Never say never again: A bone graft infection due to a hornet sting, thirty-nine years after cranioplasty
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, University of Palermo, Palermo, Italy
Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, University of Palermo, Palermo, Italy
DOI:10.4103/sni.sni_68_17Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Rosario Maugeri, Roberto G. Giammalva, Francesca Graziano, Luigi Basile, Carlo Gulì, Antonella Giugno, Domenico G. Iacopino. Never say never again: A bone graft infection due to a hornet sting, thirty-nine years after cranioplasty. 10-Aug-2017;8:189
How to cite this URL: Rosario Maugeri, Roberto G. Giammalva, Francesca Graziano, Luigi Basile, Carlo Gulì, Antonella Giugno, Domenico G. Iacopino. Never say never again: A bone graft infection due to a hornet sting, thirty-nine years after cranioplasty. 10-Aug-2017;8:189. Available from: http://surgicalneurologyint.com/surgicalint-articles/never-say-never-again-a-bone-graft-infection-due-to-a-hornet-sting-thirty%e2%80%91nine-years-after-cranioplasty/
Background:Cranioplasty (CP) is a widespread surgical procedure aimed to restore skull integrity and physiological cerebral hemodynamics, to improve neurological functions and to protect the underlying brain after a life-saving decompressive craniectomy (DC). Nevertheless, CP is still burdened by surgical complications, among which early or late graft infections are the most common outcome-threatening ones.
Case Description:We report the case of 48-year-old man admitted to our neurosurgical unit because of a painful right frontal swelling and 1-week purulent discharge from a cutaneous fistula. He had been undergone frontal CP because of severe traumatic brain injury (TBI) when he was 9-year-old. Since then, his medical history has been being unremarkable without any surgical or infective complication of the graft for 39 years, until he was accidentally stung by a hornet in the frontal region. After the CT scan and laboratory findings had evidenced a probable infection of the graft, the patient was treated by vancomycin and cefepime before he underwent surgical revision of its former CP, with the removal of the graft and the debridement of the surgical field. Subsequent bacteriological tests revealed Staphylococcus aureus as causal agent of that infection.
Conclusion:This case illustrates an anecdotal example of very late CP infection, due to an unpredictable accident. Due to lack of consensus on risk factors and on conservative or surgical strategy in case of graft infection, we aimed to share our surgical experience.
Keywords: Cranioplasty, late infection management, risk factors, surgical complications
Decompressive craniectomy (DC) has become a widespread procedure for treating life-threatening conditions that lead to a higher intracranial pressure (ICP).[
Nevertheless, severe traumatic brain injury (TBI) still remains the most common indication for DC in many clinical series.[
A 48-year-old male was admitted to our neurosurgical unit because of a frontal swelling with purulent discharge from a cutaneous fistula. In his clinical history, he reported a previous frontal TBI when he was 9-year-old. For this reason, he had undergone a frontal craniectomy with subsequent unspecified CP. Since that, his clinical history has been unremarkable for 39 years, without any surgical or infective complications related to the cranial surgical procedure. A week before his admission he had been stung by a hornet while he was working in the countryside, with a progressive swelling of frontal soft tissues, temperature raising, and local pain with inflammatory state. During that week, a progressive purulent discharge has onset from the site of the sting, so he referred to the emergency department. At the admission, he was awake and aware [Glasgow Coma Scale 15 (GSC 15)], his temperature was 37.8°C and his neurological examination was negative. Initial laboratory studies revealed a pathological increased value of white blood cell (WBC) count (22 × 109/L with 82% neutrophils, 14% lymphocytes, and 7% monocytes) and of serum C-reactive protein level (57 mg/dL with a normal range 0.08–1.5 mg/dL). A head CT scan revealed an irregular subcutaneous fluid collection, adherent to the graft's anterior face, a peripheral soft tissues edema, and a frontal hypodensity in brain parenchyma contiguous to the graft. The administration of contrast medium revealed a moderate peripheral enhancement of the collection. Because of the radiological evidence of the graft infection with subcutaneous abscess, the patient was then transferred to our neurosurgical unit. A swab test of the purulent discharge from the cutaneous fistula was performed, and, after a multidisciplinary consult, a polychemotherapy was started (1 g of vancomycin and 2 g of cefepime every 12 h). Thirty-six hours after his admission, the patient underwent surgical toilet and removal of the graft. This appeared as a porous acrylic graft, with several fibrotic bands firmly tied with the skin and the underlying synthetic dural substitute. All the samples were harvested for microbiological exam, while the surgical site was washed with iodine solution, peroxide, isotonic saline, and rifampicine. At the end, a spongy layer of dural substitute with two overlaying patch of fibrin sealant (Tachosil©) and some fibrin glue (Vivostat©) was then used to ensure dural seal and to contribute in protecting the brain parenchyma under the bone defect [Figure
Nor titanium mesh or other allograft was applied on the former craniotomy in order to prevent the rejection, waiting for the resolution of the infection in analogy with other surgical procedures.[
Further bacteriological tests revealed Staphylococcus aureus as causal agent of that graft infection. Due to this, the patient was discharged 7 days after surgical procedure under an antibiotic therapy with linezolid and ceftazidime and he is still in follow-up for further CP after the infection resolution and inflammatory markers normalization.
CP is a common surgical procedure requisite to restore skull integrity in such cases where it has been compromised. Moreover, it has been demonstrated that CP can be effective in preventing seizures or cerebral atrophy after a DC so avoiding the “trephined syndrome,”[
CP failure may be attributable to autologous bone flap resorption (when used) or mostly to graft infections,[
Even if CP is a relatively old procedure, there still are no solid evidences on the risk factors for graft infections. The first and most controversial issue is the time interval between DC and CP. Many clinical series state that early CP ensures better outcomes, whereas many others advocate late surgery to prevent graft infections, avoiding the risk of performing surgical procedure on a contaminated wound.[
CP is still necessary in surviving patients after life-saving DC. Despite its widespread employment and the wide variety of techniques and material, postoperative complications still threat patients’ clinical outcome. Among these, graft infections are the most common, even many years after the CP have been performed, and they are often due to skin bacterial flora. Nowadays, there is still no consensus on reliable risk factors for early graft infections, moreover late ones are often unpredictable and totally accidental, as we reported. Due to lack of similar cases of very late CP infections in literature, we aimed to share our surgical experience about the most tardive one that we treated, highlighting its extraordinary fortuity.
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Conflicts of interest
There are no conflicts of interest.
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