- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
Brian T. Ragel
Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
DOI:10.4103/2152-7806.127762Copyright: © 2014 Piedra MP. 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: Piedra MP, Nemecek AN, Ragel BT. Timing of cranioplasty after decompressive craniectomy for trauma. Surg Neurol Int 25-Feb-2014;5:25
How to cite this URL: Piedra MP, Nemecek AN, Ragel BT. Timing of cranioplasty after decompressive craniectomy for trauma. Surg Neurol Int 25-Feb-2014;5:25. Available from: http://sni.wpengine.com/surgicalint_articles/timing-of-cranioplasty-after-decompressive-craniectomy-for-trauma/
Background:The optimal timing of cranioplasty after decompressive craniectomy for trauma is unknown. The aim of this study was to determine if early cranioplasty after decompressive craniectomy for trauma reduces complications.
Methods:Consecutive cases of patients who underwent autologous cranioplasty after decompressive craniectomy for trauma at a single Level I Trauma Center were studied in a retrospective 10 year data review. Associations of categorical variables were compared using Chi-square test or Fisher's exact test.
Results:A total of 157 patients were divided into early (P = 0.0482). Overall complication rate in both cohorts was 35%. Infection rates were lower in the early (7.7%) than the late (14%) cranioplasty cohort as was bone graft resorption (15% early, 19% late), hydrocephalus rate (7.7% early, 1.3% late), and postoperative hematoma incidence (3.9% early, 1.3% late). However, these differences were not statistically significant. Patients P = 0.0162).
Conclusions:After decompressive craniectomy for trauma, early (
Keywords: Cranioplasty, decompressive craniectomy, trauma
Decompressive craniectomy to treat elevated intracranial pressure and evacuate mass lesions associated with head injury has been shown to increase survival.[
We performed a retrospective cohort study of all cases of patients who had undergone cranioplasty after craniectomy for traumaat Oregon Health & Science University (a Level I Trauma Center) between January 2001 and January 2011. The study was approved by the Oregon Health and Science University institutional review board.
Patients were identified by searching Department of Neurological Surgery and billing records using Current Procedural Terminology codes (62140, 62141, 62142, 62143, 62145, 62146, and 62147) to identify all patients who underwent cranioplasty within the study timeframe. Patients who underwent craniectomy for causes other than trauma (e.g. infected bone flaps after tumor surgery, vascular causes of increased intracranial pressure such as stroke or aneurysmal subarachnoid hemorrhage, skull tumors, skull fracture without cerebral edema, and craniosynostosis repair) were excluded.
The following data were collected: Age at cranioplasty, sex, indications for craniectomy, laterality of craniectomy, time between craniectomy and cranioplasty, type of cranioplasty prosthesis (autograft or synthetic), operative time, use of surgical subgaleal drains, length of hospital stay after cranioplasty, and postoperative complications including hematoma, infection, hydrocephalus, or bone resorption.
A hematoma was defined as an epidural or subdural hematoma with clinical signs and symptoms of increased intracranial pressure with or without mid-line shift on postoperative computed tomography (CT) scan. Infection was defined as a surgical-site infection with signs and symptoms of infection (fever, erythema, drainage at the surgical site, elevated white blood cell count) with or without CT imaging characteristics consistent with infection (all patients with infection complications had reoperation with removal of the cranioplasty flap followed by treatment with a several-week course of intravenous antibiotics). All bone flaps were frozen-stored at −40°C to −80°C. Hydrocephalus was defined as clinical signs and symptoms of hydrocephalus (headache, nausea, decreased mental status) with ventriculomegaly on imaging requiring treatment with a cerebrospinal fluid (CSF) shunt. Bone resorption was defined as clinically significant erosion of the bone flap that could be palpated or seen on follow up imaging that was a concern for patient safety and cosmesis. Although follow up time was not consistent among patients, all patients were seen at least one time in follow up within 3 months of cranioplasty.
Timing of cranioplasty
Patients were divided into two cohorts, early and late, based on the median time to cranioplasty for all patients (median 12 weeks; determined after data collection). The early cohort consisted of patients that underwent cranioplasty within 12 weeks of craniectomy (<12 weeks). The late cohort included all other patients (≥12 weeks). The study included cranioplasty procedures performed by 14 different neurosurgeons within the Department of Neurological Surgery at Oregon Health & Science University. The timing of cranioplasty after craniectomy for trauma was at the discretion of the attending neurosurgeon. While no standardized protocol exists for deciding the appropriate time to perform cranioplasty, factors that are used to make the decision include patient's overall clinical status and a well-healed craniectomy scar as well as patient characteristics such as, distance to the hospital from their living arrangement and the availability of postoperative support once discharged following cranioplasty.
Demographic, clinical, and outcome data were compared for these two cohorts. Statistical analysis was performed using Stata (StataCorp LP, College Station, TX). Data were recorded as numbers and proportions. Associations of categorical variables were compared using Chi-square test or Fisher's exact test (when expected numbers were less than 5). Associations between continuous variables were compared using the unpaired 2-tailed Student t-test. The associations between the outcomes and effect variables were adjusted for confounders using multivariate logistic regression models. Significance was established at the 95% level.
We identified 157 patients who had undergone cranioplasty after craniectomy for trauma between 2001 and 2010. The mean time to cranioplasty for these patients was 17.4 weeks (range 1-99 weeks). Median time to cranioplasty was 12 weeks. The mean follow up time after cranioplasty for all patients was 24.2 months (range 1-124 months). The mean age for all patients was 29.5 years (range 1 month-83 years) [
There were 78 patients in the early cohort (within 12 weeks of craniectomy) and 79 patients in the late cohort. There was no statistically significant difference in age, sex, reason for craniectomy, type of implant (autograft or synthetic), presence of CSF shunt, or use of surgical subgaleal drains between the two cohorts [
Comparison of the complication rates between the early and late cohorts revealed no significant difference (34.6% early vs. 35.4% late, P = 0.9302). The rates of postoperative hematomas (3.85% early vs. 1.27% late, P = 0.3111) and hydrocephalus (7.69% early vs. 1.27% late, P = 0.0565) while higher in the early cohort did not reach statistical significance. The rates of infection (7.69% early vs. 13.9% late, P = 0.2354) and bone resorption (15.4% early vs. 19.0% late, P = 0.5863) were higher in the late cohort but also revealed no statistical significance [
Logistic regression analysis was performed using age category (<18 years of age or ≥18 years of age), time to cranioplasty (<12 or ≥12 weeks), sex, type of cranioplasty material (autologous or synthetic), presence of CSF shunt at the time of cranioplasty, or use of subgaleal surgical drains to determine predictors of the two most common complications, infection and bone resorption [
Overall complication rates for patients undergoing cranioplasty after craniectomy measured at 6, separate 4 week intervals (<4 weeks, ≥4 to <8 weeks, ≥8 to <12 weeks, ≥12 to <16 weeks, ≥16 to <20 weeks, and ≥20 weeks after craniectomy) are shown in
This retrospective study revealed no statistically significant difference in complications rates between performing cranioplasty early (within 12 weeks) and late (≥12 weeks) in patients undergoing decompressive craniectomy for trauma. The overall complication rate for these trauma patients was 35%, which is similar to previous literature reports.[
Overall bone resorption rate was 17% (15% early vs. 19% late, P = 0.5863). Surprisingly, few bone resorption after cranioplasty reports can be found in the literature.[
This study suggests that performing cranioplasty after trauma craniectomy at <12 weeks is as safe as delaying cranioplasty for ≥12 weeks. Complication rate increased in a dose-dependent fashion as the length of time between craniectomy and cranioplasty increased (up to ≥16 to <20 weeks after craniectomy) [
Performing cranioplasty <12 weeks after trauma craniectomy may carry some advantages to delaying cranioplasty for ≥12 weeks. In this study, operative time was significantly shorter in the early cohort (102 minutes early, 125 minutes late, P = 0.0482), this could be a result of greater difficult in dissecting the scalp flap and fitting the bone flap. Another possible advantage to performing cranioplasty <12 weeks after trauma craniectomy is the decrease in at risk for additional injury time for patients recovering without a bone flap in place. Rehabilitation therapists may also be overly cautious in recovery efforts while the patient is without a bone flap. Some studies have shown an improved level of consciousness after cranioplasty[
This study is limited by the risk of bias inherent to retrospective cohort investigations. The study is underpowered (80% power) to show equivalence of complication rates between early and late cohorts, due to the small number of patients evaluated. The factors that lead to timing of cranioplasty for this group of patients were not taken into consideration in the analysis. The cases were obtained from review of 10 years of data at one institution and the procedures were performed by multiple surgeons with varied practices in terms of managing patients after craniectomy, which also subjects the results to a risk of selection bias.
Further, while prior publications have detailed outcomes in larger series of patients,[
The rates of infection, hydrocephalus, epidural hematoma, or bone resorption are not affected by performing cranioplasty <12 weeks after craniectomy for trauma. When cranioplasty is delayed operative times are longer, which may increase costs. While no optimal time to perform cranioplasty was revealed in this study, the time interval of ≥16 to <20 weeks after craniectomy was shown to carry the highest risk of complication. As we have previously shown children are highly susceptible to bone resorption when cranioplasty is delayed for 6 weeks or more after craniectomy.[
The authors thank Shirley McCartney, Ph.D. for editorial assistance.
1. Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM. Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg. 2006. 104: 469-79
2. Albanese J, Leone M, Alliez JR, Kaya JM, Antonini F, Alliez B. Decompressive craniectomy for severe traumatic brain injury: Evaluation of the effects at one year. Crit Care Med. 2003. 31: 2535-8
3. Beauchamp KM, Kashuk J, Moore EE, Bolles G, Rabb C, Seinfeld J. Cranioplasty after postinjury decompressive craniectomy: Is timing of the essence?. J Trauma. 2010. 69: 270-4
4. Chang V, Hartzfeld P, Langlois M, Mahmood A, Seyfried D. Outcomes of cranial repair after craniectomy. J Neurosurg. 2010. 112: 1120-4
5. Chibbaro S, Di Rocco F, Mirone G, Fricia M, Makiese O, Di Emidio P. Decompressive craniectomy and early cranioplasty for the management of severe head injury: A prospective multicenter study on 147 patients. World Neurosurg. 2011. 75: 558-62
6. Chun HJ, Yi HJ. Efficacy and safety of early cranioplasty, at least within 1 month. J Craniofac Surg. 2011. 22: 203-7
7. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011. 364: 1493-502
8. De Bonis P, Frassanito P, Mangiola A, Nucci CG, Anile C, Pompucci A. Cranial repair: How complicated is filling a “hole”?. J Neurotrauma. 2012. 29: 1071-6
9. Figaji AA, Fieggen AG, Peter JC. Early decompressive craniotomy in children with severe traumatic brain injury. Childs Nerv Syst. 2003. 19: 666-73
10. Gooch MR, Gin GE, Kenning TJ, German JW. Complications of cranioplasty following decompressive craniectomy: Analysis of 62 cases. Neurosurg Focus. 2009. 26: E9-
11. Grant GA, Jolley M, Ellenbogen RG, Roberts TS, Gruss JR, Loeser JD. Failure of autologous bone-assisted cranioplasty following decompressive craniectomy in children and adolescents. J Neurosurg. 2004. 100: 163-8
12. Hutchinson P, Timofeev I, Kirkpatrick P. Surgery for brain edema. Neurosurg Focus. 2007. 22: E14-
13. Jiang JY, Xu W, Li WP, Xu WH, Zhang J, Bao YH. Efficacy of standard trauma craniectomy for refractory intracranial hypertension with severe traumatic brain injury: A multicenter, prospective, randomized controlled study. J Neurotrauma. 2005. 22: 623-8
14. Kan P, Amini A, Hansen K, White GL, Brockmeyer DL, Walker ML. Outcomes after decompressive craniectomy for severe traumatic brain injury in children. J Neurosurg. 2006. 105: 337-42
15. Liang W, Xiaofeng Y, Weiguo L, Gang S, Xuesheng Z, Fei C. Cranioplasty of large cranial defect at an early stage after decompressive craniectomy performed for severe head trauma. J Craniofac Surg. 2007. 18: 526-32
16. Matsuno A, Tanaka H, Iwamuro H, Takanashi S, Miyawaki S, Nakashima M. Analyses of the factors influencing bone graft infection after delayed cranioplasty. Acta Neurochir (Wien). 2006. 148: 535-40
17. Moreira-Gonzalez A, Jackson IT, Miyawaki T, Barakat K, DiNick V. Clinical outcome in cranioplasty: Critical review in long-term follow-up. J Craniofac Surg. 2003. 14: 144-53
18. Piedra MP, Ragel BT, Dogan A, Coppa ND, Delashaw JB. Timing of cranioplasty after decompressive craniectomy for ischemic or hemorrhagic stroke. J Neurosurg. 2013. 118: 109-14
19. Piedra MP, Thompson EM, Selden NR, Ragel BT, Guillaume DJ. Optimal timing of autologous cranioplasty after decompressive craniectomy in children. J Neurosurg. 2012. 10: 268-72
20. Sahuquillo J, Arikan F. Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury. Cochrane Database Syst Rev. 2006. 1: CD003983-
21. Schuss P, Vatter H, Marquardt G, Imohl L, Ulrich CT, Seifert V. Cranioplasty after decompressive craniectomy: The effect of timing on postoperative complications. J Neurotrauma. 2012. 29: 1090-5
22. Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfield M, Lewis E. A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst. 2001. 17: 154-62
23. Waziri A, Fusco D, Mayer SA, McKhann GM, Connolly ES. Postoperative hydrocephalus in patients undergoing decompressive hemicraniectomy for ischemic or hemorrhagic stroke. Neurosurgery. 2007. 61: 489-93