- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, India
Correspondence Address:
Rajesh Alugolu
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, India
DOI:10.4103/2152-7806.107547
Copyright: © 2013 Reddy S 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: Reddy S, Alugolu R, Kumar A. Sinking of bone flap-looking beyond cosmesis and costs. Surg Neurol Int 20-Feb-2013;4:20
How to cite this URL: Reddy S, Alugolu R, Kumar A. Sinking of bone flap-looking beyond cosmesis and costs. Surg Neurol Int 20-Feb-2013;4:20. Available from: http://sni.wpengine.com/surgicalint_articles/sinking-of-bone-flap-looking-beyond-cosmesis-and-costs/
Dear Editor,
Decompressive craniectomy is a common procedure performed for raised intracranial hypertension with obligatory subsequent bone flap replacement or cranioplasty at varying intervals, for various side effects of the lack of bone flap, well described in the literature. However, the complications during and following the replacement of bone flap did not strike the limelight, which may require another surgical intervention.[
A 35-year-old male who underwent right fronto- temporo- parietal decompressive craniectomy for right temperoparietal contusion sustained following road traffic accident 7 years ago. The bone flap was replaced after 2 months and was fixed with two clamps. Patient was asymptomatic for 6 years when he noticed gradually progressive weakness involving his left upper and lower limbs, associated with sinking of the bone into the parenchyma and worsening of his hemiparesis to hemiplegia. There was no history of any trauma prior to the onset of symptoms. Computed tomography (CT) brain revealed sunken free bone flap, breaking the clutches of the bone clamps used to fix the bone flap, causing midline shift and mass effect [
The pathophysiological mechanism ascribed to the neurological deterioration include (a) the alteration of vascular flow both in sunken skin and bone flaps; with improvement following proper cranioplasty reverting the normal blood flow and (b) secondary diaschisis.
Free bone flap, devoid of its periosteum, and subjected to resorptive mechanisms both during the storage in the abdominal parieties and on replacement, requires a firm fixation. Patients with ventriculo-peritoneal shunt are at higher risk of complications following cranioplasty when compared with non shunted patients and in particular this complication can be attributed to over function of shunts.[
A concrete fixation of the bone flap following a decompressive craniotomy with judicious and adequate clamps is essential.
References
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2. Del Mar Carmona Abellán M, Murie Fernández M, Esteve Belloch P. Cranioplasty sinking should affect normal brain function mimicking other neurologic illness. AJNR Am J Neuroradiol. 2012. 33: E65-
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4. Schuss P, Vatter H, Marquardt G, Imöhl L, Ulrich CT, Seifert V. Cranioplasty after decompressive craniectomy: The effect of timing on postoperative complications. J Neurotrauma. 2012. 29: 1090-5