Evaluation of simultaneous cranioplasty and ventriculoperitoneal shunt procedures

Clinical article

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Object

Some patients with severe brain swelling treated with decompressive craniectomy may develop hydrocephalus. Consequently, these patients require cranioplasty and a ventriculoperitoneal (VP) shunt to relieve the hydrocephalus. However, there is no consensus as to the timing of the cranioplasty and VP shunt placement in patients requiring both. The authors assessed the results of performing cranioplasty and VP shunt placement at the same time in patients with cranial defects and hydrocephalus.

Methods

A retrospective review was performed of 51 patients who had undergone cranioplasty and VP shunt operations after decompressive craniectomy for refractory intracranial hypertension between 2003 and 2012 at the authors' institution. Patient characteristics, data on whether the operations were performed simultaneously, brain bulging, hydrocephalus, cranial defect size, and complications were analyzed.

Results

The overall complication rate was 43% (22 of 51 patients). In 32 cases, cranioplasty and VP shunt placement were performed at the same time. Complications included subdural hematoma, subdural fluid collection, and infection. The group undergoing cranioplasty and VP shunt placement at the same time had higher complication rates than the group undergoing the procedures at different times (56% vs 21%, respectively). The severity of complications was also greater in the former group. Patients with severe brain bulging had higher complication rates than did those without brain bulging (51% vs 0%, respectively). Cranial defect size, severity of hydrocephalus, indication for decompressive craniectomy, age, sex, and interval between decompressive craniectomy and subsequent operation did not affect complication rates.

Conclusions

Patients undergoing cranioplasty and VP shunt placement at the same time had higher complication rates, especially those with severe brain bulging.

Abbreviations used in this paper:ICH = intracerebral hemorrhage; SAH = subarachnoid hemorrhage; VP = ventriculoperitoneal.

Abstract

Object

Some patients with severe brain swelling treated with decompressive craniectomy may develop hydrocephalus. Consequently, these patients require cranioplasty and a ventriculoperitoneal (VP) shunt to relieve the hydrocephalus. However, there is no consensus as to the timing of the cranioplasty and VP shunt placement in patients requiring both. The authors assessed the results of performing cranioplasty and VP shunt placement at the same time in patients with cranial defects and hydrocephalus.

Methods

A retrospective review was performed of 51 patients who had undergone cranioplasty and VP shunt operations after decompressive craniectomy for refractory intracranial hypertension between 2003 and 2012 at the authors' institution. Patient characteristics, data on whether the operations were performed simultaneously, brain bulging, hydrocephalus, cranial defect size, and complications were analyzed.

Results

The overall complication rate was 43% (22 of 51 patients). In 32 cases, cranioplasty and VP shunt placement were performed at the same time. Complications included subdural hematoma, subdural fluid collection, and infection. The group undergoing cranioplasty and VP shunt placement at the same time had higher complication rates than the group undergoing the procedures at different times (56% vs 21%, respectively). The severity of complications was also greater in the former group. Patients with severe brain bulging had higher complication rates than did those without brain bulging (51% vs 0%, respectively). Cranial defect size, severity of hydrocephalus, indication for decompressive craniectomy, age, sex, and interval between decompressive craniectomy and subsequent operation did not affect complication rates.

Conclusions

Patients undergoing cranioplasty and VP shunt placement at the same time had higher complication rates, especially those with severe brain bulging.

Decompressive craniectomy is a life-saving procedure used in the treatment of medically refractory intracranial hypertension in patients suffering from traumatic brain injury, cerebral infarction, subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH).1,8,9,14 Indications for cranioplasty are usually protective and cosmetic. Cranioplasty has also been reported to facilitate neurological recovery3,15 and improve cerebral blood flow, CSF hydrodynamics, and metabolic activity after a decompressive craniectomy.2–7 Some patients with severe brain swelling treated with decompressive craniectomy may develop communicating hydrocephalus, with or without persistent brain bulging. Consequently, these patients also require a ventriculoperitoneal (VP) shunt to relieve the hydrocephalus.

There is no consensus as to the timing of the cranioplasty and VP shunt placement in patients who require both operations. A large cranial defect could lead to turbulence in CSF circulation hydrodynamics and cerebral blood perfusion due to exposure to atmospheric pressure, followed by hydrocephalus.4–7 Cranioplasty and VP shunts each affect CSF circulation, but exactly how each operation affects it is as yet unknown. Thus, undergoing both operations at the same time may cause complications due to unexpected CSF circulation changes. In this study, we assessed the results of undergoing cranioplasty and VP shunting at the same time in patients with cranial defects and hydrocephalus. We hypothesized that the outcomes after simultaneous cranioplasty and VP shunting may be worse than those when the operations are performed at different times.

Methods

This study was approved by the institutional review board of the Soonchunhyang University Seoul Hospital, and data were obtained by retrospective review of medical records, including radiographic images. A retrospective review was conducted in 54 patients who had undergone cranioplasty and VP shunt operations after a decompressive craniectomy for refractory intracranial hypertension between 2003 and 2012 at our institution. The interval between the cranioplasty and VP shunt placement was within 6 months. Of the 54 patients, the charts of 2 were incomplete for the purposes of this study, and 1 patient was lost to follow-up in the early postoperative period. As a result, 51 patients were identified who had undergone cranioplasty and VP shunt procedures. Baseline patient characteristics, operative details, and complication rates are shown in Table 1. In all cranioplasty procedures, we used autologous bone, and all autologous bone had been stored in our bone bank.

TABLE 1:

Demographic and operative details of 51 patients who underwent cranioplasty and VP shunt procedures*

CharacteristicsValue
Group 1 (n = 19)Group 2 (n = 32)
no. of patients
 male1318
 female614
craniectomy
 mean age (yrs)55.357.3
 mean interval btwn craniectomy & subsequent op (mos)3.912.25
pathology
 trauma1112
 SAH312
 ICH06
 cerebral infarction21
 brain tumor30
 IVH01
cranial defect size
 smaller than half of hemisphere16
 larger than half of hemisphere1826
degree of brain bulging
 flaccid concave cranial defect30
 flaccid w/ partial convex cranial defect41
 tense convex cranial defect1231
severity of hydrocephalus
 bifrontal index <0.41313
 bifrontal index >0.4619

Group 1 patients underwent cranioplasty and VP shunt placement at different time points, and Group 2 patients underwent cranioplasty and VP shunt placement at the same time. IVH = intraventricular hemorrhage.

Values are number of patients unless otherwise specified.

We routinely checked follow-up brain CT scans in patients with brain bulging after the decompressive craniectomy; if ventricular enlargement was observed on brain CT scans, we suspected hydrocephalus. If the diagnosis of hydrocephalus was uncertain, we performed a lumbar puncture to withdraw 30 ml CSF and we obtained brain metrizamide-enhanced CT scans. We defined hydrocephalus as: 1) a bifrontal index (the ratio of maximum width of the frontal horn to the width of the inner table) greater than 0.3 on brain CT scanning or MRI; 2) progressive increase in ventricular size; 3) enlargement of the temporal horn and third ventricle; 4) periventricular decreased density on CT; 5) contrast reflux into the ventricular system with delayed clearance on brain metrizamide CT (2- and 24-hour delayed scanning after intrathecal iodine contrast injection through lumbar puncture); and 6) neurological improvement after withdrawal of CSF via lumbar puncture. The severity of hydrocephalus was categorized according to the bifrontal index, with an index greater than 0.4 regarded as severe hydrocephalus (Fig. 1).

Fig. 1.
Fig. 1.

Computed tomography images showing mild hydrocephalus with bifrontal index less than 0.4 (left) and severe hydrocephalus with bifrontal index greater than 0.4 (right).

We inserted a programmable valve in 50 patients and a gravity-assisted valve in 1 patient; 41 patients received a Codman Hakim programmable valve (Codman & Shurtleff, Inc.), 9 received a MIETHKE proGAV (Christoph Miethke GmbH & Co. KG & BBraun), and 1 received a MIETHKE GAV shunt (Christoph Miethke GmbH & Co. KG & BBraun). We set the shunt pressure in consideration of ventricular puncture pressure and lumbar puncture pressure. The shunt pressure for most patients was set at 9–13 cm H2O (mean 11.38 cm H2O); in 26 patients the pressure was set at 11 cm H2O. All patients underwent brain CT scanning 7 days after surgery, and the shunt pressure was raised or lowered by 2–3 cm H2O. If there was neurological compromise after the operation, we checked brain CT scans immediately. If there were signs of CNS infection (such as fever, headache, and nuchal rigidity), we checked brain CT scans with contrast enhancement and CSF studies. If CNS infection was revealed by the CSF study, prophylactic antibiotics were started immediately and then were changed depending on culture.

Brain bulging was classified into 3 types: flaccid concave cranial defect, flaccid with partial convex cranial defect, and tense convex cranial defect (Fig. 2). A flaccid concave cranial defect was designated when all the brain was under the skull line. If part of the brain was bulging above the skull line, it was defined as flaccid with a partial convex cranial defect. A tense convex cranial defect was designated when all the brain was above the skull line. We considered the former two cranial defects (flaccid concave and flaccid with partial convex) to be mild brain bulging, and a tense convex cranial defect to be severe brain bulging.

Fig. 2.
Fig. 2.

Computed tomography images showing degrees of brain bulging. The red line is the assumed skull line. Flaccid concave cranial defect (A), flaccid with partial convex cranial defect (B), and tense convex cranial defect (C).

The cranial defect size was categorized according to maximum diameter: if the cranial defect size was smaller than half of the hemisphere diameter, it was regarded as a small cranial defect. A cranial defect larger than half of the hemisphere diameter was regarded as a large cranial defect.

Patients were classified according to complications. Additionally, the group with complications was classified according to whether reoperation was required. Complications requiring reoperations included infections (subdural abscess or shunt infection), subdural fluid collection, and hemorrhage that caused neurological compromise or was refractory to medical treatment. Patients with small amounts of subdural fluid collection that could be managed by adjusting the VP shunt pressure were excluded from complications requiring reoperation.

Data analyses were performed using SPSS software (version 19, SPSS, Inc.). Categorical variables were analyzed in contingency tables using Fisher's exact test; p values < 0.05 were considered to indicate statistical significance.

Results

Baseline patient characteristics and complications are shown in Table 1. The most common indication for craniectomy was trauma (45%). Other reasons for decompressive craniectomy included SAH, ICH, and cerebral infarct. In total, 32 patients (64%) underwent cranioplasty and VP shunt placement at the same time, and the others underwent the operations at different times. In the latter group, the interval between the two operations ranged from 0.5 to 6 months (average interval, 2.4 months). The average interval between decompressive craniectomy and subsequent operation (cranioplasty or shunt placement) was 2.88 ± 1.85 months, and there was some difference between the groups. Most (86%) of the skull defects were larger than half of the hemisphere. Of the patients, 43 (84%) had tense convex cranial defects; the others had flaccid or flaccid with partial convex cranial defects. The bifrontal indices in approximately half the patients (26 patients, 51%) were less than 0.4, and those of the remaining patients were above 0.4.

Postoperative complications are summarized in Table 2. Of the 51 patients who underwent cranioplasty and VP shunt placement, 29 (57%) experienced no complication, and 22 (43%) experienced at least 1 complication. These complications included subdural fluid collection, infection, subdural hemorrhage, ICH, and epidural hemorrhage, which were diagnosed clinically and were confirmed with CT scans (Fig. 3). Among the patients with complications, 12 (24%) had complications that required an additional surgery to address the primary cranioplasty or VP shunt site. Complications requiring reoperation were infection (subdural abscess or shunt infection), subdural fluid collection, or hemorrhage with neurological compromise.

TABLE 2:

Complications in 51 patients who underwent cranioplasty and VP shunt procedures*

ComplicationsNo. of Patients
Group 1 (n = 19)Group 2 (n = 32)
subdural fluid collection
 max depth <10 mm & no neurological compromise27
 max depth >10 mm or neurological compromise01
subdural hemorrhage
 w/o neurological compromise10
 w/ neurological compromise02
infection16
others
 ICH01
 epidural hemorrhage01
total4 (21%)18 (56%)

Group 1 patients underwent cranioplasty and VP shunt placement at different time points, and Group 2 patients underwent cranioplasty and VP shunt placement at the same time.

Fig. 3.
Fig. 3.

Computed tomography images showing complications after operations. Subdural fluid collection (A), subdural hematoma with fluid collection and pneumocephalus (B), and epidural hematoma (C).

We encountered infections in 7 cases (Table 3). Pathogens were methicillin-resistant Staphylococcus aureus, Staphylococcus epidermidis, and Enterobacter spp. Primary sites of infection were epidural abscess, CSF, and distal or peritoneal catheter. A cure was obtained with surgery and antibiotics in 5 patients, but 2 patients died. Data regarding categorical variables and complications are summarized in Table 4. Statistical analysis showed that the degree of brain bulging was significantly associated with complications (flaccid concave cranial defect or flaccid with partial convex cranial defect: 0 of 8; tense convex cranial defect: 22 of 43 [p = 0.01]). The timing of cranioplasty and VP shunt placement was found to be significantly associated with complications (simultaneous: 18 of 32; at different times: 4 of 19 [p = 0.01]), and with complications requiring reoperation (simultaneous: 11 of 32; at different times: 1 of 19 [p = 0.02]). Among the patients with severe brain bulging (Table 5), the timing of the two operations was not statistically significantly associated with complications; however, the patients undergoing simultaneous cranioplasty and VP shunt placement showed a tendency toward a higher complication rate and more severe complications. Cranial defect size, severity of hydrocephalus, indication for decompressive cranioplasty, age, sex, and interval between decompressive craniectomy and subsequent operation did not affect complication rates.

TABLE 3:

Characteristics and progress in 7 patients who encountered infections*

Case No.Age (yrs), SexGroupPathogen on Primary SiteCSF InfectionInfection at Op SiteProgress1st Treatment
182, F2MRSA/epidural abscessnoyesPOD 7: epidural hematoma occurred; hematoma was removed & shunt pressure was increased. POD 14: abscess at op site; abscess was removedinfected bone & abscess removed
276, M1MRSA/shuntyesnoshunt infectionshunt removed
354, F2MRSA/epidural abscessnoyessubdural fluid collection occurred at op site; abscess occurred laterinfected bone & abscess removed
437, M2MRSA/epidural abscessyesyessubdural fluid collection occurred at op site; abscess occurred laterinfected bone, abscess, shunt removed
575, M2S. epidermidis/shuntyesnoshunt infectionshunt removed
610, F2Enterobacter spp./epidural abscessyesyespneumocephalus occurred at op site; abscess occurred laterbone & abscess removed; patient died
746, M2Enterobacter spp./CSF, abdomenyesyessubdural fluid collection & abscess on peritoneal catheter tipinfected bone, abscess, shunt removed; patient died

Group 1 patients underwent cranioplasty and VP shunt placement at different time points, and Group 2 patients underwent cranioplasty and VP shunt placement at the same time. MRSA = methicillin-resistant Staphylococcus aureus; POD = postoperative day.

TABLE 4:

Categorical variables and complications

ParameterNo. of PatientsNo. of ComplicationsNo. of Complications Requiring Reop
timing of cranioplasty & VP shunt placement
 at the same time321811
 at different times1941
 p value0.010.02
cranial defect size
 smaller than half the hemisphere721
 larger than half the hemisphere442011
 p value0.681.00
degree of brain bulging
 flaccid concave cranial defect or flaccid w/ partial convex cranial defect800
 tense convex cranial defect432212
 p value0.010.10
severity of hydrocephalus
 bifrontal index <0.42686
 bifrontal index >0.425146
 p value0.070.94
TABLE 5:

Relationship between timing of the two operations and complication rate in patients with severe brain bulging

Timing of Ops in Patients w/ Severe Brain BulgingNo. of PatientsNo. of ComplicationsNo. of Complications Requiring Reop
at the same time3118 (58%)11 (35%)
at different times124 (33%)1 (8%)
p value0.130.08

Discussion

Decompressive craniectomy is a significant part of neurosurgical practice, as is the requirement for subsequent cranioplasty. However, while cranioplasty may be integral, no comprehensive guidelines are available regarding the technique or timing of the procedure, especially with regard to possible complications. Current practices relating to cranioplasty are largely subjective and are based on surgeon preferences or institutional policies.16 Hydrocephalus is a common complication of decompressive craniectomy.18,19 When hydrocephalus develops in a patient after a decompressive craniectomy, the brain may progressively bulge at the craniectomy site. In this situation, there is little doubt about the need for shunting.11

The overall complication rate of cranioplasty is 16%–34%, depending on the study.7,12,16 Wu et al. reported that the cumulative complication rate of VP shunting at 5 years was 32%.17 In our study, the overall complication rate was 43%. Patients undergoing both operations at the same time and patients with large cranial defect and severe brain bulging had much higher complication rates (56%, 45%, and 51%, respectively) than previously published complication rates for cranioplasty and shunt placement. However, patients undergoing the two operations at different times had a lower complication rate (21%). Rocque et al. reported that there is no considerable effect of craniectomy defect size on complication rate. Also, time between craniectomy and cranioplasty did not have a significant effect on complication rate.13 The results came from studies in the pediatric population but were consistent with our study. In contrast to our study, Zhou et al. reported that the outcome of a single-stage operation combining VP shunt placement and cranioplasty did not significantly differ from that for two separate operations.20 More research on the safety of a single-stage operation is needed.

The brain with a skull bone defect is affected by several factors that do not affect the brain without such a defect. The general purpose of cranioplasty is cosmetic and protection from external impact, but some authors have also suggested that cranioplasty can result in neurological improvement,3,15 which has been explained by several theories. According to the literature, cranioplasty protects the brain from the effects of barometric pressure, so it affects the cerebral vasculature and cerebral perfusion pressure; this can change the intracranial pressure.3–5,10 We also presume that performing cranioplasty in the presence of a sunken or bulging brain creates a negative or positive pressure, respectively, in the subdural space. Secondarily, this may also change the intracranial pressure. Because of these changes in intracranial pressure, adjusting the VP shunt pressure is difficult. Indeed, how best to adjust VP shunt pressure has not been defined in patients undergoing cranioplasty and VP shunt placement. Most of the patients undergoing simultaneous cranioplasty and VP shunt placement who had complications had subdural fluid collection or subdural hematoma. Such complications could be caused, or aggravated, by CSF drainage via the VP shunt.17 The higher complication rate in patients undergoing the two operations at the same time may be explained by difficulties in adjusting the VP shunt pressure in these patients.

Our study was retrospective in nature and, as such, does not provide rigorous evidence supporting any particular course of action, especially the small cohorts, the selection bias in determining which patients would have both procedures simultaneously, and certain nonquantitative outcome measures. However, it does illustrate some important observations that we think are useful to consider. Simultaneous cranioplasty and VP shunt placement was associated with a tendency toward higher complication rates, as was the same dual procedure in patients with severe brain bulging. Other factors such as age, sex, cranial defect size, severity of hydrocephalus, interval between decompressive craniectomy and subsequent operation, and indication for decompressive craniectomy did not apparently affect complication rates. However, our data are too limited to reach definite conclusions. Prospective studies are needed to further evaluate cranioplasty with VP shunting. We think that when a patient needs both operations simultaneously, especially with a bulging brain, CSF drainage via lumbar or ventricular puncture should be considered before the operation to control the intracranial pressure and avoid complications.

Conclusions

Cranioplasty and shunt placement, two procedures performed after decompressive craniectomy, have higher complication rates than do other elective cranial procedures. In our study, patients who underwent cranioplasty and VP shunt placement at the same time tended to have higher complication rates. Patients with severe brain bulging also had a higher complication rate. We conclude that simultaneous cranioplasty and VP shunt placement should be avoided, especially in patients with severe brain bulging. Furthermore, because complications caused or aggravated by CSF drainage via the VP shunt were frequent in our study, cautious adjustment of VP shunt pressure is required. However, our data are too limited to draw definite conclusions. Prospective studies are needed to further evaluate cranioplasty with VP shunting.

Disclosure

This work was supported by the Soonchunhyang University Research Fund.

Author contributions to the study and manuscript preparation include the following. Conception and design: SQ Park. Acquisition of data: Heo. Analysis and interpretation of data: SQ Park, Heo. Drafting the article: SQ Park, Heo. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: SQ Park. Statistical analysis: SQ Park, Heo. Study supervision: SQ Park, Cho, Chang, HK Park.

This article contains some figures that are displayed in color online but in black-and-white in the print edition.

References

  • 1

    Bullock MRChesnut RGhajar JGordon DHartl RNewell DW: Surgical management of acute subdural hematomas. Neurosurgery 58:S2-16S2-242006

  • 2

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

  • 3

    Dujovny MAviles AAgner CFernandez PCharbel FT: Cranioplasty: cosmetic or therapeutic?. Surg Neurol 47:2382411997

  • 4

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

  • 5

    Fodstad HEkstedt JFridén H: CSF hydrodynamic studies before and after cranioplasty. Acta Neurochir Suppl (Wien) 28:5145181979

  • 6

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

  • 7

    Gooch MRGin GEKenning TJGerman JW: Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases. Neurosurg Focus 26:6E92009

  • 8

    Güresir EBeck JVatter HSetzer MGerlach RSeifert V: Subarachnoid hemorrhage and intracerebral hematoma: incidence, prognostic factors, and outcome. Neurosurgery 63:108810942008

  • 9

    Güresir ERaabe ASetzer MVatter HGerlach RSeifert V: Decompressive hemicraniectomy in subarachnoid haemorrhage: the influence of infarction, haemorrhage and brain swelling. J Neurol Neurosurg Psychiatry 80:7998012009

  • 10

    Joseph VReilly P: Syndrome of the trephined. Case report. J Neurosurg 111:6506522009

  • 11

    Liao CCKao MC: Cranioplasty for patients with severe depressed skull bone defect after cerebrospinal fluid shunting. J Clin Neurosci 9:5535552002

  • 12

    Moreira-Gonzalez AJackson ITMiyawaki TBarakat KDiNick V: Clinical outcome in cranioplasty: critical review in long-term follow-up. J Craniofac Surg 14:1441532003

  • 13

    Rocque BGAmancherla KLew SMLam S: Outcomes of cranioplasty following decompressive craniectomy in the pediatric population. A systematic review. J Neurosurg Pediatr 12:1201252013

  • 14

    Schwab SSteiner TAschoff ASchwarz SSteiner HHJansen O: Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 29:188818931998

  • 15

    Segal DHOppenheim JSMurovic JA: Neurological recovery after cranioplasty. Neurosurgery 34:7297311994

  • 16

    Sobani ZAShamim MSZafar SNQadeer MBilal NMurtaza SG: Cranioplasty after decompressive craniectomy: an institutional audit and analysis of factors related to complications. Surg Neurol Int 2:1232011

  • 17

    Wu YGreen NLWrensch MRZhao SGupta N: Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery 61:5575632007

  • 18

    Yang XFWen LShen FLi GLou RLiu WG: Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir (Wien) 150:124112482008

  • 19

    Yang XJHong GLSu SBYang SY: Complications induced by decompressive craniectomies after traumatic brain injury. Chin J Traumatol 6:991032003

  • 20

    Zhou QZhang SZXu RXWang JQTu YY: [One-stage operation of ventriculoperitoneal shunt and cranioplasty: analysis of 54 cases.]. Di Yi Jun Yi Da Xue Xue Bao 25:2542552005. (Chinese)

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Article Information

Address correspondence to: Sukh Que Park, M.D., Ph.D., Department of Neurosurgery, Soonchunhyang University Seoul Hospital, 657 Hannam-dong, Yongsan-Gu, Seoul 140-743, Korea. email: drcolor@schmc.ac.kr.

Please include this information when citing this paper: published online March 21, 2014; DOI: 10.3171/2014.2.JNS131480.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Computed tomography images showing mild hydrocephalus with bifrontal index less than 0.4 (left) and severe hydrocephalus with bifrontal index greater than 0.4 (right).

  • View in gallery

    Computed tomography images showing degrees of brain bulging. The red line is the assumed skull line. Flaccid concave cranial defect (A), flaccid with partial convex cranial defect (B), and tense convex cranial defect (C).

  • View in gallery

    Computed tomography images showing complications after operations. Subdural fluid collection (A), subdural hematoma with fluid collection and pneumocephalus (B), and epidural hematoma (C).

References

1

Bullock MRChesnut RGhajar JGordon DHartl RNewell DW: Surgical management of acute subdural hematomas. Neurosurgery 58:S2-16S2-242006

2

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

3

Dujovny MAviles AAgner CFernandez PCharbel FT: Cranioplasty: cosmetic or therapeutic?. Surg Neurol 47:2382411997

4

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

5

Fodstad HEkstedt JFridén H: CSF hydrodynamic studies before and after cranioplasty. Acta Neurochir Suppl (Wien) 28:5145181979

6

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

7

Gooch MRGin GEKenning TJGerman JW: Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases. Neurosurg Focus 26:6E92009

8

Güresir EBeck JVatter HSetzer MGerlach RSeifert V: Subarachnoid hemorrhage and intracerebral hematoma: incidence, prognostic factors, and outcome. Neurosurgery 63:108810942008

9

Güresir ERaabe ASetzer MVatter HGerlach RSeifert V: Decompressive hemicraniectomy in subarachnoid haemorrhage: the influence of infarction, haemorrhage and brain swelling. J Neurol Neurosurg Psychiatry 80:7998012009

10

Joseph VReilly P: Syndrome of the trephined. Case report. J Neurosurg 111:6506522009

11

Liao CCKao MC: Cranioplasty for patients with severe depressed skull bone defect after cerebrospinal fluid shunting. J Clin Neurosci 9:5535552002

12

Moreira-Gonzalez AJackson ITMiyawaki TBarakat KDiNick V: Clinical outcome in cranioplasty: critical review in long-term follow-up. J Craniofac Surg 14:1441532003

13

Rocque BGAmancherla KLew SMLam S: Outcomes of cranioplasty following decompressive craniectomy in the pediatric population. A systematic review. J Neurosurg Pediatr 12:1201252013

14

Schwab SSteiner TAschoff ASchwarz SSteiner HHJansen O: Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 29:188818931998

15

Segal DHOppenheim JSMurovic JA: Neurological recovery after cranioplasty. Neurosurgery 34:7297311994

16

Sobani ZAShamim MSZafar SNQadeer MBilal NMurtaza SG: Cranioplasty after decompressive craniectomy: an institutional audit and analysis of factors related to complications. Surg Neurol Int 2:1232011

17

Wu YGreen NLWrensch MRZhao SGupta N: Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery 61:5575632007

18

Yang XFWen LShen FLi GLou RLiu WG: Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir (Wien) 150:124112482008

19

Yang XJHong GLSu SBYang SY: Complications induced by decompressive craniectomies after traumatic brain injury. Chin J Traumatol 6:991032003

20

Zhou QZhang SZXu RXWang JQTu YY: [One-stage operation of ventriculoperitoneal shunt and cranioplasty: analysis of 54 cases.]. Di Yi Jun Yi Da Xue Xue Bao 25:2542552005. (Chinese)

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