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1.
World Neurosurg ; 133: e627-e632, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31568916

RESUMO

BACKGROUND: Decompressive craniectomy (DC) is a surgical procedure performed to manage intracranial hypertension. Once performed, patients are obligated to undergo another surgical procedure known as cranioplasty to reconstruct the cranial defect. Cranioplasty still has one of the highest rates of infection. The factors contributing to the high rate of surgical site infection (SSI) after cranioplasty are not well established. This study aims to estimate the incidence of SSI and determine its possible risk factors for patients who underwent cranioplasty using bone flaps subcutaneously preserved in abdominal pockets. METHODS: A retrospective cohort study was conducted to investigate the predictors of infection among patients who underwent cranioplasty from subcutaneously preserved bone flaps in abdominal pockets between January 2005 and December 2018 at a level l trauma center. RESULTS: A total of 103 cases of cranioplasty from subcutaneously preserved bone flaps were included in the study. The mean age of the patients was 31.2 ± 14.8 years (range, 5-67 years). The median interval between DC and cranioplasty was 115 days. The most frequent indication for DC was traumatic brain injury (76.4%). The incidence of SSI was noted in 15.7% of patients. The most significant predictors of infection in patients requiring cranioplasty were blood glucose levels and skull defect size (P = 0.03 and P = 0.02, respectively). CONCLUSIONS: Blood glucose levels and skull defect size were the only identifiable risk factors associated with SSI. Storing bone flaps in subcutaneous abdominal pockets is cost-efficient but carries considerable risk of infection.


Assuntos
Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Retalhos Cirúrgicos , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Adolescente , Adulto , Idoso , Criança , Estudos de Coortes , Craniectomia Descompressiva/efeitos adversos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Crânio/cirurgia , Adulto Jovem
2.
J Stroke Cerebrovasc Dis ; 28(11): 104361, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31515185

RESUMO

BACKGROUND AND PURPOSE: Spontaneous supratentorial intracerebral hemorrhage (ICH) contributes disproportionately to stroke mortality, and randomized trials of surgical treatments for ICH have not shown benefit. Decompressive hemicraniectomy (DHC) improves functional outcome in patients with malignant middle cerebral artery ischemic stroke, but data in ICH patients is limited. We hypothesized that DHC would reduce in-hospital mortality and poor functional status (defined as modified Rankin scale ≥5) among survivors at 3 months, without increased complications. METHODS: We performed a retrospective, case-control, propensity score matched study to determine whether hemicraniectomy affected outcome in patients with spontaneous supratentorial ICH. The propensity score consisted of variables associated with outcome or predictors of hemicraniectomy. Forty-three surgical patients were matched to 43 medically managed patients on ICH location, sex, and nearest neighbor matching. Three-month functional outcomes, in-hospital mortality, and in-hospital complications were measured. RESULTS: In the medical management group, 72.1% of patients had poor outcome at 3 months compared with 37.2% who underwent hemicraniectomy (odds ratio 4.8, confidence interval 1.6-14). In-hospital mortality was 51.2% for medically managed patients and 16.3% for hemicraniectomy patients (odds ratio 8.5, confidence interval 2.0-36.8). There were no statistically significant differences in the occurrence of in-hospital complications. CONCLUSIONS: In our retrospective study of selected patients with spontaneous supratentorial ICH, DHC resulted in lower rate of in-hospital mortality and better 3-month functional status compared with medically managed patients. A randomized trial is necessary to evaluate DHC as a treatment for certain patients with spontaneous supratentorial ICH.


Assuntos
Hemorragia Cerebral/cirurgia , Craniectomia Descompressiva/métodos , Adulto , Idoso , Anticoagulantes/uso terapêutico , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/fisiopatologia , Craniectomia Descompressiva/efeitos adversos , Craniectomia Descompressiva/mortalidade , Avaliação da Deficiência , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
3.
J Stroke Cerebrovasc Dis ; 28(11): 104320, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31395424

RESUMO

BACKGROUND: Decompressive hemicraniectomy (DHC) is commonly offered after large spontaneous intracerebral hemorrhage (ICH) as a life-saving measure. Based on limited available evidence, surgery is sometimes avoided in the elderly. The association between age and outcomes following DHC in spontaneous ICH remains largely understudied. OBJECTIVE: The goal of this study is to investigate the influence of older age on outcomes of patients who undergo DHC for spontaneous ICH. METHODS: In this retrospective cohort study, inpatient data were obtained from the United States Nationwide Inpatient Sample from 2000 to 2011. Using International Classification of Diseases, ninth revision designations, patients with a primary diagnosis of nontraumatic ICH who underwent DHC were identified. The primary outcome of interest was the association of age to inpatient mortality and poor outcome. Subjects were grouped by age: 18-50, 51-60, 61-70, and more than 70 years. Sample characteristics were compared across age groups using χ2 testing, and univariate and multivariate Poisson Regression was performed using a generalized equation to estimate rate ratios for primary and secondary outcomes. RESULTS: One thousand one hundred and forty four patient cases were isolated. Death occurred in an estimated 28.9% and poor outcome in 86.4%. In multivariate Poisson regression models, there was no difference in hospital mortality or poor outcome by age group. Although younger patients were more likely to be diagnosed with herniation, total complication rate was similar between age groups. CONCLUSIONS: Our study results do not provide evidence that age independently predicts in-hospital mortality or poor outcomes. The true influence of age on outcomes is unclear, and further study is needed to determine which factors may be best in selecting candidates for DHC following spontaneous ICH.


Assuntos
Hemorragia Cerebral/cirurgia , Craniectomia Descompressiva/efeitos adversos , Adolescente , Adulto , Fatores Etários , Idoso , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/mortalidade , Bases de Dados Factuais , Craniectomia Descompressiva/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Adulto Jovem
4.
World Neurosurg ; 132: e479-e486, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31465852

RESUMO

BACKGROUND: Management of pediatric skull defects after decompressive craniectomy (DC) poses unique problems, particularly in children younger than 24 months. These problems include complications such as resorption and infection as well as difficulties with plagiocephaly and reconstruction. The goal of this study was to evaluate bone resorption complications after cranioplasty in patients <24 months. METHODS: A single-center retrospective case study was performed of all patients younger than 24 months who underwent cranioplasty after DC between 2011 and 2018. The following variables were assessed: injury cause, age at craniotomy, time to cranioplasty, craniectomy size, mode of fixation, drain use, shunt use, subdural fluid collection, resorption, need for synthetic graft revision, and plagiocephaly. RESULTS: A total of 10 patients were identified who met inclusion criteria; 3 patients were excluded for insufficient follow-up. Ages ranged from <1 day to 19 months, with a mean of 10.7 months. Overall rate of cranioplasty resorption was 85.7%, 57.1% of which required revision with synthetic graft. There were univariate trends toward more frequent implant resorption with subdural fluid collection (P = 0.1071) and without shunt placement (P = 0.1429). These effects persisted through multivariable analysis and even reached statistical significance in the case of subdural collection when controlling for operative and demographic characteristics (P = 0.01138, P = 0.0694). In addition, univariate analysis showed a trend toward more frequent neurologic complications with greater craniotomy-to-cranioplasty intervals (P = 0.1043), which reached significance on multivariable analysis (P = 0.00518). CONCLUSIONS: In patients younger than 24 months undergoing cranioplasty subdural collection, a lack of shunt placement and increased time to cranioplasty were associated with increased rates of resorption.


Assuntos
Craniectomia Descompressiva/efeitos adversos , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Reconstrutivos/métodos , Reabsorção Óssea/etiologia , Substitutos Ósseos/uso terapêutico , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Reoperação , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
5.
J Clin Neurosci ; 70: 234-237, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31439481

RESUMO

The objective of this study was to investigate cranioplasty after decompressive craniectomy in hemorrhagic moyamoya disease (MMD). We retrospectively reviewed seven patients with hemorrhagic MMD after decompressive craniectomy from January 1, 2010 to December 31, 2018. Clinical features, radiological findings, and outcomes were analyzed. The study included four females and three males, with a mean age at diagnosis of 38.7 years (range 19-56 years). The mean days between craniectomy and DSA was 255 days (with a range of 92-382 days). Three in seven patients had good spontaneous revascularization, while four patients had poor spontaneous revascularization. For patients with good spontaneous revascularization, the computer-assisted design titanium implants for cranioplasty was cut off on the lower edge of the bone window, and all three patients had no complications after cranioplasty and had relatively stable prognosis. For patients with poor spontaneous revascularization, only two patients received cranioplasty. And one in those had unfavorable outcome because of recurrent hemorrhage. In conclusion, spontaneous revascularization after decompressive craniectomy in MMD patients should be evaluated before cranioplasty, and postoperative treatment should be discussed individually.


Assuntos
Craniectomia Descompressiva/efeitos adversos , Doença de Moyamoya/patologia , Doença de Moyamoya/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Crânio/cirurgia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Próteses e Implantes , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
6.
World Neurosurg ; 130: e941-e952, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31302278

RESUMO

BACKGROUND: Poorly understood cranial fluid accumulations are frequently observed after decompressive craniectomy and often termed "external hydrocephalus." These findings are difficult to explain using traditional models of hydrocephalus. METHODS: Representative cases, clinical management, and literature overview are presented. RESULTS: We present a hypothesis that abnormal cranial fluid accumulations develop after decompressive craniectomy in a vulnerable subset of patients as a result of 1) the large compliant cranial defect with durotomy causing reduced internal brain expansion, ventricular squeezing, and pulsatile cerebrospinal fluid (CSF) circulation; 2) impaired pulsatile CSF flow along major cerebral arteries and the adjoining perivascular spaces (Virchow-Robin spaces); 3) reduced clearance of interstitial fluid by the glymphatic system; and 4) redistribution of CSF from the subarachnoid space into the subdural and subgaleal compartments and the ventricles. CONCLUSION: Closure of the cranial defect with cranioplasty improves cerebral blood flow and CSF pulsatile circulation and is frequently sufficient to resolve the external hydrocephalus.


Assuntos
Líquido Cefalorraquidiano , Craniectomia Descompressiva/efeitos adversos , Sistema Glinfático/diagnóstico por imagem , Hemodinâmica , Hidrocefalia/diagnóstico por imagem , Linfangioma Cístico/diagnóstico por imagem , Adulto , Encéfalo/irrigação sanguínea , Encéfalo/diagnóstico por imagem , Encéfalo/fisiologia , Líquido Cefalorraquidiano/fisiologia , Craniectomia Descompressiva/tendências , Feminino , Sistema Glinfático/fisiologia , Hemodinâmica/fisiologia , Humanos , Hidrocefalia/etiologia , Hidrocefalia/fisiopatologia , Hidrodinâmica , Linfangioma Cístico/etiologia , Linfangioma Cístico/fisiopatologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia
7.
BMJ Case Rep ; 12(6)2019 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-31189547

RESUMO

Decompressive craniectomy is a life-saving procedure performed to treat intracranial hypertension caused by a variety of conditions. Subsequent cranioplasty reconstruction is needed for brain protection. Different alloplastic materials with different advantages and disadvantages are available for cranial reconstruction. We present the first case of a deformed titanium cranioplasty mesh in a paediatric patient following head trauma. Children who have undergone cranioplasty reconstruction should be counselled to wear a protective helmet when involved in contact sports or activities that may put their implant at risk of trauma.


Assuntos
Traumatismos Craniocerebrais/cirurgia , Craniectomia Descompressiva/efeitos adversos , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Fraturas Cranianas/cirurgia , Retalhos Cirúrgicos/efeitos adversos , Telas Cirúrgicas/efeitos adversos , Criança , Traumatismos Craniocerebrais/complicações , Humanos , Masculino , Falha de Prótese , Fraturas Cranianas/etiologia , Titânio
8.
World Neurosurg ; 128: e841-e850, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31082551

RESUMO

OBJECTIVE: Cranioplasty is a technically simple procedure intended to repair defects of the skull to provide protection after craniectomy, improve functional outcomes, and restore cosmesis. Several materials have been used for the restoration of skull defects, including autologous bone grafts (AGs), polymethyl methacrylate (PMMA) flaps, and titanium mesh (T-mesh). However, the long-term results of cranioplasty after use of these materials are controversial. METHODS: Medical records of 596 patients who underwent cranioplasty at our medical center between 2009 and 2015 with at least 2.5 years of follow-up were retrospectively reviewed. Patients were classified into 3 groups according to the materials used: AG, three-dimensional PMMA, and T-mesh. Demographic and clinical characteristics and postoperative complications were analyzed. RESULTS: Cranioplasty with AG had the highest bone flap depression rate (4.9%; P = 0.02) and was associated with a 26% long-term bone flap resorption. Younger age was a risk factor for bone flap resorption. T-mesh had a higher risk of postoperative skin erosion and bone exposure (17%; P = 0.004). Patients with diabetes, previous craniotomy, or hydrocephalus showed a higher risk of postoperative skin erosion. PMMA was associated with the highest rate of postoperative infection (14.4% <3 months, 28.1% >3 months; P < 0.05), and previous craniotomy may increase the infection risk after cranioplasty with PMMA. CONCLUSIONS: Complications after cranioplasty are high, and the various types of cranioplasty materials used are associated with different complications. Surgeons need to be aware of these potential complications and should choose the appropriate material for each individual patient.


Assuntos
Cimentos para Ossos/efeitos adversos , Transplante Ósseo/efeitos adversos , Craniotomia/efeitos adversos , Craniectomia Descompressiva/métodos , Polimetil Metacrilato/efeitos adversos , Telas Cirúrgicas/efeitos adversos , Titânio/efeitos adversos , Adulto , Fatores Etários , Idoso , Craniectomia Descompressiva/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Fatores de Risco , Crânio/cirurgia , Retalhos Cirúrgicos , Adulto Jovem
9.
J Neurol Surg A Cent Eur Neurosurg ; 80(6): 498-502, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31075809

RESUMO

BACKGROUND: Cranioplasty is a common procedure in neurosurgery. It is usually performed following decompressive craniectomy (DC). However, complications may occur after the operation, such as massive brain swelling. Up to now, far too little attention has been given to this severe complication. We report one case of fatal cerebral swelling after cranioplasty and analyze the possible mechanism of this complication. CASE DESCRIPTION: The patient was a 40-year-old man who had a severe right basal ganglia cerebral hemorrhage and underwent DC ∼ 2 months before. One day before scheduled cranioplasty, a lumbar cerebrospinal fluid drainage was placed. The cranioplasty itself was uneventful. However, he gradually fell into a coma, and his right pupil was moderately dilated 20 hours after the surgery. A brain computed tomography (CT) scan indicated massive right cerebral edema with compressed right midbrain. The patient did not regain consciousness, and he remained quadriplegic. CONCLUSION: It is necessary to increase awareness of complications of cranioplasty in high-risk patients. The lessons learned from this case include avoiding excessive drainage of cerebrospinal fluid. Patients with low-density lesions in the brain need to be treated with caution. Once the CT scan shows massive cerebral swelling, the patient has a poor prognosis.


Assuntos
Hemorragia dos Gânglios da Base/cirurgia , Edema Encefálico/etiologia , Craniectomia Descompressiva/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Adulto , Hemorragia dos Gânglios da Base/diagnóstico por imagem , Edema Encefálico/diagnóstico por imagem , Drenagem , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Tomografia Computadorizada por Raios X
10.
World Neurosurg ; 129: e81-e86, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31096024

RESUMO

BACKGROUND: Cranioplasty (CP) is an obligatory surgery after decompressive craniectomy (DC). The primary objective is to protect the brain from external injury and prevent syndrome of trephined. In a government hospital, such cases pose a significant burden to a trauma center. Because of this reason, cosmetic outcome is never taken into account for the CP. We present results of CP performed at our hospital. METHODS: This is a retrospective review of the cases of CP performed over the past 3 years at our hospital. The cosmetic outcome was divided into 3 grades: 1-good symmetrical, 2-irregularities, 2a-elevated and 2b depressed, and 3-bad cosmetic outcome requiring reoperation. RESULTS: A total of 133 patients with acute brain injury underwent CP during the study period. The outcome was good in 74 (55.6%) and bad, requiring reoperation, in 2 (1.5%) cases. Various types of the CP materials like autologous bone flap, titanium mesh, and customized titanium plates were used. Methods of fixation were threads or miniplates and screws. In univariate analysis, cerebral venous thrombosis as an indication for DC, use of autologous bone flap, and fixation with thread were associated with poor outcome. However, in multivariate analysis only the method of implant fixation was associated with poor outcome. It was found that if screws and plates are used for fixation of bone flap, the chances of bad outcome are reduced by 74.6%. CONCLUSIONS: The cosmetic outcome is overlooked for CP. The bone flap fixation has to be rigid for a good outcome.


Assuntos
Craniectomia Descompressiva/efeitos adversos , Craniectomia Descompressiva/métodos , Estética , Adolescente , Adulto , Lesões Encefálicas/cirurgia , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Reconstrutivos/métodos , Estudos Retrospectivos , Adulto Jovem
11.
World Neurosurg ; 127: 366-369, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31004859

RESUMO

BACKGROUND: The sinking skin flap syndrome, also known as the syndrome of the trephined or the trephination syndrome, occurs in patients who have undergone a decompressive craniectomy. As opposed to this, persistent brain herniation also occurs in patients after a decompressive craniectomy and a cerebrospinal fluid (CSF) drainage procedure is one of the therapies used to reduce it. A continuous lumbar CSF drainage procedure can upset the pressure dynamics of the atmosphere versus intracranial pressures to a point of fatal clinical deterioration and hence needs to be closely monitored. CASE DESCRIPTION: Our case report speaks of persistent brain herniation in which drainage of CSF led to a trephination syndrome, which was reversed once again, by measures to increase CSF production and intracranial pressure. CONCLUSIONS: Timely intervention eventually led to a favorable outcome and avoidance of a catastrophy.


Assuntos
Pressão Atmosférica , Craniectomia Descompressiva/efeitos adversos , Drenagem/efeitos adversos , Dura-Máter/diagnóstico por imagem , Hérnia/diagnóstico por imagem , Pressão Intracraniana , Encefalopatias/diagnóstico por imagem , Encefalopatias/etiologia , Encefalopatias/cirurgia , Dura-Máter/cirurgia , Feminino , Seguimentos , Hérnia/terapia , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia
12.
World Neurosurg ; 127: e1166-e1171, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30995562

RESUMO

BACKGROUND: Hydrocephalus is a common complication following decompressive craniectomy. Ventriculoperitoneal shunt (VPS) is required for some patients before receiving a cranioplasty (CP). The presence of a VPS is regarded as a risk factor for overall CP complications. METHODS: A retrospective survey was conducted on 176 patients with traumatic brain injury who underwent late (>3 months) titanium CP (Ti-CP) in our hospital from April 2014 to July 2018. Thirteen patients (7.4%) had preoperative VPS. Propensity score matching was performed for these 13 patients with a ratio of 1:5. A total of 78 patients were selected. Preoperative clinical parameters and postoperative complications were analyzed. The period of postoperative follow-up ranged from 3 to 63 months (mean 21.3 ± 17.0 months). RESULTS: The overall complication rate was greater in the VPS group (P = 0.010). These patients were more likely to develop a sunken skin flap (P < 0.001). The rate of postoperative cerebral hemorrhage was greater in the VPS group. Logistic analysis showed that preoperative VPS was an independent risk factor for postoperative extradural collection (odds ratio 17.714, P < 0.001). VPS was not related to postoperative infection and seizure. Postoperative drainage duration longer than 2.5 days significantly increased the risk of postoperative infection (odds ratio 7.715, P = 0.023). CONCLUSIONS: The presence of a VPS significantly increased the risk of extradural collection in patients with traumatic brain injury who underwent late Ti-CP. It also was related to postoperative hemorrhage. The sunken skin flap in patients with VPS increased surgical difficulty and the likelihood of extradural accumulation. Preoperative VPS was not related to postoperative infection and seizure in Ti-CP.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/efeitos adversos , Complicações Pós-Operatórias/etiologia , Titânio/efeitos adversos , Derivação Ventriculoperitoneal/efeitos adversos , Adolescente , Adulto , Idoso , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Craniectomia Descompressiva/tendências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos Retrospectivos , Derivação Ventriculoperitoneal/tendências , Adulto Jovem
13.
Seizure ; 69: 11-16, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30952091

RESUMO

Decompressive craniectomy (DC) is used for the treatment of raised intracranial pressure secondary to traumatic brain injury. Cranioplasty is a reconstructive procedure that restores the structural integrity of the skull following (DC). Seizures are a recognised complication of cranioplasty but its incidence and risk factors in TBI patients are unclear. Accurate prognostication can help direct prophylactic and treatment strategies for seizures. In this systematic review, we aim to evaluate current literature on these factors. A PROSPERO-registered systematic review was performed in accordance with PRISMA guidelines. Data was synthesised qualitatively and quantitatively in meta-analysis where appropriate. A total of 8 relevant studies were identified, reporting 919 cranioplasty patients. Random-effects meta-analysis reveals a pooled incidence of post-cranioplasty seizures (PCS) of 5.1% (95% CI 2.6-8.2%). Identified risk factors from a single study included increasing age (OR 6.1, p = 0.006), contusion at cranioplasty location (OR 4.8, p = 0.015), and use of monopolar diathermy at cranioplasty (OR 3.5, p = 0.04). There is an association between an extended DC-cranioplasty interval and PCS risk although it did not reach statistical significance (p = 0.062). Predictive factors for PCS are poorly investigated in the TBI population to date. Heterogeneity of included studies preclude meta-analysis of risk factors. Further studies are required to define the true incidence of PCS in TBI and its predictors, and trials are needed to inform management of these patients.


Assuntos
Lesões Encefálicas Traumáticas/complicações , Craniectomia Descompressiva/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Convulsões/etiologia , Lesões Encefálicas Traumáticas/terapia , Humanos , Complicações Pós-Operatórias/etiologia , Fatores de Risco
14.
Neurol Med Chir (Tokyo) ; 59(5): 172-175, 2019 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-30867358

RESUMO

Cranioplasty following decompressive craniectomy is highly associated with complications. Methods for avoiding these complications have been well-documented; however, approaching reconstruction through the previous incision, especially if it was on or very near the bone defect, can sometimes lead to wound dehiscence and infection, with exposure of the artificial bone. For such complicated cases, we propose a multi-staged preparation that includes creating a delayed skin flap for the actual skull reconstruction. Flap was elevated in three stages, with 4 week intervals between each stage to allow for adequate blood supply. Cranioplasty using custom-made implants was then performed. Four patients (age range, 10-25 years) were prepared for skull reconstruction using this technique. During follow-up period for 12 months, no complications, including infections, exposure of the artificial bone, or flap necrosis, were observed. Despite the multiple stages required, we consider that our technique makes a significant contribution to the literature because it suggests a technique for cranioplasty following decompressive craniectomy that may avoid many of the complications following such cranioplasty using current methods.


Assuntos
Craniossinostoses/cirurgia , Craniectomia Descompressiva/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Reconstrutivos/métodos , Fraturas Cranianas/cirurgia , Retalhos Cirúrgicos , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Próteses e Implantes , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
15.
BMC Surg ; 19(1): 26, 2019 Feb 27.
Artigo em Inglês | MEDLINE | ID: mdl-30813919

RESUMO

BACKGROUND: Subdural effusion with hydrocephalus (SDEH) is a rare complication of traumatic brain injury, especially following decompressive craniectomy (DC) for posttraumatic cerebral infarction. The diagnosis and treatment are still difficult and controversial for neurosurgeons. CASE PRESENTATION: A 45-year-old man developed traumatic cerebral infarction after traumatic brain injury and underwent DC because of the mass effect of cerebral infarction. Unfortunately, the complications of traumatic subdural effusion (SDE) and hydrocephalus occurred in succession following DC. Burr-hole drainage and subdural peritoneal shunt were performed in sequence because of the mass effect of SDE, which only temporarily improved the symptoms of the patient. Cranioplasty and ventriculoperitoneal shunt were performed ultimately, after which SDE disappeared completely. However, the patient remains severely disabled, with a Glasgow Outcome Scale of 3. CONCLUSIONS: It is important for neurosurgeons to consider the presence of accompanying hydrocephalus when treating patients with SDE. Once the diagnosis of SDEH is established and the SDE has no mass effect, timely ventriculoperitoneal shunt may be needed to avoid multiple surgical procedures, which is a safe and effective surgical method to treat SDEH.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/efeitos adversos , Hidrocefalia/cirurgia , Derrame Subdural/cirurgia , Lesões Encefálicas Traumáticas/complicações , Infarto Cerebral/etiologia , Drenagem , Humanos , Hidrocefalia/etiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Derrame Subdural/etiologia , Resultado do Tratamento , Derivação Ventriculoperitoneal
16.
World Neurosurg ; 126: e1160-e1168, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30880206

RESUMO

BACKGROUND: Temporalis muscle (TM) hollowing is a complication of cranioplasty which diminishes the aesthetical outcome of the surgery and results in suboptimal functional outcome. We present and compare a modified split-temporalis muscle elevated margin cranioplasty using 3-dimensional printed titanium implant with conventional 3-dimensional printed titanium implant cranioplasty to determine an effective treatment method. METHODS: A modified 3-dimensional printed cranial implant was designed where the anteroinferior border of the implant was extended and elevated between the frontozygomatic suture and root of zygomatic process. Furthermore, the implant was placed in between superficial and deep layers of the temporalis muscle. Aesthetical evaluation was carried out at the outpatient clinic, and a quantitative analysis showing the percentage difference in length of the operated and nonoperated sides was performed. RESULTS: For both conventional and augmented groups, there were 0% major or minor complications. Out of 10 conventional cranioplasty patients, there were 3 cases of mild and 1 case of severe TM hollowing, whereas for 10 augmented cranioplasty patients, there was only 1 patient with mild TM hollowing. When a quantitative analysis was carried out, the overall percentage difference in length at the coronal view for conventional and augmented cranioplasty was -2.17% and 0.07%, respectively. CONCLUSIONS: The augmented cranioplasty leads to superior aesthetical outcome, and the quantitative analysis also supports the efficacy of augmented cranioplasty. The surgery is technically simpler than the conventional method, therefore lowering the risk of surgical complications. Therefore, we hope that the modified cranioplasty method will be considered as an effected cranioplasty method for preventing TM hollowing.


Assuntos
Impressão Tridimensional , Próteses e Implantes , Procedimentos Cirúrgicos Reconstrutivos/métodos , Crânio/cirurgia , Adolescente , Adulto , Idoso , Craniectomia Descompressiva/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Titânio , Adulto Jovem
17.
J Clin Neurosci ; 63: 62-67, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30827885

RESUMO

Decompressive craniectomy (DC) has been performed increasingly to control medically refractory intracranial hypertension in patients with traumatic brain injury (TBI). Although DC is a potentially life-saving procedure and technically straightforward, it is associated with some significant complications that include subdural hygroma (SDG) and posttraumatic hydrocephalus (PTH). A retrospective analysis of 143 TBI patients who underwent unilateral DC was undertaken to investigate the incidence and risk factors of PTH and investigate the relationship between the types of SDG and PTH. Among these patients, the incidence of PTH was 30.1%. SDG was noted in 25 patients (58.1%) who developed PTH. SDG was noted in 27 patients (27%) without PTH. The patients with PTH had a significantly unfavorable outcome (p < 0.0001). After stepwise logistic regression analyses, only age (p = 0.004, odds ratio [OR] = 1.036, 95% confidence interval [CI] = 1.011-1.061) and contralateral SDG (p < 0.0001, OR = 5.613, 95% CI = 2.232-14.115) remained independently associated with PTH development, and PTH development rate increased by 3.6% with every 1-year increase in age. Close surveillance is indicated in older TBI patients with contralateral SDG after unilateral DC to prompt early detection and timely management of PTH.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/efeitos adversos , Hidrocefalia/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Feminino , Humanos , Hidrocefalia/etiologia , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Derrame Subdural/epidemiologia , Derrame Subdural/etiologia
18.
Seizure ; 66: 15-21, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30772643

RESUMO

PURPOSE: Cranioplasty can improve a patient's psychosocial and cognitive functions after decompressive craniectomy, however seizures are a common complication after cranioplasty. The risk factors for early and late seizures after cranioplasty are unclear. This study is to evaluate the risk factors for early and late seizure after cranioplasty. METHODS: Two hundred and thirty-eight patients who received cranioplasty following craniectomy between January 2012 and December 2014 were included in this study. The risk factors of the patients with early and late post-cranioplasty seizures were compared to those with no post-cranioplasty seizures. RESULTS: Seizures (73/238, 30.3%) were the most common complication after cranioplasty. Of these 73 patients, 17 (7.1%) had early post-cranioplasty seizures and 56 (23.5%) had late post-cranioplasty seizures. Early post-cranioplasty seizures were related to a longer interval between craniectomy and cranioplasty (P = 0.006), artificial materials (P < 0.001), and patients with late post-craniectomy seizures (P = 0.001). Late post-cranioplasty seizures were related to the presence of neurological deficits (P = 0.042). After stepwise logistic regression analysis, a longer interval between craniectomy and cranioplasty (P = 0.012; OR: 1.004, 95% CI: 1.001-1.007) and late post-craniectomy seizures (P = 0.033; OR: 4.335, 95% CI: 1.127-16.675) were independently associated with early post-cranioplasty seizures. CONCLUSION: Delayed cranioplasty procedures and seizures before cranioplasty were significantly associated with early post-cranioplasty seizures. Further studies are warranted to investigate whether early surgery after craniectomy can reduce the risk of early post-cranioplasty seizures.


Assuntos
Craniectomia Descompressiva/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Convulsões/epidemiologia , Convulsões/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Curva ROC , Estudos Retrospectivos , Fatores de Risco , Estatísticas não Paramétricas , Taiwan/epidemiologia , Adulto Jovem
19.
Acta Neurochir (Wien) ; 161(3): 467-472, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30715606

RESUMO

BACKGROUND: Cranioplasty is an increasingly common procedure performed in neurosurgical centres following a decompressive craniectomy (DC), however, timing of the procedure varies greatly. OBJECTIVES: The aim of this study is to compare the surgical outcomes of an early compared to a late cranioplasty procedure. METHODS: Ninety adult patients who underwent a prosthetic cranioplasty between 2014 and 2017 were studied retrospectively. Timing of operation, perioperative complications and length of stay were assessed. Early and late cranioplasties were defined as less or more than 3 months since craniectomy respectively. RESULTS: Of the 90 patients, 73% received a late cranioplasty and 27% received an early cranioplasty. The median interval between craniectomy and cranioplasty was 13 months [range 3-84] in late group versus 54 days [range 33-90] in early group. Twenty-two patients in the early group (91%) received a cranioplasty during the original admission while undergoing rehabilitation. Complications were seen in 25 patients (28%). These included wound or cranioplasty infection, hydrocephalus, symptomatic pneumocephalus, post-operative haematoma and cosmetic issues. The complication rate was 21% in the early group and 30% in the late group (P value 0.46). There was no significant difference in the rate of infection or hydrocephalus between the two groups. Length of stay was not significantly increased in patients who received an early cranioplasty during their initial admission (median length of stay 77 days versus 63 days, P value 0.28). CONCLUSION: We have demonstrated the potential for early cranioplasty to be a safe and viable option, when compared to delayed cranioplasty.


Assuntos
Craniectomia Descompressiva/métodos , Hidrocefalia/epidemiologia , Pneumocefalia/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Infecção da Ferida Cirúrgica/epidemiologia , Adulto , Craniectomia Descompressiva/efeitos adversos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Estudos Retrospectivos , Crânio/cirurgia
20.
Acta Neurochir (Wien) ; 161(3): 483-491, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30617716

RESUMO

BACKGROUND: Changes after reimplantation of the autologous bone have been largely described. However, the rate and the extent of resorption in cranial grafts have not been clearly defined. Aim of our study is to evaluate the bone flap resorption (BFR) after cryopreservation. METHODS: We retrospectively reviewed 27 patients, aged 18 years or older, subjected to cranioplasty (CP) adopting autologous cryopreserved flap. The BFR was derived from the percentage of decrease in flap volume (BFR%), comparing the first post-operative computed tomography (CT) and the last one available (performed at least 1 year after surgery). We also proposed a semiquantitative scoring system, based on CT, to define a clinically workable BFR classification. RESULTS: After a mean ± SE follow-up of 32.5 ± 2.4 months, the bone flap volume decreased significantly (p < 0.0001). The mean BFR% was 31.7 ± 3.8% and correlated with CT-score (p < 0.001). Three BFR classes were described: mild (14.8% of cases) consisting in minimal bone remodelling, CT-score ≤ 6, mean BFR% = 3.5 ± 0.7%; moderate (51.9% of cases) corresponding to satisfactory cerebral protection, CT-score < 13, mean BFR% = 25.6 ± 2.2%; severe (33.3% of cases) consisting in loss of cerebral protection, CT-score ≥ 13, mean BFR% = 54.2 ± 3.9%. Females had higher BFR% than males (p = 0.022). BFR classes and new reconstructive surgery were not related (p = 0.58). CONCLUSIONS: BFR was moderate or severe in 85.2% of re-implanted cryopreserved flaps. The proposed CT-score is an easy and reproducible tool to define resorption extent.


Assuntos
Reabsorção Óssea/diagnóstico por imagem , Craniectomia Descompressiva/efeitos adversos , Complicações Pós-Operatórias/diagnóstico por imagem , Adolescente , Adulto , Idoso , Reabsorção Óssea/classificação , Reabsorção Óssea/cirurgia , Criopreservação , Craniectomia Descompressiva/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Crânio/cirurgia , Retalhos Cirúrgicos/patologia , Retalhos Cirúrgicos/cirurgia , Tomografia Computadorizada por Raios X , Transplante Autólogo
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