- University Clinical Center of KOSOVA, Clinic of Neurosurgery, Prishtina, Kosova, Germany
- Clinic of Anesthesiology, Rruga e spitalit p.n. 10 000, Prishtina, Kosova, Germany
- Clinic of Abdominal Surgery, Rruga e spitalit p.n. 10 000, Prishtina, Kosova, Germany
- Stadtische Kliniken Duisburg, Klinikum Kalkweg – Neurochirurgische Klinik, Zu den Rehwiesen 9 – 47055 Duisburg, Germany
Correspondence Address:
Arsim Morina
Clinic of Abdominal Surgery, Rruga e spitalit p.n. 10 000, Prishtina, Kosova, Germany
DOI:10.4103/2152-7806.81735
Copyright: © 2011 Morina A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Morina A, Kelmendi F, Morina Q, Dragusha S, Ahmeti F, Morina D, Gashi K. Cranioplasty with subcutaneously preserved autologous bone grafts in abdominal wall—Experience with 75 cases in a post-war country Kosova. Surg Neurol Int 28-May-2011;2:72
How to cite this URL: Morina A, Kelmendi F, Morina Q, Dragusha S, Ahmeti F, Morina D, Gashi K. Cranioplasty with subcutaneously preserved autologous bone grafts in abdominal wall—Experience with 75 cases in a post-war country Kosova. Surg Neurol Int 28-May-2011;2:72. Available from: http://sni.wpengine.com/surgicalint_articles/cranioplasty-with-subcutaneously-preserved-autologous-bone-grafts-in-abdominal-wall-experience-with-75-cases-in-a-post-war-country-kosova/
Abstract
Background:The study is to show the advantages of preservation of a calvarial bone flap in the abdominal pocket after decompressive craniotomy. Decompressive craniectomy is an option in the surgical management of refractory hypertension when maximal medical treatment (sedation, drainage of cerebrospinal fluid, moderate cooling, etc) has failed to control refractory high intracranial pressure.
Methods:We have prospectively analyzed 82 consecutively operated cases decompressive craniotomies done at the University Neurosurgical Clinic in Prishtina/KOSOVA over a period of eight years (June 1999 to Aug 2008). Of the 75 who had their grafts replaced (7 patient died before replacement of bone graft), 62 patients had hemicraniectomy (fronto-parieto-temporal) 7 of them were bilateral.
ResultsIn 66 out of 75 patients was achieved a satisfactory and cosmetically reconstruction, in 9 cases was required augmentation with methyl methacrylate to achieve cosmetic needs. Two patients had infection and the bone was removed; 6 months later these patients had cranioplasty with methyl methacrylate. The duration of storage of calvarial bone in abdominal pouch before reimplantation was 14 – 232 days (range 56 days).
Conclusion:We think that storage of the patients own bone flap in the abdominal pocket is a safe, easy, cheap, sterile, histocompatible, and better cosmetic results.
Keywords: Autogenous bone, bone flap, cranioplasty, subgaleal pocket
INTRODUCTION
Decompressive craniectomy can be defined as the removal of a large area of the skull with opening of the dura to increase the volume of the cranial cavity, facilitating a reduction in intracranial pressure. Decompressive craniectomy is an option in the surgical management of refractory hypertension when maximal medical treatment (sedation, drainage of cerebrospinal fluid, moderate cooling, etc) has failed to control refractory high intracranial pressure, especially in brain trauma, stroke, and post-operative edema after brain surgery. The technique of storing the craniectomy graft in a subcutaneous location in the patient offers a theoretical advantage in that the patient's own body might provide a storage environment, thereby reducing graft devitalization.[
Various preservation techniques include deep freezing, preservation in bactericidal solutions, sterilization, and preservation in a subgaleal pouch.[
In 1920, Kreider[
The aim of the present clinical study was to assess the efficacy of preservation of calvarial bone in an abdominal pouch.
MATERIALS AND METHODS
We have prospectively analyzed 82 consecutively operated cases decompressive craniotomies done at the University Neurosurgical Clinic in Prishtina / KOSOVA over a period of 8 years (June 1999 to Aug 2008). Of the 75 who had their grafts replaced (7 patient died before replacement of bone graft), 62 patients had hemicraniectomy (fronto-parieto-temporal), 7 of them were bilateral. The rest of the 13 patients required smaller craniectomy for decompression. Dura was always opened in a stellate fashion and after brain herniation it was closed with fascia pericranialis. Six patients were thin, 57 were normal, and 12 were obese. The mean age of patients was 39 years (range, 1 to 68 years). Male were 49 and female were 33. Out of 82, children were 16. Etiology of brain swelling requiring decompressive craniectomy in 82 patients is listed in
In the region of mesogastrium of left abdomen, we performed a linear horizontal incision with length between 8 and 12 cm (depend on the size of bone graft). With surgical scissors, we prepare the so-called abdominal pocket. After meticulous surgical hemostasis, we placed the bone graft with the convex part on upper site, because the bone edges can injure the skin. Under skin and skin are sutured with interrupted sutures. We do not prefer the right sight because in the future the scar might suggest the procedures like cholecystectomia or appendectomia.
Presentation of a case:
The post operative evaluation was based on adequacy of the recovered craniotomy graft to achieve satisfactory reconstruction.
RESULTS
In 66 out of 75 patients was achieved a satisfactory and cosmetically reconstruction, and in 9 cases was required augmentation with methyl methacrylate to achieve cosmetic needs. During surgery the temporo-basal region was removed in small pieces with rongeurs the part that required augmentation with methyl methacrylate. Two patients had infection and the bone was removed; 6 months later these patients had cranioplasty with methyl methacrylate. The duration of storage of calvarial bone in an abdominal pouch before reimplantation was 14 – 232 days (range 56 days).
At the time of cranioplasty done and after a few months, we did not encounter microscopic resorption of the bone flap in any of our patients. The average of GCS on admission was 6 (range 3 - 15). After calvarial bone replacement hematomas occurred in 4 patients: 3 were subgaleactic and 1 in abdominal pouch, there was no need for percutaneous aspiration. After the onset of symptoms and mass effect on computed tomography, timing of decompressive craniectomy was 1 – 6 h (range 2 hours). Involvement of dominant hemisphere was in 51 cases. Average extra time required for preparing abdominal pouch to insert calvarial bone was 14 min (range 9 – 21 minutes) average size of bone was 9 × 11cm (range 8 – 12 × 10 – 13).
Two patients were complaining because of unpleasant abdominal pressure sensation. In seven cases of bilateral craniectomy, calvarial bones were preserved on both sides each.
CONCLUSION
When there is a high intracranial pressure and is not linked to evacuable mass lesions, such as in patients with massive bilateral brain swelling or unilateral massive brain swelling, medical treatment in such cases is frequently ineffective in controlling high intracranial pressure. Decompression craniotomy should be seen as a last resort therapeutic option. Routine decompression craniotomy should not be recommended for all patients with brain swelling. Early decompressive craniotomy is a therapeutic option in the management of these patients.
The size of craniectomy is of critical importance. Small craniectomies risk brain herniation with venous infarction and increased edema at the bone margins.
Replacement of the bone removed at craniotomy, a fresh skull autograft, is superior to all alternative forms of cranioplasty.[
We think that storage of the patients own bone flap in the abdominal pocket is a safe, easy, cheap, sterile, histocompatible, and better cosmetic results. When replacement the bone removed at craniotomy, a fresh skull autograft is superior to all alternative forms of cranioplasty such as methylmetacrylate or some metals like tantalum. When compared to the use of synthetic cranioplasty materials, a personal bone flap has very low percentage of inflammatory complications. This procedure is standardized in our University Neurosurgical Clinic of Kosova (post war country) from 1999 and we kindly prefer this procedure to other centers.
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