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Routine but risky: A multi-centre analysis of the outcomes of cranioplasty in the Northeast of England

Acta Neurochirurgica volume 156, pages 1361–1368 (2014)Cite this article

Abstract

Background

Cranioplasty is undertaken as a routine secondary operation following craniectomy. At a time when decompressive craniectomy is being evaluated by several large trials, we aimed to evaluate the morbidity associated with cranioplasty and investigate its potential effect on outcome.

Methods

The outcomes of 166 patients undergoing cranioplasty at two centres in the United Kingdom between June 2006 and September 2011 were retrospectively analysed. Outcome measures included mortality, morbidity and functional outcome determined by the modified Rankin score (mRS) at last follow-up. A logistic regression analysis was performed to model and predict determinants related to neurological outcome following cranioplasty.

Results

Sixty-seven out of 166 patients (40.4 %) experienced at least one complication during a median follow-up time of 15 months (inter-quartile range 5-38 months). Thirty six patients (21.7 %) developed infection requiring antibiotics, with 27 (16.3 %) requiring removal of the cranioplasty. Nine of 25 patients (36 %) with bi-frontal defects developed an infection whereas 21 of the 153 patients (16.4 %) with a defect other than bi-frontal developed an infection (Chi square p = 0.009). Further surgery in the two groups was required in 16.4 % and 11.7, % respectively. Pseudomeningocoele (9 %), seizures (8.4 %) and poor cosmesis (7.2 %) were also commonly observed. Logistic regression analysis identified initial operation (p < 0.03), mRS at the time of cranioplasty (p < 0.0001) and complications (p < 0.04) as being predictive of neurological outcome at last follow-up. Age at the time of cranioplasty and the timing of cranioplasty were not predictive of last mRS score at follow-up.

Conclusions

Cranioplasty harbours significant morbidity, a risk that appears to be higher with a bifrontal defect. The complications experienced influence subsequent functional outcome. The timing of cranioplasty, early or late, after the initial operation does not impact on the ultimate outcome. These findings should be considered when making decisions relating to craniectomy and cranioplasty.

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References

  1. Agner C, Dujovny M, Gaviria M (2002) Neurocognitive assessment before and after cranioplasty. Acta Neurochir (Wien) 144(10):1033–1040

    CAS  Article  Google Scholar 

  2. Archavlis E, Carvi Y, Nievas M (2012) The impact of timing of cranioplasty in patients with large cranial defects after decompressive hemicraniectomy. Acta Neurochir (Wien) 154(6):1055–1062

    CAS  Article  Google Scholar 

  3. Beauchamp KM, Kashuk J, Moore EE, Bolles G, Rabb C, Seinfeld J, Szentirmai O, Sauaia A (2010) Cranioplasty after postinjury decompressive craniectomy: is timing of the essence? J Trauma 69(2):270–274

    PubMed  Article  Google Scholar 

  4. Bender A, Heulin S, Röhrer S, Mehrkens JH, Heidecke V, Straube A, Pfefferkorn T (2013) Early cranioplasty may improve outcome in neurological patients with decompressive craniectomy. Brain Inj 27(9):1073–1079

    PubMed  Article  Google Scholar 

  5. Bobinski L, Koskinen LO, Lindvall P (2013) Complications following cranioplasty using autologous bone or polymethylmethacrylate-retrospective experience from a single center. Clin Neurol Neurosurg 115(9):1788–1791

    PubMed  Article  Google Scholar 

  6. Broughton E, Pobereskin L, Whitfield PC (2014) Seven years of cranioplasty in a regional neurosurgical centre. Br J Neurosurg 28(1):34–39

    PubMed  Article  Google Scholar 

  7. Cabraja M, Klein M, Lehmann TN (2009) Long-term results following titanium cranioplasty of large skull defects. Neurosurg Focus 26(6):E10

    PubMed  Article  Google Scholar 

  8. Chang V, Hartzfeld P, Langlois M, Mahmood A, Seyfried D (2010) Outcomes of cranial repair after craniectomy. J Neurosurg 112(5):1120–1124

    PubMed  Article  Google Scholar 

  9. Cheng YK, Weng HH, Yang JT, Lee MH, Wang TC, Chang CN (2008) Factors affecting graft infection after cranioplasty. J Clin Neurosci 15(10):1115–1119

    PubMed  Article  Google Scholar 

  10. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D'Urso P, Kossman T, Ponsford J, Seppelt I, Reilly P, Wolfe R, DECRA Trial Investigators, Australia and New Zealand Intensive Care Society Clinical Trials Group (2011) Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364(16):1493–1502

    CAS  PubMed  Article  Google Scholar 

  11. Dujovny M, Agner C, Aviles A (1999) Syndrome of the trephined: theory and facts. Crit Rev Neurosurg 9(5):271–278

    PubMed  Article  Google Scholar 

  12. Fodstad H, Love JA, Ekstedt J, Fridén H, Liliequist B (1984) Effect of cranioplasty on cerebrospinal fluid hydrodynamics in patients with the syndrome of the trephined. Acta Neurochir (Wien) 70(1–2):21–30

    CAS  Article  Google Scholar 

  13. Goldstein JA, Paliga JT, Bartlett SP (2013) Cranioplasty: indications and advances. Curr Opin Otolaryngol Head Neck Surg 21(4):400–409

    PubMed  Article  Google Scholar 

  14. Gooch MR, Gin GE, Kenning TJ, German JW (2013) Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases. Neurosurg Focus 26(6):E9

    Google Scholar 

  15. Hill CS, Luoma AM, Wilson SR, Kitchen N (2012) Titanium cranioplasty and the prediction of complications. Br J Neurosurg 26(6):832–837

    PubMed  Article  Google Scholar 

  16. Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB, HAMLET investigators (2009) Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 8(4):326–333

    PubMed  Article  Google Scholar 

  17. Honeybul S (2011) Sudden death following cranioplasty: a complication of decompressive craniectomy for head injury. Br J Neurosurg 25(3):343–345

    PubMed  Article  Google Scholar 

  18. Honeybul S, Janzen C, Kruger K, Ho KM (2013) The impact of cranioplasty on neurological function. Br J Neurosurg 27(5):636–641

    PubMed  Article  Google Scholar 

  19. Hutchinson PJ, Corteen E, Czosnyka M, Mendelow AD, Menon DK, Mitchell P, Murray G, Pickard JD, Rickels E, Sahuguillo J, Servadei F, Teasdale GM, Timofeev I, Unterberg A, Kirkpatrick PJ (2006) Decompressive craniectomy in traumatic brain injury: the randomized multicenter RESCUEicp study (www.RESCUEicp.com) Acta Neurochir Suppl. 96:17-20

  20. Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, Witte S, Jenetsky E, Hacke W, Destiny Study Group (2007) Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 38(9):2518–2525

    PubMed  Article  Google Scholar 

  21. Kim H, Sung SO, Kim SJ, Kim SR, Park IS, Jo KW (2013) Analysis of the factors affecting graft infection after cranioplasty. Acta Neurochir (Wien) 155(11):2171–2176

    Article  Google Scholar 

  22. Klinger DR, Madden C, Beshay J, White J, Gambrell K, Rickert K (2013) Autologous and Acrylic Cranioplasty: A Review of Ten Years and 258 Cases. World Neurosurg. doi:10.1016/j.wneu.2013.08.005

    PubMed  Google Scholar 

  23. Kolias AG, Butlers DO, Cowie CJ, Wilson MH, Afshari FT, Helmy A, Broughton E, Joannides AJ, Zebian B, Harrison SE, Hill CS, Ahmed AI, Barone DG, Thakur B, McMahon CJ, Adlam DM, Bentley RP, Tolias CM, Mitchell PM, Whitfield PC, Critchley GR, Belli A, Brennan PM, Hutchinson PJ, Collaborative BNTR, British Neurotrauma Group UKCRR, Group C (2013) Proposal for establishment of the UK Cranial Reconstruction Registry (UKCRR). Br J Neurosurg. doi:10.3109/0288697

    Google Scholar 

  24. Kolias AG, Kirkpatrick PJ, Hutchinson PJ (2013) Decompressive craniectomy: past, present and future. Nat Rev Neurol 9(7):405–415

    CAS  PubMed  Article  Google Scholar 

  25. Kolias AG, Li M, Guilfoyle MR, Timofeev I, Corteen EA, Pickard JD, Kirkpatrick PJ, Menon DK, Hutchinson PJ (2013) Decompressive craniectomy for acute subdural hematomas: time for a randomized trial. Acta Neurochir (Wien) 155(1):183–184

    Article  Google Scholar 

  26. Lee CH, Chung YS, Lee SH, Yang HJ, Son YJ (2012) Analysis of the factors influencing bone graft infection after cranioplasty. J Trauma Acute Care Surg 73(1):255–260

    PubMed  Article  Google Scholar 

  27. Lee L, Ker J, Quah BL, Chou N, Choy D, Yeo TT (2013) A retrospective analysis and review of an institution’s experience with the complications of cranioplasty. Br J Neurosurg 27(5):629–635

    PubMed  Article  Google Scholar 

  28. Liang W, Xiaofeng Y, Weiguo L, Gang S, Xuesheng Z, Fei C, Gu L (2007) Cranioplasty of large cranial defect at an early stage after decompressive craniectomy performed for severe head trauma. J Craniofac Surg 18(3):526–532

    PubMed  Article  Google Scholar 

  29. Lund-Johansen M, Svendsen F, Wester K (1994) Shunt failures and complications in adults as related to shunt type, diagnosis, and the experience of the surgeon. Neurosurg 35(5):839–844

    CAS  Article  Google Scholar 

  30. Matsuno A, Tanaka H, Iwamuro H, Takanashi S, Miyawaki S, Nakashima M, Nakaguchi H, Nagashima T (2006) Analyses of the factors influencing bone graft infection after delayed cranioplasty. Acta Neurochir (Wien) 148(5):535–540

    CAS  Article  Google Scholar 

  31. Moreira-Gonzalez A, Jackson IT, Miyawaki T, Barakat K, DiNick V (2003) Clinical outcome in cranioplasty: critical review in long-term follow-up. J Craniofac Surg 14(2):144–153

    PubMed  Article  Google Scholar 

  32. Nagayama K, Yoshikawa G, Somekawa K, Kohno M, Segawa H, Sano K, Shiokawa Y, Saito I (2002) Cranioplasty using the patient’s autogenous bone preserved by freezing–an examination of post-operative infection rates. No Shinkei Geka 30(2):165–169

    PubMed  Google Scholar 

  33. Piedra MP, Ragel BT, Dogan A, Coppa ND, Delashaw JB (2013) Timing of cranioplasty after decompressive craniectomy for ischemic or hemorrhagic stroke. J Neurosurg 118(1):109–114

    PubMed  Article  Google Scholar 

  34. Piedra MP, Thompson EM, Selden NR, Ragel BT, Guillaume DJ (2012) Optimal timing of autologous cranioplasty after decompressive craniectomy in children. J Neurosurg Pediatr 10(4):268–272

    PubMed  Article  Google Scholar 

  35. Rocque BG, Amancherla K, Lew SM, Lam S (2013) Outcomes of cranioplasty following decompressive craniectomy in the pediatric population. J Neurosurg Pediatr 12(2):120–125

    PubMed  Article  Google Scholar 

  36. Roth J, Galeano E, Milla S, Hartmannsgruber MW, Weiner HL (2011) Multiple epidural hematomas and hemodynamic collapse caused by a subgaleal drain and suction-induced intracranial hypotension: case report. Neurosurgery 68(1):E271–E275

    PubMed  Article  Google Scholar 

  37. Stelling H, Graham L, Mitchell P (2011) Does cranioplasty following decompressive craniectomy improve consciousness? Br J Neurosurg 25(3):407–409

    PubMed  Article  Google Scholar 

  38. Stephens FL, Mossop CM, Bell RS, Tigno T Jr, Rosner MK, Kumar A, Moores LE, Armonda RA (2010) Cranioplasty complications following wartime decompressive craniectomy. Neurosurg Focus 28(5):E3

    PubMed  Article  Google Scholar 

  39. Sundseth J, Sundseth A, Berg-Johnsen J, Sorteberg W, Lindegaard KF (2014) Cranioplasty with autologous cryopreserved bone after decompressive craniectomy. Complications and risk factors for developing surgical site infection. Acta Neurochir (Wien) [Epub ahead of print] PMID: 24493001

  40. Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfield M, Lewis E, Klug G, Wallace D, Henning R, Tibballs J (2001) A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst 17(3):154–162

    CAS  PubMed  Article  Google Scholar 

  41. Thavarajah D, De Lacy P, Hussien A, Sugar A (2012) The minimum time for cranioplasty insertion from craniectomy is six months to reduce risk of infection–a case series of 82 patients. Br J Neurosurg 26(1):78–80

    PubMed  Article  Google Scholar 

  42. Tokoro K, Chiba Y, Tsubone K (1989) Late infection after cranioplasty–review of 14 cases. Neurol Med Chir (Tokyo) 29(3):196–201

    CAS  Article  Google Scholar 

  43. Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A (2007) Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 6(3):215–222

    PubMed  Article  Google Scholar 

  44. Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, Boutron C, Couvreur G, Rouanet F, Touzé E, Guillon B, Carpentier A, Yelnik A, George B, Payen D, Bousser MG, Investigators DECIMAL (2007) Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 38(9):2506–2517

    PubMed  Article  Google Scholar 

  45. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J (1988) Interobserver agreement for the assessment of handicap in stroke patients. Stroke 19(5):604–607

    PubMed  Article  Google Scholar 

  46. Wachter D, Reineke K, Behm T, Rohde V (2013) Cranioplasty after decompressive hemicraniectomy: underestimated surgery-associated complications? Clin Neurol Neurosurg 115(8):1293–1297

    PubMed  Article  Google Scholar 

  47. Walcott BP, Kwon CS, Sheth SA, Fehnel CR, Koffie RM, Asaad WF, Nahed BV, Coumans JV (2013) Predictors of cranioplasty complications in stroke and trauma patients. J Neurosurg 118(4):757–762

    PubMed  Article  Google Scholar 

  48. Wiggins A, Austerberry R, Morrison D, Ho KM, Honeybul S (2013) Cranioplasty with custom-made titanium plates-14 years experience. Neurosurgery 72(2):248–256

    PubMed  Article  Google Scholar 

  49. Yadla S, Campbell PG, Chitale R, Maltenfort MG, Jabbour P, Sharan AD (2011) Effect of early surgery, material, and method of flap preservation on cranioplasty infections: a systematic review. Neurosurgery 68(4):1124–1129

    PubMed  Google Scholar 

  50. Zebian B, Critchley G (2011) Sudden death following cranioplasty: a complication of decompressive craniectomy for head injury. Br J Neurosurg 25(6):785–786

    PubMed  Article  Google Scholar 

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Acknowledgments

ICC and JDPS contributed equally to the design, implementation and writing of this study and should ,therefore be considered as joint first authors.

Conflict of interest

None

Author information

Affiliations

  1. Department of Neurosurgery, James Cook University Hospital, Middlesbrough, TS4 3BW, UK

    Ian C. Coulter, William B. Cato-Addison, Shahid A. Khan, Roger D. Strachan & Nitin Mukerji

  2. Department of Neurosurgery, Royal Victoria Infirmary, Newcastle, NE1 4LP, UK

    Jonathan D. Pesic-Smith & Alistair J. Jenkins

  3. University of Newcastle Upon Tyne, Newcastle, UK

    Daniel Thompson

Authors
  1. Ian C. Coulter
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  2. Jonathan D. Pesic-Smith
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Correspondence to Ian C. Coulter.

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Coulter, I.C., Pesic-Smith, J.D., Cato-Addison, W.B. et al. Routine but risky: A multi-centre analysis of the outcomes of cranioplasty in the Northeast of England. Acta Neurochir 156, 1361–1368 (2014). https://doi.org/10.1007/s00701-014-2081-1

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  • DOI: https://doi.org/10.1007/s00701-014-2081-1

Keywords

  • Decompressive craniectomy
  • Cranioplasty
  • Complications
  • Functional outcome