gms | German Medical Science

Objective: Cranioplasty procedure (CP) is often performed after decompressive hemicraniectomy (DHC) in patients suffering from refractory ICP elevation caused by traumatic brain injury (TBI), malignant brain infarction (MBI) or aneurysmatic subarachnoid hemorrhage (SAH). However timing of CP and ventriculo-peritoneal shunt procedures (VPS) are controversial discussed as well as the kind of usage of cranioplastic material.

Methods: A retrospective chart analysis was performed of all patients at our institution admitted with TBI, MBI or SAH that underwent DHC and subsequent CP in the period from 01/2009 to 12/2015. Demographic data, diagnosis, timing of CP (early < 90 days vs. late > 90 days), type of cranioplastic material, VP-shunt procedures, CP related complications and patients outcome were analyzed. Data are given as mean values ± SD.

Results: 41 patients after DHC caused by TBI were identified. 26 patients (20m, 6f) received early CP (procedure time 91 ± 43 min) all with autologous material (defect size 103 ± 23 cm²). Simultaneous shunt implantations were performed in 4 cases. In 5 cases a postoperative hematoma with revision surgery and 2 cases of bone osteolysis occurred. In 15 patients (12m, 3f) late CP (procedure time 96 ± 42 min), in 5 cases with synthetic material, was performed (defect size was 92 ± 33 cm²). In 1 case concurrent VPS was done. 3 wound healing disorders and 1 hematoma developed. 16 patients after DHC caused by MBI were evaluated. 6 patients (3m, 3f) with early CP (procedure time 92 ± 33 min) all with autologous material was performed (defect size 103 ± 23 cm²). No VPS were necessary. 1 case of meningitis and hematoma occurred. In 10 patients (8m, 2f) late CP (procedure time 104 ± 39 min) was performed. Synthetic material was used in 1 case. The mean defect size was 119 ± 32 cm². In 1 case lumbar drainage application and VPS were performed. 16 patients after DHC caused by SAH were worked out. In 10 patients (2m, 8f) early CP (procedure time 69 ± 18 min) was done, in 2 cases with synthetic material. The mean defect size was 73 ± 31 cm2. In 5 cases an early VPS was necessary before CP. In 1 case a postoperative hematoma occurred. 6 patients (2m, 4f) received late CP (mean procedure time 115 ± 57 min) and defect size was 94 ± 31 cm2. Synthetic material was used in 1 case. In 2 cases VPS were performed concurrently with DHC.

Conclusion: Early and late CP procedures can be safely performed in nearly same surgery time after DHC in patients suffering from TBI and MBI. In the early CP group after TBI there was a trend towards more complications (hematoma/hygroma and bone osteolysis) compared to late CP patients. Patients suffering from SAH need more often a VPS (before or concurrent with CP) than other groups (TBI and MBI). A second hospital stay has to be considered in the most cases of late CP for all (TBI, MBI and SAH) patients.