An altered posterior question-mark incision is associated with a reduced infection rate of cranioplasty after decompressive hemicraniectomy

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  • 1 Department of Neurosurgery, RWTH Aachen University Hospital, Aachen; and
  • 2 Department of Neurosurgery, Military Hospital Koblenz, Germany
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OBJECTIVE

Performing a cranioplasty (CP) after decompressive craniotomy is a straightforward neurosurgical procedure, but it remains associated with a high complication rate. Surgical site infection (SSI), aseptic bone resorption (aBR), and need for a secondary CP are the most common complications. This observational study aimed to identify modifiable risk factors to prevent CP failure.

METHODS

A retrospective analysis was performed of all patients who underwent CP following decompressive hemicraniectomy (DHC) between 2010 and 2018 at a single institution. Predictors of SSI, aBR, and need for allograft CP were evaluated in a univariate analysis and multivariate logistic regression model.

RESULTS

One hundred eighty-six patients treated with CP after DHC were included. The diagnoses leading to a DHC were as follows: stroke (83 patients, 44.6%), traumatic brain injury (55 patients, 29.6%), subarachnoid hemorrhage (33 patients, 17.7%), and intracerebral hemorrhage (15 patients, 8.1%). Post-CP SSI occurred in 25 patients (13.4%), whereas aBR occurred in 32 cases (17.2%). An altered posterior question-mark incision, ending behind the ear, was associated with a significantly lower infection rate and CP failure, compared to the classic question-mark incision (6.3% vs 18.4%; p = 0.021). The only significant predictor of aBR was patient age, in which those developing resorption were on average 16 years younger than those without aBR (p < 0.001).

CONCLUSIONS

The primary goal of this retrospective cohort analysis was to identify adjustable risk factors to prevent post-CP complications. In this analysis, a posterior question-mark incision proved beneficial regarding infection and CP failure. The authors believe that these findings are caused by the better vascularized skin flap due to preservation of the superficial temporal artery and partial preservation of the occipital artery. In this trial, the posterior question-mark incision was identified as an easily and costless adaptable technique to reduce CP failure rates.

ABBREVIATIONS aBR = aseptic bone resorption; CP = cranioplasty; CRP = C-reactive protein; DHC = decompressive hemicraniectomy; DM = diabetes mellitus; EVD = external ventricular drain; GOS-E = Glasgow Outcome Scale–Extended; ICH = intracerebral hemorrhage; ICU = intensive care unit; MMI = malignant middle cerebral artery infarction; PMMA = polymethylmethacrylate; SAH = subarachnoid hemorrhage; SSI = surgical site infection; STA = superficial temporal artery; TBI = traumatic brain injury; WBC = white blood cell.

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Contributor Notes

Correspondence Michael Veldeman: RWTH Aachen University Hospital, Aachen, Germany. mveldeman@ukaachen.de.

INCLUDE WHEN CITING Published online April 24, 2020; DOI: 10.3171/2020.2.JNS193335.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Hutchinson PJ , Kolias AG , Tajsic T , Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury: consensus statement . Acta Neurochir (Wien) . 2019 ;161 (7 ):1261 1274 .

    • Search Google Scholar
    • Export Citation
  • 2

    Hofmeijer J , Kappelle LJ , Algra A , Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial . Lancet Neurol . 2009 ;8 (4 ):326 333 .

    • Search Google Scholar
    • Export Citation
  • 3

    Jüttler E , Schwab S , Schmiedek P , Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial . Stroke . 2007 ;38 (9 ):2518 2525 .

    • Search Google Scholar
    • Export Citation
  • 4

    Vahedi K , Vicaut E , Mateo J , Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial) . Stroke . 2007 ;38 (9 ):2506 2517 .

    • Search Google Scholar
    • Export Citation
  • 5

    Goedemans T , Verbaan D , Coert BA , Decompressive craniectomy in aneurysmal subarachnoid haemorrhage for hematoma or oedema versus secondary infarction . Br J Neurosurg . 2018 ;32 (2 ):149 156 .

    • Search Google Scholar
    • Export Citation
  • 6

    Güresir E , Raabe A , Setzer M , Decompressive hemicraniectomy in subarachnoid haemorrhage: the influence of infarction, haemorrhage and brain swelling . J Neurol Neurosurg Psychiatry . 2009 ;80 (7 ):799 801 .

    • Search Google Scholar
    • Export Citation
  • 7

    Fung C , Murek M , Z’Graggen WJ , Decompressive hemicraniectomy in patients with supratentorial intracerebral hemorrhage . Stroke . 2012 ;43 (12 ):3207 3211 .

    • Search Google Scholar
    • Export Citation
  • 8

    Takeuchi S , Wada K , Nagatani K , Decompressive hemicraniectomy for spontaneous intracerebral hemorrhage . Neurosurg Focus . 2013 ;34 (5 ):E5 .

    • Search Google Scholar
    • Export Citation
  • 9

    Malcolm JG , Rindler RS , Chu JK , Early cranioplasty is associated with greater neurological improvement: a systematic review and meta-analysis . Neurosurgery . 2018 ;82 (3 ):278 288 .

    • Search Google Scholar
    • Export Citation
  • 10

    Honeybul S , Ho KM . Cranioplasty: morbidity and failure . Br J Neurosurg . 2016 ;30 (5 ):523 528 .

  • 11

    Herteleer M , Ectors N , Duflou J , Van Calenbergh F . Complications of skull reconstruction after decompressive craniectomy . Acta Chir Belg . 2017 ;117 (3 ):149 156 .

    • Search Google Scholar
    • Export Citation
  • 12

    Klinger DR , Madden C , Beshay J , Autologous and acrylic cranioplasty: a review of 10 years and 258 cases . World Neurosurg . 2014 ;82 (3–4 ):e525 e530 .

    • Search Google Scholar
    • Export Citation
  • 13

    Shibahashi K , Hoda H , Takasu Y , Cranioplasty outcomes and analysis of the factors influencing surgical site infection: a retrospective review of more than 10 years of institutional experience . World Neurosurg . 2017 ;101 :20 25 .

    • Search Google Scholar
    • Export Citation
  • 14

    Zanaty M , Chalouhi N , Starke RM , Complications following cranioplasty: incidence and predictors in 348 cases . J Neurosurg . 2015 ;123 (1 ):182 188 .

    • Search Google Scholar
    • Export Citation
  • 15

    Kim JS , Park IS , Kim SK , Analysis of the risk factors affecting the surgical site infection after cranioplasty following decompressive craniectomy . Korean J Neurotrauma . 2015 ;11 (2 ):100 105 .

    • Search Google Scholar
    • Export Citation
  • 16

    Kim SH , Kang DS , Cheong JH , Comparison of complications following cranioplasty using a sterilized autologous bone flap or polymethyl methacrylate . Korean J Neurotrauma . 2017 ;13 (1 ):15 23 .

    • Search Google Scholar
    • Export Citation
  • 17

    Mukherjee S , Thakur B , Haq I , Complications of titanium cranioplasty—a retrospective analysis of 174 patients . Acta Neurochir (Wien) . 2014 ;156 (5 ):989 998 .

    • Search Google Scholar
    • Export Citation
  • 18

    Rosenthal G , Ng I , Moscovici S , Polyetheretherketone implants for the repair of large cranial defects: a 3-center experience . Neurosurgery . 2014 ;75 (5 ):523 529 .

    • Search Google Scholar
    • Export Citation
  • 19

    Jin SW , Kim SD , Ha SK , Analysis of the factors affecting surgical site infection and bone flap resorption after cranioplasty with autologous cryopreserved bone: the importance of temporalis muscle preservation . Turk Neurosurg . 2018 ;28 (6 ):882 888 .

    • Search Google Scholar
    • Export Citation
  • 20

    Kim H , Sung SO , Kim SJ , Analysis of the factors affecting graft infection after cranioplasty . Acta Neurochir (Wien) . 2013 ;155 (11 ):2171 2176 .

    • Search Google Scholar
    • Export Citation
  • 21

    Sundseth J , Sundseth A , Berg-Johnsen J , Cranioplasty with autologous cryopreserved bone after decompressive craniectomy: complications and risk factors for developing surgical site infection . Acta Neurochir (Wien) . 2014 ;156 (4 ):805 811 .

    • Search Google Scholar
    • Export Citation
  • 22

    Abode-Iyamah KO , Chiang HY , Winslow N , Risk factors for surgical site infections and assessment of vancomycin powder as a preventive measure in patients undergoing first-time cranioplasty . J Neurosurg . 2018 ;128 (4 ):1241 1249 .

    • Search Google Scholar
    • Export Citation
  • 23

    Güresir E , Vatter H , Schuss P , Rapid closure technique in decompressive craniectomy . J Neurosurg . 2011 ;114 (4 ):954 960 .

    • Search Google Scholar
    • Export Citation
  • 24

    Vieira E , Guimarães TC , Faquini IV , Randomized controlled study comparing 2 surgical techniques for decompressive craniectomy: with watertight duraplasty and without watertight duraplasty . J Neurosurg . 2018 ;129 (4 ):1017 1023 .

    • Search Google Scholar
    • Export Citation
  • 25

    Tanrikulu L , Oez-Tanrikulu A , Weiss C , The bigger, the better? About the size of decompressive hemicraniectomies . Clin Neurol Neurosurg . 2015 ;135 :15 21 .

    • Search Google Scholar
    • Export Citation
  • 26

    Malcolm JG , Rindler RS , Chu JK , Complications following cranioplasty and relationship to timing: a systematic review and meta-analysis . J Clin Neurosci . 2016 ;33 :39 51 .

    • Search Google Scholar
    • Export Citation
  • 27

    Lyon KA , Patel NP , Zhang Y , Novel hemicraniectomy technique for malignant middle cerebral artery infarction: technical note . Oper Neurosurg (Hagerstown). 2019 ;17 (3 ):273 276 .

    • Search Google Scholar
    • Export Citation
  • 28

    Yang HS , Hyun D , Oh CH , A faster and wider skin incision technique for decompressive craniectomy: n-shaped incision for decompressive craniectomy . Korean J Neurotrauma . 2016 ;12 (2 ):72 76 .

    • Search Google Scholar
    • Export Citation
  • 29

    Mustroph CM , Malcolm JG , Rindler RS , Cranioplasty infection and resorption are associated with the presence of a ventriculoperitoneal shunt: a systematic review and meta-analysis . World Neurosurg . 2017 ;103 :686 693 .

    • Search Google Scholar
    • Export Citation
  • 30

    Schuss P , Borger V , Güresir Á , Cranioplasty and ventriculoperitoneal shunt placement after decompressive craniectomy: staged surgery is associated with fewer postoperative complications . World Neurosurg . 2015 ;84 (4 ):1051 1054 .

    • Search Google Scholar
    • Export Citation
  • 31

    Yang XF , Wang H , Wen L , The safety of simultaneous cranioplasty and shunt implantation . Brain Inj . 2017 ;31 (12 ):1651 1655 .

    • Search Google Scholar
    • Export Citation
  • 32

    Schwarz F , Dünisch P , Walter J , Cranioplasty after decompressive craniectomy: is there a rationale for an initial artificial bone-substitute implant? A single-center experience after 631 procedures . J Neurosurg . 2016 ;124 (3 ):710 715 .

    • Search Google Scholar
    • Export Citation
  • 33

    Grant GA , Jolley M , Ellenbogen RG , Failure of autologous bone-assisted cranioplasty following decompressive craniectomy in children and adolescents . J Neurosurg . 2004 ;100 (2 )(Suppl Pediatrics):163–168 .

    • Search Google Scholar
    • Export Citation
  • 34

    Butenschoen VM , Seifert M , Meyer B , Presence of Propionibacterium acnes in patients with aseptic bone graft resorption after cranioplasty: preliminary evidence for low-grade infection . J Neurosurg . Published online August 30, 2019. doi:10.3171/2019.5.JNS191200

    • Search Google Scholar
    • Export Citation

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