Craniotomy flap osteomyelitis: a diagnostic approach

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✓ Nine cases of suspected craniotomy flap osteomyelitis evaluated by combined bone and gallium scanning are presented. In six cases, the clinical data were inconclusive and evaluation by radionuclide imaging provided an accurate negative diagnosis. The other three cases considered positive by this technique were proven infected at subsequent exploration and flap removal. The use of radionuclide bone and gallium imaging should be considered in cases of possible craniotomy flap osteomyelitis.

Article Information

Address reprint requests to: Bennett Blumenkopf, M.D., Department of Neurological Surgery, Vanderbilt Medical Center, T-4224 Medical Center North, Nashville, Tennessee 37232.

Address for Dr. Patton: Department of Radiology and Radiological Sciences, Vanderbilt University, Nashville, Tennessee.

Address for Dr. Friedman: Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.

© AANS, except where prohibited by US copyright law.

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Figures

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    Studies in Case 2. A: The 24-hour gallium-67 citrate scan, posterior vertex view, showing a small area of increased activity around the posterior margin of the craniotomy (arrows). B: The corresponding 4-hour technetium-99m methylene diphosphonate bone scan showing a bright rim of activity around the entire circumference of the flap. C: The Ga:Tc ratio image (which is normalized so that normal bone of a geometry similar to the flap is blue) indicates that high ratio values expected in soft tissues are pink and red while low ratio values around the rim of the flap are yellow and white. A preponderance of osteoblastic activity relative to inflammatory activity around the flap is thus mapped by the Ga:Tc ratio image.

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    Studies in Case 5. A: The 24-hour gallium-67 citrate scan, right lateral view, showing no abnormal activity. B: The 4-hour technetium-99m methylene diphosphonate bone scan showing a rim around the craniotomy site. C: The Ga:Tc ratio (which is normalized to uninvolved bone over the occipital region) indicates the expected yellow and white rim characteristic of osteoblastic repair which far outstrips inflammatory processes.

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    Skull radiographs in Case 6, anteroposterior (left) and lateral (right) views, showing a lucent area in the middle of the portion of bone affixed to the craniotomy site. This appearance was highly suggestive of osteomyelitis.

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    Studies in Case 6. The 24-hour gallium-67 citrate scans (left) and 4-hour technetium-99m methylene diphosphonate bone scans (right), anteroposterior views (upper) and lateral views (lower). Several areas of increased tracer activity in the right frontal region on the gallium study (left) were more impressive than the ill-defined increase in tracer activity noted on the bone scan (right). The uninvolved bone in the occipital region can also be examined for comparison.

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    Studies in Case 7. A: The 24-hour gallium-67 citrate scan, lateral view, showing increased activity in the posterior parietal region. B: Corresponding 4-hour technetium-99m methylene diphosphonate bone scan showing markedly decreased activity over the cranioplasty plate. C: The mean count over the cranioplasty plate was then corrected to zero (see Clinical Material and Methods). D: The Ga:Tc ratio reveals intense inflammatory activity in the posterior parietal region (shunt catheter abscess) and along the margin of the calvarial defect (arrow).

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    Anterior view of rabbit tibia with experimental osteomyelitis 3 days after inoculation with Staphylococcus aureus on the right. The increased ratio of gallium-67 citrate: echnetium-99m methylene diphosphonate (Ga:Tc) is represented as the region of red and pink along the mid-shaft when compared to the normal region on the left which appears blue (that is, Ga:Tc ratio =1:1).

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