Cranioplastia do Osso Frontal com a Utilização de Implantes Customizados através de Protótipo 3D: Relato de Caso / Frontal Bone Cranioplasty using Customized Implants through a 3D Prototype: Case Report

A cranioplastia para os tratamentos de defeitos ósseos cranianos tem como o seu principal objetivo a reconstrução tridimensional e funcional da calota craniana. As cirurgias assistidas por computador (CAS) vem sendo utilizadas desde os anos 90 de forma eficiente e trazendo melhorias e otimização nas abordagens cirúrgicas craniofaciais reconstrutivas, principalmente em grandes defeitos ósseos. Este relato de caso clínico aborda o planejamento virtual e de tecnologia CAD/CAM na reconstrução craniofacial secundária com a utilização de polimetilmetacrilato (PMMA). Paciente de sexo masculino, 48 anos, apresentava dois defeitos ósseos em região frontal com deiscência da pele para dentro do seio frontal. Foi realizada uma tomografia computadorizada com cortes de 1mm e convertidos em um modelo 3D do osso frontal e no molde do defeito ósseo em tamanho real. Para abordagem dos defeitos ósseos, houve a participação de um neurocirurgião para o tratamento em dura-máter, cranialização do seio frontal e obliteração do ducto naso-frontal, sendo finalizada pela equipe de cirurgia bucomaxilofacial. Após a cirurgia, foi realizado um exame tomográfico sendo observados uma perfeita adaptação entre a prótese e os contornos ósseos e um ótimo contorno anatômico do osso frontal, tornando-se satisfatório ao planejamento cirúrgico inicial. A utilização de um planejamento virtual e do sistema CAD/CAM resultou em uma maior previsibilidade e maior segurança ao procedimento de reconstrução craniofacial além de redução do tempo transoperatório. O material utilizado, o PMMA, apresentou-se como um material de fácil manipulação, baixo custo e com perfeita adaptação aos contornos ósseos.

Cranioplasty for the treatment of cranial bone defects has as its main objective the three-dimensional and functional reconstruction of the skull. Computer-assisted surgeries (CAS) have been used since the 1990s efficiently and bring improvements and optimization in reconstructive craniofacial surgical approaches, especially in large bone defects. This clinical case report addresses virtual planning and CAD/CAM technology in secondary craniofacial reconstruction using polymethylmethacrylate (PMMA). A 48-year-old male patient had two bone defects in the frontal region with skin dehiscence into the frontal sinus. A computed tomography was performed with 1mm slices and converted into a 3D model of the frontal bone and in the mold of the bone defect in real size. To address the bone defects, a neurosurgeon was involved in the treatment of dura mater, cranialization of the frontal sinus, and obliteration of the nasofrontal duct, and was completed by the oral and maxillofacial surgery team. After the surgery, a tomographic exam was performed, and a perfect adaptation between the prosthesis and the bone contours and a great anatomical contour of the frontal bone were observed, making it satisfactory to the initial surgical planning. The use of virtual planning and the CAD/CAM system resulted in greater predictability and greater safety for the craniofacial reconstruction procedure, as well as a reduction in the perioperative time. The material used, PMMA, presented itself as a material of easy manipulation, low cost, and with perfect adaptation to bone contours.Keywords: PMMA, Bone transplantation, Maxillofacial Prosthesis, Cranioplasty, Customized implants.

Intradiploic Epidermoid Cyst of the Posterior Fossa ­ Case Report and Review of the Literature / Cisto epidermoide intradiploico da fossa posterior ­ Caso clinico e revisão da literatura

Intracranial epidermoid cysts represent 0.2 to 1.8% of all intracranial tumors. These tumors are most frequently encountered in the cerebellar pontine angle or in the parasellar region. Rarely, they arise from the cranial diploe, being able to affect every flat bone of the cranium. We report a case of a 63-year-old male who presented with progressively worsening headache and vertigo with 6 months of evolution. Neuroimaging identified a probable occipital intradiploic epidermoid cyst with mass effect on the cerebellar hemispheres. This lesion was approached using a suboccipital craniotomy, followed by total resection of the tumor and cranioplasty with titanium plate placement. The histological evaluation confirmed the diagnosis of intraosseous epidermoid cyst. The patient had a successful recovery, without complications or neurologic dysfunction. Being benign lesions, commonly remaining asymptomatic and rarely presenting as a bony lump in the skull bone, it could be straightforward to assume a conservative management with planned follow-up. On the other side, a more aggressive strategy with surgical excision has been advocated, especially in lesions that tend to enlarge and erode the cranial bone with possible consequent epidural extension and mass effect symptoms. A preoperative diagnosis is extremely helpful in proper surgical planning. Diffusion weighted imaging facilitates a straightforward diagnosis. As was observed in our case, the largest reviews on intradiploic epidermoids available in the literature mostly demonstrated a benign clinical course. However, malignant transformation can occur. Some patients develop permanent neurologic deficits from mass effect or tumor infiltration. However, surgical approach of the tumor is curative in most cases. Nonetheless, from our experience, it is important to maintain clinical and imaging follow-up with regular monitoring to prevent possible tumor recurrences.

Os cistos epidermoides intracranianos representam cerca de 0,2 a 1,8% de todos os tumores intracranianos. Esses tumores são mais frequentemente encontrados no ângulo pontocerebeloso ou na região parasselar. Raramente surgem na diploe, no entanto podem afetar todos os ossos do crânio. Relatamos o caso de um homem de 63 anos que apresentou agravamento progressivo da cefaleia e vertigem e desequilíbrio com 6 meses de evolução. O estudo de imagem realizado identificou um provável cisto epidermoide intradiploico occipital com efeito de massa nos hemisférios cerebelosos. A lesão foi abordada por craniotomia suboccipital, seguida de ressecção total do tumor e cranioplastia com colocação de placa de titânio. A avaliação histológica confirmou o diagnóstico de cisto epidermoide intraósseo. O doente teve uma recuperação bem sucedida, sem complicações ou disfunção neurológica. Sendo lesões benignas, que geralmente permanecem assintomáticas, pode-se assumir um tratamento conserva dor com seguimento clínico. Por outro lado, uma estratégia mais agressiva com excisão cirúrgica tem sido preconizada, principalmente em lesões que tendem a aumentar e invadir as estruturas ósseas cranianas com possível extensão peridural e sintomas causados pelo efeito de massa. Um diagnóstico pré-operatório é extremamente útil no planeamento cirúrgico adequado. A imagem ponderada por difusão facilita um diagnóstico direto. Como observado no nosso caso, as maiores revisões sobre epidermoides intradiploicos disponíveis na literatura demonstraram, na sua maioria, um curso clínico benigno. No entanto, a transformação maligna pode ocorrer. Alguns doentes desenvolvem déficits neurológicos permanentes por efeito de massa ou infiltração tumoral. A abordagem cirúrgica do tumor é curativa na maioria dos casos. Consideramos importante manter o seguimento clínico e imagiológico regular para prevenir possíveis recidivas tumorais.

Recent advance in paradoxical herniation / 中华神经医学杂志

Paradoxical herniation (PH) is a rare complication after decompressive craniectomy, which manifests as that intracranial contents collapse due to atmospheric pressure higher than intracranial pressure and gravity after decompression, and the brain parenchyma eventually herniates through the tentorial notch or the foramen magnum. Contrary to the traditional treatment of cerebral hernia, the intracranial pressure in PH patients should be increased by early cranioplasty or other measures. This article reviews the clinical manifestations, mechanism, diagnoses and treatments of PH, and provides further reference for clinical work.

Comparison of clinical outcomes of polyetheretherketone and titanium mesh as cranial repair materials in cranioplasty for cranial defect patients / 中华神经医学杂志

Objective:To compare the clinical outcomes of polyetheretherketone (PEEK) and titanium mesh as repair materials in the cranioplasty for cranial defect patients, and to screen the independent factors for postoperative complications of cranioplasty.Methods:A total of 95 patients with cranial defects admitted to our hospital from June 2012 to June 2019 were selected for this study. According to the different repair materials used in cranioplasty, these patients were divided into PEEK group ( n=36) and titanium mesh group ( n=59). General data (hospitalization cost, hospital stay, et al), postoperative complications (intracranial hemorrhage, subcutaneous effusion, infection, seizures, and implant exposure), postoperative plastic satisfaction, and improvement of postoperative neurological function (differences of Glasgow outcome scale [GOS] scores and Mini-mental State Examination [MMSE] scores before and 6 months after surgery) were compared between the 2 groups. Univariate and multivariate Logistic regression analyses were used to screen the independent factors for postoperative complications of cranioplasty. Results:The patients in the PEEK group had significantly higher hospitalization cost but significantly shortened length of hospital stay as compared with those in the titanium mesh group ( P<0.05). The overall incidence of complications in PEEK group was significantly lower than that in titanium mesh group ( P<0.05); the incidence of subcutaneous effusion in PEEK group was significantly lower than that in titanium mesh group ( P<0.05). The PEEK group had significantly higher proportion of patients with good satisfaction in postoperative plasticity, and significantly higher proportions of patients having increased GOS and MMSE scores as compared with the titanium mesh group ( P<0.05). Multivariate Logistic regression analysis showed that repair material was an independent factor for postoperative complications of cranioplasty ( OR=4.550, P=0.019, 95%CI: 1.281-16.161). Conclusion:As compared with titanium mesh, PEEK costs more, but its clinical application effect is better, especially in reducing postoperative complications; selection of appropriate repair materials can be used as one of the methods to reduce postoperative complications.

Craneoplastia sin materiales aloplásticos. Reporte de caso / Cranioplasty without alloplastic materials. Case report

RESUMEN La craneoplastia es la reconstrucción de los elementos cutáneos, óseos, y meningeos que resguardan los elementos nobles del cráneo usando materiales aloplásticos, la búsqueda de la mejor alternativa a estos nos llevó a desarrollar una técnica que utiliza los propios tejidos peri lesiónales, practicada en un paciente, que luego de 15 días de haber sufrido un traumatismo con herramienta cortante que expuso tejidos nobles intracraneales comprometiendo su vida. Se realizó la reconstrucción de la bóveda craneal en un solo tiempo quirúrgico. Esta técnica permitió alcanzar resultados satisfactorios, logrando evitar rechazos de los materiales utilizados frecuente en otras técnicas.

ABSTRACT Cranioplasty is the reconstruction of the skin, bone, and meningeal elements that protect the noble elements of the skull using alloplastic materials, the search for the best alternative to these led us to develop a technique that uses the peri-lesion tissues themselves, practiced in a patient, who after 15 days of having suffered a trauma with a cutting tool that exposed intracranial noble tissues, compromising his life. Reconstruction of the cranial vault was performed in a single surgical time. This technique allowed to achieve satisfactory results, managing to avoid rejections of the materials used frequently in other techniques.

Clinical study on different period cranioplasty after decompressive craniectomy in patients with craniocerebral injury / 中国医师进修杂志

Objective To investigate the clinical effects and complications of different period cranioplasty after decompressive craniectomy in patients with craniocerebral injury.Methods The clinical data of 96 craniocerebral injury patients who had underwent decompressive craniectomy in the First Affiliated Hospital of Chengdu Medical College from January 2014 to January 2018 were retrospectively analyzed.According to the different time of cranioplasty,the patients were divided into early group and routine group.In the early group,50 patients received cranioplasty between 1.5 to 3.0 months after decompressive craniectomy;while in the conventional group,46 patients received cranioplasty between 3.1 to 6.0 months after decompressive craniectomy.The complications after cranioplasty were observed in 2 groups,and Glasgow outcome score (GOS) and Karnofsky performance score (KPS) before cranioplasty and 3,6 and 12 months after cranioplasty were recorded.Results There were no statistical difference in delayed wound healing,subcutaneous hydrops,incision infection,hydrocephalus,intracranial hemorrhage and total incidence of complications between 2 groups (P ＞ 0.05).However,the incidence of postoperative epilepsy in early group was significantly lower than that in routine group:0 vs.8.70％ (4/46),and there was statistical difference (P ＜ 0.05).There were no statistical differences in GOS and KPS before cranioplasty between 2 groups (P ＞ 0.05);the GOS and KPS 3,6 and 12 months after cranioplasty in early group were significantly higher than those in routine group,GOS:(3.58 ± 0.64) scores vs.(3.20 ± 0.74) scores,(3.90 ± 0.58) scores vs.(3.61 ± 0.61) scores and (4.22 ± 0.55) scores vs.(3.98 ± 0.45) scores;KPS:(56.20 ± 8.55) scores vs.(52.17 ± 7.86) scores,(68.40 ± 9.12) scores vs.(63.91 ± 10.22) scores and (75.20 ± 9.31) scores vs.(70.43 ± 10.53) scores,and there were statistical differences (P＜0.01 or ＜0.05).Conclusions Early cranioplasty after decompressive craniectomy in patients with craniocerebral injury can not only reduce the incidence of postoperative epilepsy,but also be more conducive to the recovery of postoperative neurological function and improve the prognosis of patients.

Clinical study on different period cranioplasty after decompressive craniectomy in patients with craniocerebral injury / 中国医师进修杂志

Objective@#To investigate the clinical effects and complications of different period cranioplasty after decompressive craniectomy in patients with craniocerebral injury.@*Methods@#The clinical data of 96 craniocerebral injury patients who had underwent decompressive craniectomy in the First Affiliated Hospital of Chengdu Medical College from January 2014 to January 2018 were retrospectively analyzed. According to the different time of cranioplasty, the patients were divided into early group and routine group. In the early group, 50 patients received cranioplasty between 1.5 to 3.0 months after decompressive craniectomy; while in the conventional group, 46 patients received cranioplasty between 3.1 to 6.0 months after decompressive craniectomy. The complications after cranioplasty were observed in 2 groups, and Glasgow outcome score (GOS) and Karnofsky performance score (KPS) before cranioplasty and 3, 6 and 12 months after cranioplasty were recorded.@*Results@#There were no statistical difference in delayed wound healing, subcutaneous hydrops, incision infection, hydrocephalus, intracranial hemorrhage and total incidence of complications between 2 groups (P>0.05). However, the incidence of postoperative epilepsy in early group was significantly lower than that in routine group: 0 vs. 8.70% (4/46), and there was statistical difference (P<0.05). There were no statistical differences in GOS and KPS before cranioplasty between 2 groups (P>0.05); the GOS and KPS 3, 6 and 12 months after cranioplasty in early group were significantly higher than those in routine group, GOS: (3.58 ± 0.64) scores vs. (3.20 ± 0.74) scores, (3.90 ± 0.58) scores vs. (3.61 ± 0.61) scores and (4.22 ± 0.55) scores vs. (3.98 ± 0.45) scores; KPS: (56.20 ± 8.55) scores vs. (52.17 ± 7.86) scores, (68.40 ± 9.12) scores vs. (63.91 ± 10.22) scores and (75.20 ± 9.31) scores vs. (70.43 ± 10.53) scores, and there were statistical differences (P<0.01 or <0.05).@*Conclusions@#Early cranioplasty after decompressive craniectomy in patients with craniocerebral injury can not only reduce the incidence of postoperative epilepsy, but also be more conducive to the recovery of postoperative neurological function and improve the prognosis of patients.

Effect of subcutaneous negative pressure drainage and absorbable suture on prevention of postoperative complications of cranioplasty / 中国基层医药

Objective To explore the therapeutic effect of subcutaneous negative pressure drainage and absorbable suture in preventing postoperative complications of cranioplasty.Methods The clinical data of 175 cases of skull defect admitted and treated in Department of Neurosurgeryof the Affiliated Hospital of Binzhou Medical University from January 2012 to February 2018 were retrospectively analyzed.According to the different intraoperative treatment methods,97 cases were treated with thread suture to the galea aponeurotica combined with general drainage (the general drainage group),and 78 cases were treated with absorbable suture to the galea aponeurotica combined with negative pressure drainage(the negative pressure drainage group).The galea aponeurotica were sutured intermittently with both silk thread and absorbable suture,and the drainage tube was placed outside the metal titanium plate under the skin,and removed after 48-72 hours.The postoperative complications of the two groups were compared.Results The incidence rates of subcutaneous hemorrhage,knotting reaction,infection of incision in the negative pressure drainage group were 1.3％ (1/78),0.0％ (0/78),and 0.0％ (0/78),respectively,which were significantly lower than those in the average drainage group [11.3％ (11/97),20.6％ (20/97),7.2％ (7/97)],the differences were statistically significant (x2 =6.85,18.16,4.13,all P ＜ 0.05).Conclusion The application of absorbable suture suturing galea aponeurotica and subcutaneous negative pressure drainage in skull repair can significantly reduce and prevent postoperative complications of cranioplasty.

Advance in Relationship between Cerebral Hemodynamics and Clinical Manifestations after Cranioplasty (review) / 中国康复理论与实践

Cranioplasty is one of the common operations in neurosurgery at present. It can not only restore the integrity of the cranial cavity and meet the aesthetic requirements, but also relieve the clinical symptoms of headache, dizziness, fatigue, mood swings and so on. Cranioplasty can improve cerebral hemodynamics to promote the recovery of neurological function. The researches on relationship between cerebral hemodynamics and clinical symptoms were reported in recent years. However, the results were not consistent. Cranioplasty is recommended as early as permit.

Bone Flap Changes after Cranioplasty Using Frozen Autologous Bone Flaps: A Three-Dimensional Volumetric Reconstruction Study

PURPOSE: Bone flap resorption (BFR) after cranioplasty with an autologous bone flap (ABF) is well known. However, the prevalences and degrees of BFR remain unclear. This study aimed to evaluate changes in ABFs following cranioplasty and to investigate factors related with BFR. MATERIALS AND METHODS: We retrospectively reviewed 97 patients who underwent cranioplasty with frozen ABF between January 2007 and December 2016. Brain CT images of these patients were reconstructed to form three-dimensional (3D) images, and 3D images of ABF were separated using medical image editing software. ABF volumes on images were measured using 3D image editing software and were compared between images in the immediate postoperative period and at postoperative 12 months. Risk factors related with BFR were also analyzed. RESULTS: The volumes of bone flaps calculated from CT images immediately after cranioplasty ranged from 55.3 cm³ to 175 cm³. Remnant bone flap volumes at postoperative 12 months ranged from 14.2% to 102.5% of the original volume. Seventy-five patients (77.3%) had a BFR rate exceeding 10% at 12 months after cranioplasty, and 26 patients (26.8%) presented severe BFR over 40%. Ten patients (10.3%) underwent repeated cranioplasty due to severe BFR. The use of a 5-mm burr for central tack-up sutures was significantly associated with BFR (p<0.001). CONCLUSION: Most ABFs after cranioplasty are absorbed. Thus, when using frozen ABF, patients should be adequately informed. To prevent BFR, making holes must be kept to a minimum during ABF grafting.

Effect of subcutaneous negative pressure drainage and absorbable suture on prevention of postoperative complications of cranioplasty / 中国基层医药

Objective@#To explore the therapeutic effect of subcutaneous negative pressure drainage and absorbable suture in preventing postoperative complications of cranioplasty.@*Methods@#The clinical data of 175 cases of skull defect admitted and treated in Department of Neurosurgeryof the Affiliated Hospital of Binzhou Medical University from January 2012 to February 2018 were retrospectively analyzed.According to the different intraoperative treatment methods, 97 cases were treated with thread suture to the galea aponeurotica combined with general drainage(the general drainage group), and 78 cases were treated with absorbable suture to the galea aponeurotica combined with negative pressure drainage(the negative pressure drainage group). The galea aponeurotica were sutured intermittently with both silk thread and absorbable suture, and the drainage tube was placed outside the metal titanium plate under the skin, and removed after 48-72 hours.The postoperative complications of the two groups were compared.@*Results@#The incidence rates of subcutaneous hemorrhage, knotting reaction, infection of incision in the negative pressure drainage group were 1.3%(1/78), 0.0%(0/78), and 0.0%(0/78), respectively, which were significantly lower than those in the average drainage group[11.3%(11/97), 20.6%(20/97), 7.2%(7/97)], the differences were statistically significant(χ2=6.85, 18.16, 4.13, all P<0.05).@*Conclusion@#The application of absorbable suture suturing galea aponeurotica and subcutaneous negative pressure drainage in skull repair can significantly reduce and prevent postoperative complications of cranioplasty.

Effect of cranioplasty on prognosis of patients accepted intracranial aneurysm clipping combined with simultaneous decompressive craniectomy / 中华神经医学杂志

Objective To investigate the effect ofcranioplasty on prognosis of patients accepted intracranial aneurysm clipping combined with simultaneous decompressive craniectomy.Methods One hundred and forty-four patients accepted intracranial aneurysm clipping combined with simultaneous decompressive craniectomy (first-stage operation) in our hospital from January 2013 to June 2017 were chosen;there were 56 patients without cranioplasty in the control group and 88 patients with cranioplasty (second-stage operation) in the observation group.The degrees of coma before first-stage operation were assessed by Glasgow coma scale (GCS).The general state three months after first-stage operation was assessed by GCS and activity of daily living (ADL) scale.The prognoses of these patients 9 and 15 months after first-stage operation were assessed by Glasgow outcome scale (GOS) and ADL scale.The clinical data,prognoses and incidence of hydrocephalus of patients from the two groups were compared.Related factors associated with hydrocephalus were analyzed by multivariate Logistic regression analysis.Results GCS,GOS and ADL scale scores in the observation group 9 and 15 months after first-stage operation were all significantly higher than those in the control group (P＜0.05);incidence of hydrocephalus in the observation group after first-stage operation (31.82％) was significantly lower than that in the control group (62.5％,P＜0.05).Logistic regression model revealed that cranioplasty,Hunt-Hess grading and Fisher grading were independent related factors for incidence of hydrocephalus (P＜0.05);cranioplasty was the protective factor of hydrocephalus (OR=0.126),and Hunt-Hess grading and Fisher grading were the risk factors of hydrocephalus (OR=5.311 and 5.073).Conclusion Cranioplasty can reduce the incidence of hydrocephalus and improve the prognosis of patients accepted intracranial aneurysm clipping combined with simultaneous decompressive craniectomy.

Coma secundario a síndrome del trefinado / Coma due to syndrome of the trephined

El síndrome del trefinado o craniectomizado abarca manifestaciones neurológicas asociadas a la depresión del flap cutáneo y se distingue del síndrome postraumático por su reversibilidad con el tratamiento reparador del defecto craneano. El coma no es una forma habitual de presentación. Comunicamos un caso de presentación atípica en un hombre de 36 años de edad con antecedente de craniectomía descompresiva, que presentó un cuadro de deterioro neurológico profundo atribuible al síndrome del trefinado, el cual revirtió tras la craneoplastía. En la fisiopatología del síndrome intervienen trastornos cerebrovasculares, metabólicos, hidrodinámicos del líquido cefalorraquídeo e hiperdinamismo de las estructuras encefálicas. El gold standard terapéutico es la craneoplastía. Se requieren estudios de mayor peso estadístico para determinar el tiempo quirúrgico apropiado.

The syndrome of the trephined or craniectomized is commonly referred as neurological manifestations associated to skin flap depression and reversible after craneoplasty, which allows its differentiation from post-traumatic syndrome. We present the case of a male patient, 36 years old, with history of decompressive craniectomy. He evolved with sudden neurological worsening associated to syndrome of the trephined and recovery after craneoplasty. Physiopathology of the syndrome involves cerebrovascular, metabolic and cerebrospinal fluid hydrodynamic disturbances as well as parenchymal hyperdynamic mechanisms. Cranioplasty is the gold standard treatment. Still, studies with statistical power are needed to assess correct surgical timing.

Factors affecting incidence of epilepsy after cranioplasty / 中华创伤杂志

Objective To investigate the factors affecting the incidence of epilepsy after cranioplasty.Methods A retrospective case control study was conducted on the clinical data of 171 patients with skull defect who underwent cranioplasty between January 2012 and December 2015.There were 126 males and 45 females,with an average age of 50.9 years (range,16-78 years).The patients were divided into epileptic seizure group (61 cases) and non epileptic seizure group (110 cases).The gender,age,defect cause,defect location,defect duration,perioperative antiepileptic drug use,skull defect regional depression volume (Vd),skull defect regional integrity volume (Vf),skull defect regional depression rate (Pd) of two groups were recorded.Univariate analysis and multivariate logistic regression analysis were used to identify the independent risk factor of epilepsy after cranioplasty.Results All patients were followed up for 54 months averagely (range,18-90 months).Sixty-one patients (35.7％) had epilepsy after cranioplasty.Univariate analysis suggested that age,defect cause,defect location,defect duration,perioperative antiepileptic drug use,and Vf were not associated with epilepsy after cranioplasty (all P ＞ 0.05);while gender,Vd,and Pd was associated with epilepsy after cranioplasty (P ＜ 0.05).Multivariate logistic regression analysis demonstrated that Pd (OR =0.024,95％ CI 0.001-0.502,P ＜0.05) was independent predictor of epilepsy after cranioplasty.Conclusion Pd is an independent risk factor for epilepsy after cranioplasty and depression degree could significantly affect its incidence.

Effects of cranioplasty on neurological function:a CT perfusion study / 实用医学杂志

Objective To explore the effects of cranioplasty onneurological functionin patients based on the cerebral CT perfusion technique. Methods Twenty cases of patients receiving cranioplasty were rerecorded during the study period,and they wererespectively scanned by CT perfusion within 72 hours before and 2 weeks after the cranioplasty. Meanwhile,the neurological function was evaluated by neurological function scale. Results The difference of cerebral blood flow before and after cranioplasty was statistically significant(P<0.05), whereas the difference of cerebral blood volume,transit time to the peak and mean transit time was not statistically significant(P>0.05).Correlation analysis showed that the preoperativedifference ratio of thecerebral blood infusio-nis not correlated with the neurological function score(P > 0.05). The changes of preoperative and postoperative difference rateof the cerebral blood infusionwas correlated with the functional independence measure(P < 0.05), whereas not with mini-mental state examination(P > 0.05). Conclusions The neurological function of the patients after cranioplasty may be improved.This improvement may benefit from the improvement of cerebral blood flow after cranioplasty.

Effect of different electric coagulation method for cranioplasty / 中国医师进修杂志

Objective To compare the effect of the bipolar electric coagulation and unipolar electric coagulation on cranioplasty of scalp separation. Methods The clinical data of 67 patients who underwent unilateral frontotemporal cranioplasty from 2014 to 2017 were retrospectively analyzed. According to coagulation method during operation, these patients were divided into two groups, unipolar electric coagulation group (32 cases) and bipolar electric coagulation group (35 cases). The operation time, postoperative intracranial hemorrhage, infection, epilepsy and subcutaneous effusion were compared between two groups. Results The operation time of two groups had no significant difference (P > 0.05). The incidence of intracranial hemorrhage, infection and epilepsy of two groups had no significant differences (P > 0.05). But the incidence of subcutaneous effusion in unipolar electric coagulation group was significantly higher than that in bipolar electric coagulation group: 28.1%(9/32) vs. 5.7%(2/35), P<0.05. Conclusions The use of unipolar electric coagulation during the scalp separation in cranioplasty can reduce operation time in a certain extent, but significantly increase the incidence of postoperative subcutaneous effusion.

Epidural fluid collection secondary to cranioplasty in 47 patients with traumatic brain injury after decompressive craniectomy / 中华神经医学杂志

Objective To identify the reasons and treatment strategies of epidural fluid collection (EFC) secondary to cranioplasty in patients with traumatic brain injury after decompressive craniectomy.Methods From June 2013 to July 2017,a retrospective analysis was performed on clinical data of 150 patients with traumatic brain injury after decompressive craniectomy in our hospital.A total of 47 patients experienced EFC following cranioplasty and 103 not.Risk factors of EFC after cranioplasty were analyzed by multiple factor Logistic regression.Results For the 47 EFC patients,32 patients had no obvious clinical symptoms and EFC was absorbed gradually through conservative therapy;15 patients had clinical symptoms,such as mental deterioration,headache,or limb weakness.EFC disappeared through vacuation in 4 patients and subcutaneous drainage in 11.The proportions of patients with skull defect＞80 cm2,dural defect and dural calcification in patients with EFC were significantly higher as compared with those without EFC (P＜0.05).Multiple factor Logistic regression analysis showed that skull defect＞80 cm2 and dural mater calcification were independent risk factors for EFC after cranioplasty.Conclusions Patients with large skull defect＞80 cm2 and dural calcification are prone to have EFC after cranioplasty.Careful evaluation of imaging data,good surgical skills and strengthening postoperative management can reduce incidence of EFC after cranioplasty.

Clinical outcomes of custom-designed polyetheretherketone and titanium in cranioplasty after decompressive craniectomy: a single center study / 中华神经医学杂志

Objective To compare the clinical outcomes and complications of alloplasfic cranioplasty performed with custom-designed polyetheretherketone (PEEK) and titanium mesh after decompressive craniectomy.Methods Eighty-six patients admitted to our hospital from June 2014 to December 2017 were chosen;and 28 patients underwent cranioplasty with PEEK and 58 with titanium mesh by the same surgical team.The general clinical data and postoperative complications were compared between the two groups.Multivariable Logistic regression analysis was performed to analyze the influencing factors of postoperative complications.The surgical time,molding quality and cost were compared between the two groups.Results Patients in PEEK group trended to be younger and had higher GOS scores as compared with patients in the titanium group,with significant differences (P＜0.05).Overall complication rates of 10.7％ and 32.8％ for PEEK and titanium cranioplasty were identified respectively;as compared with that in titanium group,the incidence of overall complication in PEEK group was significant lower (P＜0.05).Logistic regression analysis identified material was the independent influencing factor for cranioplasty complications (OR=4.486,P=0.047,95％CI:1.021-19.703).Overall satisfaction rate with cranioplasty and aesthetic result in PEEK group was significantly higher than that in titanium group (96.4％ vs.79.3％,P＜0.05);however,the treatment cost for cranioplasty with PEEK was considerably higher than skull bone reconstruction based on titanium mesh.Conclusion Despite of high treatment cost,custom-designed PEEK implants seem to be good choice for patients with large cranial defects after decompressive craniectomy,enjoying few complications and high satisfaction of cranioplasty and aesthetic result.

Clinical therapy of paradoxical herniation / 中华神经医学杂志

Objective To explore the treatment of paradoxical herniation after bone flap decompression surgery,and improve people's understanding of paradoxical herniation.Methods From April 2014 to July 2017,the clinical data of 12 patients with paradoxical herniation were retrospectively analyzed.The treatment efficacies of position adjusting,sufficient hydration,and cranioplasty were explored.Results Nine patients (75％) had paradoxical herniation within two weeks of surgery,two(16.67％) developed paradoxical herniation from two weeks to one month of surgery,and one (8.33％) developed paradoxical herniation at two months after operation.But no all the patients had sunken and collapsed skin flap.After position adjusting,sufficient hydration,and cranioplasty,12 patients had periodic improvement;the neurological function of 9 patients accepted cranioplasty recovered obviously.Conclusion Paradoxical herniation is reversible after effective treatments,as position adjusting,sufficient hydration,and cranioplasty,enjoying good results.

Factors Affecting Optimal Time of Cranioplasty: Brain Sunken Ratio / 대한신경손상학회지

OBJECTIVE: After a rigorous management of increased intracranial pressure by decompressive craniectomy (DC), cranioplasty (CP) is usually carried out for functional and cosmetic purposes. However, the optimal timing of CP remains controversial. Our study aims to analyze the relationship between the optimal timing of CP and the post-operative complications. METHODS: From January 2013 to December 2015, ninety patients who underwent CP in a single institution were analyzed. We set the independent variables as follows: 1) patient characteristics; 2) the time interval between the DC and CP; 3) operation time; 4) anesthesia time; and 5) pre-operative computed tomography (CT) findings such as a degree of sunken brain by ratio of A (the median length from scalp to midline) to B (the length from midline to inner table of skull at this level). The dependent variables of this study are the event of post-operative complications. RESULTS: The overall complication rate was 33.3%. There was no statistical significance in the time interval between the DC and CP in the groups with and without complications of CP (p=0.632). However, there was a significant statistical difference in the degree of sunken brain by ratio (A/B) between the two groups (p<0.001). CONCLUSION: From this study, we conclude that it is better to determine the optimal timing of CP by the pre-operative CT finding than by the time interval between the DC and CP. Hereby, we suggest a potentially useful determinant of optimal timing of CP.