Craniocerebral disproportion after decompressive craniectomy in infants: The hidden enemy of cranial repair?

Abstract

Introduction

Cranioplasty aims at restoring the physiological integrity and volume of the skull. Any disproportion between the intracranial content and the volume of the container may favor the occurrence of complications. A classification of volume mismatches is proposed. A negative mismatch, consisting of intracranial content minor to skull volume, is well represented by the sinking flap. On the other side, a positive mismatch, consisting of intracranial content higher than skull volume, usually depends on CSF collection or hydrocephalus once the brain edema is regressed. Though, in children, this condition may result from physiological brain growth after decompressive craniectomy. Treatment algorithm based on this classification is presented.

Illustrative case

A 1-year-old boy with a severe traumatic brain injury underwent right decompressive craniectomy, evacuation of subdural hematoma, and dural expansion at another institution. After failure of autologous bone-assisted cranioplasty for infection, a helmet was recommended in order to postpone the cranial repair. Patient was admitted to our institution 3 years later. CT scan showed brain herniation through the cranial defect, associated to a condition of acquired craniocerebral disproportion, due to the condition of “open skull”. Augmented hydroxyapatite cranioplasty (CustomBone, Finceramica, Faenza, Italy) was performed in order to manage this rare condition of positive volume mismatch. Subsequent course was uneventful and no complication was recorded at 30-month follow-up.

Conclusions

This illustrative case highlights the possible occurrence of a positive structural mismatch between the skull and the intracranial content after decompressive craniectomy, thus configuring a condition of acquired craniocerebral disproportion, aside of other brain or CSF complications. We firstly recognize this condition in the literature and propose it as a possible factor affecting the outcome of cranioplasty in infants and young children.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

References

  1. 1.

    Robles LA, Cuevas-Solórzano A (2018) Massive brain swelling and death after cranioplasty: a systematic review. World Neurosurg 111:99–108. https://doi.org/10.1016/j.wneu.2017.12.061

    Article  PubMed  Google Scholar 

  2. 2.

    Van Roost D, Thees C, Brenke C, Oppel F, Winkler PA, Schramm J (2003) Pseudohypoxic brain swelling: a newly defined complication after uneventful brain surgery, probably related to suction drainage. Neurosurgery 53:1315–1326 discussion 1326-1327

    Article  PubMed  Google Scholar 

  3. 3.

    Yu KKH, Ghosh K (2016) Letter to the editor: sudden death following cranioplasty: vacuum suction to blame? J Neurosurg 125:1610–1612. https://doi.org/10.3171/2016.4.JNS16977

    Article  PubMed  Google Scholar 

  4. 4.

    Frassanito P, Massimi L, Caldarelli M, Tamburrini G, Di Rocco C (2014) Bone flap resorption in infants. J Neurosurg Pediatr 13(2):243–244. https://doi.org/10.3171/2013.6.PEDS13312

    Article  PubMed  Google Scholar 

  5. 5.

    Frassanito P, Tamburrini G, Massimi L, Peraio S, Caldarelli M, Di Rocco C (2017) Problems of reconstructive cranioplasty after traumatic brain injury in children. Childs Nerv Syst ChNS Off J Int Soc Pediatr Neurosurg 33:1759–1768. https://doi.org/10.1007/s00381-017-3541-8

    Article  Google Scholar 

  6. 6.

    Rocque BG, Agee BS, Thompson EM, Piedra M, Baird LC, Selden NR, Greene S, Deibert CP, Hankinson TC, Lew SM, Iskandar BJ, Bragg TM, Frim D, Grant G, Gupta N, Auguste KI, Nikas DC, Vassilyadi M, Muh CR, Wetjen NM, Lam SK (2018) Complications following pediatric cranioplasty after decompressive craniectomy: a multicenter retrospective study. J Neurosurg Pediatr 22(3):225–232. https://doi.org/10.3171/2018.3.PEDS17234

    Article  PubMed  Google Scholar 

  7. 7.

    Di Rocco C, Frassanito P (2015) Craniocerebral disproportion as a late complication. In: Di Rocco C, Turgut M, Jallo G, Martinez-Lage JF (eds) Complications of CSF shunting in hydrocephalus. Springer, Cham, pp 233–246

    Google Scholar 

Download references

Acknowledgments

The authors kindly thank Dr. Angelo Nataloni and his staff (Finceramica, Faenza, Italy) for their precious cooperation in the planning phase of the present cranioplasty and the elaboration of radiological images overlapping the CT scans of the illustrative case.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Paolo Frassanito.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Frassanito, P., Bianchi, F., Stifano, V. et al. Craniocerebral disproportion after decompressive craniectomy in infants: The hidden enemy of cranial repair?. Childs Nerv Syst 35, 1467–1471 (2019). https://doi.org/10.1007/s00381-019-04166-4

Download citation

Keywords

  • Cranial growth
  • Cranial repair
  • Cranioplasty
  • Craniocerebral disproportion
  • Pediatric head injury
  • Personalized medicine