medical events. The medical events related to craniectomy are described. The evolution of patient deficiencies, the length of the hospital stay (194+/-118.93 days vs 152+/-94.64 days), the Functional Independence Measure at discharge (87+/-21.28 vs 95+/-22.19) and the number of direct home discharges (7 vs 9) did not significantly differ between groups. DISCUSSION AND CONCLUSION: No more medical problems were observed in the patients treated by craniectomy than in the patients treated medically, except for the medical events specifically related to craniectomy, which extended the hospital stay but had no major repercussions.

Tension pneumoventricle following exposure of shunt chamber.

Pneumocephalus is the presence of air within the intracranial vault. Intraventricular pneumocephalus, also known as pneumoventricle is relatively rare and commonly occurs following cerebrospinal fluid diversion procedures. This may occur immediately or be delayed. Although a small amount of pneumoventriculus is asymptomatic and may not require any treatment, when present under tension it needs to be evacuated. We present a case of tension pneumoventricle following exposure of the shunt chamber, which resulted in deterioration of the patients' neurological condition and required evacuation.

[Free temporoparietal osteomuscular flap for cranioplasty]. / Cranioplastie par lambeau libre ostéomusculaire temporo-pariétal.

PURPOSE: Advances in composite materials for craniofacial reconstruction surgery has tended to limit indications for osteomuscular free flaps which nevertheless must be used for certain septic patients. The purpose of this report was to illustrate the usefulness of the free temoroparietal osteomuscular flap in this particular situation. CASE REPORT: A 47-year-old man underwent surgical repair of an aneurysm of the anterior communicating artery complicated by acute hydrocephaly treated by external then ventriculoperitoneal bypass. The fronto-pteryonal approach was used. The early postoperative period was complicated by osteitis of the cranial piece requiring revision. The revision procedure, performed at the end of the septic period, involved cranioplasty with acrylic cement. Recurrent infection contraindicated any new attempt for prosthetic repair. The patient was treated with a controlateral free temporoparietal osteomuscular flap to achieve cranioplasty. The postoperative period was uneventful with no infection and satisfactory healing. Flap vitality was very satisfactory. The patient's neurological status improved and no further complication developed. DISCUSSION: In certain therapeutic situations, several diffent techniques may be required to overcome postoperative complications or manage particularly difficult cases. A free osteomuscular flap can be a useful alternative for cranioplasty. This technique is rarely used but can offer an optimal solution in selected patients, particularly for second intention revision after failure of prosthetic repair.

Expansion of Medicare's definition of post-acute care transfers.

In October 1998, the definition of a transfer in Medicare's hospital prospective payment system was expanded to include several post-acute care (PAC) providers in 10 high-volume PAC diagnosis-related groups (DRGs). In this methodological article, the authors respond to a congressional mandate to consider more DRGs in the definition. Empirical results support expansion to many more DRGs that are split in ways that understate total PAC volumes, including 25 DRG pairs (with/without complications) and DRG bundles (e.g., infections) that together exhibit high PAC volumes. By contrast, some DRGs (e.g., craniotomy) are questionable PAC candidates because of their heterogenous procedure mix.

Skull reconstruction with a two-part interlocking custom-made titanium plate.

We have used a two-part interlocking titanium plate for cranioplasty in two patients with large skull defects in which reconstruction with a titanium plate was required and extensive contouring of the plate was necessary.

Strategy of craniofacial reconstruction after resection of spheno-orbital "en plaque" meningiomas.

Surgical resection of spheno-orbital "en plaque" meningiomas should be as complete as possible to prevent tumor recurrence and therefore requires a bone reconstruction. We report a series of 20 patients operated on for spheno-orbital "en plaque" meningioma between 1981 and 1993. The surgical treatment included a resection of the involved dura and a wide resection of tumoral bone using a fronto-temporal craniotomy extended to the orbitozygomaticomalar bone ridge. The craniofacial reconstruction was performed in the same operative procedure using iliac bone autograft in 11 patients, internal cortical bone from the bone flap in 8 patients, and a coral graft in 1 patient. The cosmetic result was scored according to the following criteria: superior frontal paralysis, appearance of the orbitomalar bone ridge, shape of the external temporal fossa, and projection of the eyeballs. The cosmetic result was scored as excellent or good in 17 patients, average in 2 patients, and poor in 1 patient. The iliac bone autograft appeared to be the best material for craniofacial reconstruction because it could be modeled easily to the desired shape. However, the reconstruction technique was modified as necessary according to the extent of tumor removal, clinical presentation, and age of the patient.

Reconstruction of craniofacial bone defects with individual alloplastic implants based on CAD/CAM-manipulated CT-data.

Reconstruction of craniofacial bone defects by intraoperative modelling of autogenous or alloplastic materials may cause undesirable results concerning the implant shape or the long-term maintenance of this shape. Furthermore, the use of alloplastic materials to be modelled intraoperatively may result in an inflammatory tissue response. Therefore the question is raised whether CAD/CAM-techniques may be used for the pre-operative geometric modelling of the implant based on helical computed tomography data. A numerically based 3-dimensional model of the skull defect serves as the basis for a freeform-surfaces design of the implant shape, position and thickness, using modelling tools and programmes developed for industrial CAD/CAM. The precise and individual fit of the implant results from generating its margins by the borders of the defect, whereas the implant surface is generated by the geometry of the non-affected neighbouring bone contours. The implant data run a numerically controlled milling machine to fabricate the individual implant. The reconstruction of post-traumatic defects of the forehead, of post-surgical temporal defects after intracranial haemorrhage, and of a parieto-occipital defect due to ablative tumour surgery are presented as the first clinical experiences of this new method.

Colesteatoma gigante de fosa posterior / Giant cholesteatoma of rear fossa

En un varon de 30 años de edad con cefalea de dos años de evolucion asociada a sindroem cerebeloso izquierdo y sindrome de hipertension endocraneal, se realizo una craneotomia de fosa posterior con la exeresis de un gran tumor con resolucion completa de la enfermedad. El estudio histopatologico reporto un colesteatoma o tumor perlado localizado en la fosa posterior lado izquierdo. La evolucion clinica fue excelente con desaparicion de los sintomas y signos neurologicos. El paciente retorno a su trabajo como conductor de camion

[Decompressive craniotomy and its effect on recovery and rehabilitation of the patient]. / Dekompressive Kraniotomie und deren Einfluss auf Erholung und Rehabilitation des Patienten.

The rehabilitation of patients who have to be operated on because of severe craniocerebral trauma and in whom the roof of the cranium must be removed because of severe post-traumatic cerebral oedema, is extremely difficult. The slow rehabilitation and recovery of these patients, who also show psychological changes in most cases, must be attributed to the pathological intracranial conditions which have arisen in consequence of large defects in cranial bones. A causal correlation between severe pathological intracranial conditions, which have arisen not only from trauma but also from bone flap decompressions, and protracted postoperative recovery and difficult rehabilitation has only recently been established. Our experience has shown that rapid rehabilitation of the injured person can only be expected after skullcap reconstruction and normalization of intracranial conditions.

Rehabilitation of physically disabled dentists: a model for a vocationally specific rehabilitation program.

A unique collaborative program whose goal is to facilitate the return of disabled dentists to active dental practice is described. This approach includes comprehensive interdisciplinary evaluation and remediation, and it has succeeded in revealing previously undiagnosed impairments which should be considered in the formulation of a rehabilitation plan. A case report illustrates the process. This program can serve as a model for similar programs addressing the needs of other disabled health care professionals.

[Reconstruction of the base of the skull after ethmoidectomy using a mixed approach. Apropos of a necroscopy case]. / Reconstruction de la base du crâne après ethmoïdectomie par voie mixte. A propos d'une observation nécropsique.

Concerning a necropsic observation in an irradiated patient, the authors report on the current state of their technique for the reconstruction of the base of the skull, using the Galea flap technique and homologous, cryopreserved bone.