Outcomes of cranial repair after craniectomy

Clinical article

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Hemicraniectomy is a commonly practiced neurosurgical intervention with a wide range of indications and clinical data supporting its use. The extensive use of this procedure directly results in more cranioplasties to repair skull defects. The complication rate for cranial repair after craniectomy seems to be higher than that of the typical elective craniotomy. This finding prompted the authors to review their experience with patients undergoing cranial repair.


The authors performed a retrospective review of 212 patients who underwent cranial repair over a 13-year period at their institution. A database tracking age, presenting diagnosis, side of surgery, length of time before cranial repair, bone graft material used, presence of a ventricular shunt, presence of a postoperative drain, and complications was created and analyzed.


The overall complication rate was 16.4% (35 of 213 patients). Patients 0–39 years of age had the lowest complication rate of 8% (p = 0.028). For patients 40–59 years of age and older than 60, complication rates were 20 and 26%, respectively. Patients who originally presented with traumatic injuries had a lower rate of complications than those who did not (10 vs 20%; p = 0.049). Conversely, patients who presented with tumors had a higher complication rate than those without (38 vs 15%; p = 0.027). Patients who received autologous bone graft placement had a statistically significant lower risk of postoperative infection (4.6 vs 18.4%; p = 0.002). Patients who underwent cranioplasty with a 0–3 month interval between operations had a complication rate of 9%, 3–6 months 18.8%, and > 6 months 26%. Pairwise comparisons showed that the difference between the 0–3 month interval and the > 6-month interval was significant (p = 0.007). The difference between the 0–3 month interval and the 4–6 month interval showed a trend (p = 0.07). No difference was detected between the 4–6 month interval and > 6-month interval (p = 0.35).


The overall rate of complications related to cranioplasty after craniectomy is not negligible, and certain factors may be associated with increased risk. Therefore, when evaluating the need to perform a large decompressive craniectomy, the surgeon should also be aware that the patient is not only subject to the risks of the initial operation, but also the risks of subsequent cranioplasty.

Article Information

Address correspondence to: Donald Seyfried, M.D., Department of Neurosurgery, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, Michigan 48202. email: nsdos@neuro.hfh.edu.

Please include this information when citing this paper: published online July 17, 2009; DOI: 10.3171/2009.6.JNS09133.

© AANS, except where prohibited by US copyright law.




Aarabi BHesdorffer DCAhn ESAresco CScalea TMEisenberg HM: Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 104:4694792006


Bakay L: An Early History of Craniotomy: From Antiquity to the Napoleonic Era Springfield, ILCharles C Thomas1985


Bullock MRChesnut RGhajar JGordon DHartl RNewell DW: Surgical management of traumatic parenchymal lesions. Neurosurgery 58:3 SupplS25S462006


Colohan ARGhostine SEsposito D: Exploring the limits of survivability: rational indications for decompressive craniectomy and resection of cerebral contusions in adults. Clin Neurosurg 52:19232005


Compagnone CMurray GDTeasdale GMMaas AIEsposito DPrinci P: The management of patients with intradural post-traumatic mass lesions: a multicenter survey of current approaches to surgical management in 729 patients coordinated by the European Brain Injury Consortium. Neurosurgery 57:118311922005


Dujovny MAgner CAviles A: Syndrome of the trephined: theory and facts. Crit Rev Neurosurg 9:2712781999


Dujovny MFernandez PAlperin NBetz WMisra MMafee M: Post-cranioplasty cerebrospinal fluid hydrodynamic changes: magnetic resonance imaging quantitative analysis. Neurol Res 19:3113161997


Fodstad HLove JAEkstedt JFriden HLiliequist B: Effect of cranioplasty on cerebrospinal fluid hydrodynamics in patients with the syndrome of the trephined. Acta Neurochir (Wien) 70:21301984


Grant FCNorcross NC: Repair of cranial defects by cranioplasty. Ann Surg 110:4885121939


Hutchinson PJCorteen ECzosnyka MMendelow ADMenon DKMitchell P: Decompressive craniectomy in traumatic brain injury: the randomized multicenter RESCUEicp study (www.RESCUEicpcom). Acta Neurochir Suppl 96:17202006


Iwama TYamada JImai SShinoda JFunakoshi TSakai N: The use of frozen autogenous bone flaps in delayed cranioplasty revisited. Neurosurgery 52:5915962003


Jüttler ESchwab SSchmiedek PUnterberg AHennerici MWoitzik J: Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY). Stroke 38:251825252007


Liang WYang XLiu WShen GZheng XCao F: Cranioplasty of large cranial defect at an early stage after decompressive craniectomy performed for severe head trauma. J Craniofac Surg 18:5265322007


Meier UGräwe AKönig A: The importance of major extracranial injuries by the decompressive craniectomy in severe head injuries. Acta Neurochir Suppl 95:55572005


Richaud JBoetto SGuell ALazorthes Y: Effects of cranioplasty on neurological function and cerebral blood flow. Neurochirurgie 31:1831881985


Sahuquillo JArikan F: Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury. Cochrane Database Syst Rev 1:CD0039832006


Schiffer JGur RNisim UPollak L: Symptomatic patients after craniectomy. Surg Neurol 47:2312371997


Schwab SSteiner TAchoff ASchwarz SSteiner HJansen H: Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 29:188818931998


Skoglund TSEriksson-Ritzen CJensen CRydenhag B: Aspects on decompressive craniectomy in patients with traumatic head injuries. J Neurotrauma 23:150215092006


Smith ERCarter BSOgilvy CS: Proposed use of prophylactic decompressive craniectomy in poor-grade aneurismal subarachnoid hemorrhage patients presenting with associated large sylvian hematomas. Neurosurgery 51:1171242002


Stiver SIWintermark MManley GT: Reversible monoparesis following decompressive hemicraniectomy for traumatic brain injury. J Neurosurg 109:2452542009


Suzuki NSuzuki SIwabuchi T: Neurological improvement after cranioplasty. Analysis by dynamic CT scan. Acta Neurochir (Wien) 122:49531993


Timmons RLCranial defects and their repair Youmans JR: Neurological Surgery ed 2PhiladelphiaWB Saunders1982. 22282250


Timofeev IKirkpatrick PJCorteen EHiler MCzosnyka MMenon DK: Decompressive craniectomy in traumatic brain injury: outcome following protocol-driven therapy. Acta Neurochir Suppl 96:11162006


Unterberg AJüttler E: The role of surgery in ischemic stroke: decompressive surgery. Curr Opin Crit Care 13:1751792007


Vahedi KVicaut EMateo JKurtz AOrabi MGuichard JP: Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 38:250625172007


Vanaclocha VBazan ASaiz-Sapena NPaloma VIdoate M: Use of frozen cranial vault bone allografts in the repair of extensive cranial bone defects. Acta Neurochir (Wien) 139:9709761997


Winkler PAStummer WLinke RKrishnan KGTatsch K: Influence of cranioplasty on postural blood flow regulation, cerebrovascular reserve capacity, and cerebral glucose metabolism. J Neurosurg 93:53612000




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