Template Routed Patient-Specific Implant for 1-Stage Cranioplasty.

BACKGROUND AND OBJECTIVES: Cranial reconstruction presents a significant challenge in cases involving pathologies with skull invasion, and various techniques have been used, including the intraoperative shaping of titanium mesh and the manual sculpting of bone cement serving as surrogates for the excised bone graft. In the context of prefabricated patient-specific implants (PSIs) for cranioplasty, precise surgical execution of craniotomies is paramount. This ensures optimal congruity between the implant and the defect created during the craniotomy, leading to a successful single-stage procedure encompassing both bone removal and reconstruction. This article presents a meticulous method for achieving such high-fidelity craniotomy and subsequent cranioplasty using PSIs in a single-stage surgery. METHODS: The procedure was implemented for 2 cases of meningiomas with osseous invasion. Through meticulous preoperative planning, the craniotomy template and implant were designed using computer-assisted design and manufactured on a 3-dimensional printer using the patient's computed tomography scans. Intraoperative fabrication of sterile polymethyl methacrylate replicas was achieved through the creation of silicone molds and subsequent injection molding techniques. Predesignated screw holes facilitated neuronavigation-assisted positioning of the template, aligning it accurately with the target site using registration points. Mini-screws firmly secured the template to the skull. Guided by the template, a craniotomy router performed the bone resection. On completion, the implant was affixed into place using plates and screws. RESULTS: This technique demonstrably facilitated a cost-effective, streamlined and precise application of prefabricated PSIs within a single-stage craniotomy-cranioplasty procedure. Subjective patient reports indicated high levels of satisfaction with the outcome. CONCLUSION: The template routed patient-specific implant 1-stage cranioplasty technique refines previous approaches through precise template localization on the skull, enabling an accurate craniotomy to match a prefabricated PSI. This single-stage procedure rivals hand-shaped methods in aesthetics and compares with the outcomes of 2-stage PSI cranioplasties. Additional studies are needed to validate our results.

Prognostic variables predict clinical outcome after decompressive craniectomy: A single institute experience; A retrospective study.

Decompressive craniectomy (DC) is a well-established neurosurgical intervention in patients with high intracranial pressure who fail to respond to medical treatment. Data on predictive factors for functional outcomes in patients with DC who have malignant middle cerebral artery (MCA) infarction as opposed to intracranial hemorrhage (ICH) are scarce. Eighty-four patients who underwent DC treatment for ICH and malignant MCA infarction were examined. All patients underwent surgery in the Bahrain Salmaniya Medical Complex Neurosurgery Unit between January 2017 and June 2021. To determine whether any of these demonstrated a link to the functional outcome, radiographic factors were compared with clinical data. The postsurgical midline shift (MLS) (ICH group) showed the strongest correlation (ρ = 0.434; P = .006), as in the MCA infarction group as well (ρ = 0.46; P = .005). Further analyses using binary logistic regression with postsurgical basal cistern status and ∆ MLS, and it was observed to be statistically significant (odds ratios: 0.067, 95% CI: 0.007, 0.67; P = .021). The initial Glasgow coma scale, postsurgical MLS, basal cistern status, and ∆ are Measurable variables that can be used to predict outcomes in the groups with ICH and MCA infarction.

Blister-like Cerebral Aneurysm after Endovascular Catheterization: A Case Report and Literature Review.

Endovascular procedures have become a mainstay in the treatment of neurovascular pathologies like arteriovenous malformations and aneurysms. Catheter-induced blister-like aneurysms (BBAs) have not been described so far in the neurosurgical literature. The authors report a rare case of a possible, catheter-induced (iatrogenic) BBA of the supra-ventral wall of the internal carotid artery (ICA) post-endovascular coiling for posterior communicating artery (PComA) aneurysm and bring the rapid progression of BBA and the grade prognosis. A 46-year-old female presented with convulsions. Imaging studies showed diffuse subarachnoid haemorrhage (SAH) and a right saccular PComA aneurysm. Endovascular coiling of the aneurysm was performed, and it was uneventful. The patient had a good outcome (modified Rankin Scale of 1) with no neurological deficits and was discharged home on day five. However, on day nine after the first ictus, she experienced a severe headache at home and was rushed to the emergency room where she collapsed. A cranial computed tomography scan showed intracerebral haemorrhage with intraventricular extension and SAH. A cerebral angiogram showed a BBA of the supra-ventral wall of the ICA. A BBA needs to be considered as a complication of an endovascular procedure that may result in rapid neurological deterioration post-coiling due to rupture. The report also illustrates the rapid and catastrophic presentation of BBA.

Immunoglobulin G4-Related Disease Masquerading an Epidural Spinal Cord Tumor.

Background Immunoglobulin G4-related disease (IgG4-RD) is a recently identified multisystemic fibroinflammatory condition of unclear etiology. IgG4-RD of the epidural tissue causing spinal cord compression is extremely rare. Case description Here, we present a 27-year-old male with epidural mass, causing spinal cord compression at the level of D5-D6. The mass proved pathologically to be epidural inflammatory pseudotumor (IPT) related to IgG4. Spinal decompression was done. The patient was started on steroid treatment and reported a complete resolution of his symptoms over a 3 years' follow-up period. Conclusion To the authors' knowledge, this is the first case of IgG4-related epidural IPT and spinal cord compression in Bahrain and the Middle East. IgG4-RD should always be considered as a part of the differential diagnosis of spinal tumors.

Cold-Injection Molded Gentamicin-Impregnated Polymethyl Methacrylate Implants for Cranioplasty.

BACKGROUND: Cranioplasty can be carried out using either fresh, frozen autologous bone or synthetic substitutes. Ordering artificial 3 dimensional (3D) implants is challenging and time consuming depending on geographical location. In this article, we share our experience using a streamlined process of producing 3D computer-assisted design (CAD) implants using commercially available 3D printers and silicone molds that can be easily replicated with consistent results and are associated with good outcomes. OBJECTIVE: To develop patient-specific implants for patients with cranial defects that are accurate, consistent, low cost, and easy to replicate while reducing operator-dependent factors. METHODS: We present data from 15 patients who underwent cranioplasty with 3D CAD-designed gentamicin-impregnated bone cement implants that were molded using the cold injection technique. RESULTS: The technique was consistent in result production, required little postdemolding manipulation, and showed no dimensional variation in design. Postoperative computed tomography scans showed excellent implant fit, and patients had a low complication rate. CONCLUSION: We have demonstrated a technique of mold preparation that is efficient and that produces a reliable result. Polymethyl methacrylate implants molded using this technique showed better reproducibility, higher accuracy, and precision than other types of implants and required minimal postdemolding clean-up.