The effect of cranioplasty following decompressive craniectomy on cerebral blood perfusion, neurological, and cognitive outcome

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OBJECTIVE

Decompressive craniectomy is an established therapy for refractory intracranial hypertension. Cranioplasty following decompressive craniectomy not only provides protection to the brain along with cosmetic benefits, but also enhances rehabilitation with meaningful functional recovery of potentially reversible cortical and subcortical damaged areas of the affected as well as the contralateral hemisphere. The aim of the study was to assess neurological and cognitive outcome as well as cerebral blood flow after cranioplasty.

METHODS

Thirty-four patients admitted for replacement cranioplasty after decompressive craniectomy for head injury were studied prospectively. Clinical, neurological, and cognitive outcomes were assessed by the Glasgow Outcome Scale (GOS), the Glasgow Coma Scale, and a battery of cognitive tests, respectively. Simultaneously, cerebral blood perfusion was assessed by technetium-99m ethyl cysteinate dimer (99mTc-ECD) brain SPECT imaging 7 days prior to and 3 months after cranioplasty.

RESULTS

Prior to cranioplasty 9 patients (26.5%) had GOS scores of 5 and 25 patients (73.5%) had GOS scores of 4, whereas postcranioplasty all 34 patients (100%) improved to GOS scores of 5. Approximately 35.3%–90.9% patients showed cognitive improvement postcranioplasty in various tests. Also, on comparison with brain SPECT, 94% of patients showed improvement in cerebral perfusion in different lobes.

CONCLUSIONS

Cranioplasty remarkably improves neurological and cognitive outcomes supported by improvement in cerebral blood perfusion.

ABBREVIATIONS CBF = cerebral blood flow; CBP = cerebral blood perfusion; COWAT = Controlled Oral Word Association Test; DSST = Digit Symbol Substitution Test; DST = Digit Span Test; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; RAVLT-DR, RAVLT-IR = Rey Auditory Verbal Learning Test–delayed recall, RAVLT–immediate recall; TMT-A, TMT-B = Trail-Making Test, Parts A and B; 99mTc-ECD = technetium-99m ethyl cysteinate dimer.

Abstract

OBJECTIVE

Decompressive craniectomy is an established therapy for refractory intracranial hypertension. Cranioplasty following decompressive craniectomy not only provides protection to the brain along with cosmetic benefits, but also enhances rehabilitation with meaningful functional recovery of potentially reversible cortical and subcortical damaged areas of the affected as well as the contralateral hemisphere. The aim of the study was to assess neurological and cognitive outcome as well as cerebral blood flow after cranioplasty.

METHODS

Thirty-four patients admitted for replacement cranioplasty after decompressive craniectomy for head injury were studied prospectively. Clinical, neurological, and cognitive outcomes were assessed by the Glasgow Outcome Scale (GOS), the Glasgow Coma Scale, and a battery of cognitive tests, respectively. Simultaneously, cerebral blood perfusion was assessed by technetium-99m ethyl cysteinate dimer (99mTc-ECD) brain SPECT imaging 7 days prior to and 3 months after cranioplasty.

RESULTS

Prior to cranioplasty 9 patients (26.5%) had GOS scores of 5 and 25 patients (73.5%) had GOS scores of 4, whereas postcranioplasty all 34 patients (100%) improved to GOS scores of 5. Approximately 35.3%–90.9% patients showed cognitive improvement postcranioplasty in various tests. Also, on comparison with brain SPECT, 94% of patients showed improvement in cerebral perfusion in different lobes.

CONCLUSIONS

Cranioplasty remarkably improves neurological and cognitive outcomes supported by improvement in cerebral blood perfusion.

The management of refractory intracranial hypertension remains a therapeutic challenge for the neurosurgeon. In modern-day neurosurgical practice, decompressive craniectomy is often required in patients with severe head injuries, middle cerebral artery infarctions, and severe brain edema secondary to infective or neoplastic processes.1,3,22 It has been proven that therapeutic decompressive craniectomy reduces mortality and morbidity rates in a significant proportion of patients if used in appropriate settings, but it also can result in different symptomatologies like “syndrome of trephined,” altered CSF hydrodynamics, and impairment in underlying cerebral perfusion.4,18,19,22,25,29,31,32,38,39 Restorative cranioplasty following decompressive craniectomy was previously thought to be beneficial simply for protective and cosmetic purposes. However, in recent years its role in improving cortical and subcortical functions as well as restoring CSF dynamics is increasingly being recognized.7,8,10,13–17,23,27,37 In addition, subcutaneously preserved autologous bone flaps have been found to be more effective for cranioplasty following decompressive craniectomy.30 Although clinical improvement has been documented in several studies, pre-and postcranioplasty neuropsychological assessment has been documented only in few studies, and most of them are case reports.2,11,12 A few studies have also documented the role of increased cerebral blood perfusion (CBP) following cranioplasty in improvement of patients' functioning.8,15,37,40 In this investigation an attempt has been made to study the effect of cranioplasty following decompressive craniectomy on CBP, and on neurological and cognitive outcome.

Methods

This prospective observational study was conducted in the Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, in Chandigarh, India. After receiving approval from the Institute's ethics committee, 37 patients who had previously undergone decompressive craniectomy following head injury were admitted for replacement cranioplasty between January 2014 and September 2014. They were enrolled after giving informed consent. Of the 37 patients recruited, 3 were lost to follow-up and were excluded from the study. The demographic and clinical details at the time of injury and after decompressive craniectomy (at time of discharge) were recorded. There were 30 (88.2%) male and 4 (11.8%) female patients. The mean age was 31.53 ± 10.08 years, and mean educational level was 10.76 ± 2.93 years. Eleven (32.4%) patients had severe, 13 (38.2%) had moderate, and 10 (29.4%) had mild head injury. The patients with mild and moderate head injuries were initially managed conservatively, and decompressive craniectomy was done when they deteriorated after clinical and imaging evidence of significant mass effect or herniation. At the time of admission for cranioplasty, 16 patients (47.1%) had left, 17 (50.0%) had right, and 1 (2.9%) had bifrontal craniectomy defects. The median interval between craniectomy and cranioplasty was 5 months, with a range of 3–29 months. Thirty-two patients underwent autologous bone graft placement and 2 underwent titanium plate cranioplasty (due to autologous bone infection). All patients underwent neurological assessment, cognitive assessment, and SPECT imaging 1 week prior to and 3 months after cranioplasty.

Neurological Assessment

Glasgow Coma Scale (GCS)35 and Glasgow Outcome Scale (GOS) scores20 were used to assess the neurological outcome.

Cognitive Assessment

A battery comprising the following tests was used for cognitive assessment.

Trail-Making A and B Test

The Trail-Making Test (TMT) is a measure of visuoconceptual and visuomotor functions. It consists of 2 parts: part A measures visual attention and psychomotor speed, and part B measures cognitive flexibility and task switching.26

Controlled Oral Word Association Test

The Controlled Oral Word Association Test (COWAT) is a measure of phonemic fluency. In this test the subject generates words based on their phonetic similarity.6

Rey Auditory Verbal Learning Test

The Rey Auditory Verbal Learning Test (RAVLT) is a measure of verbal learning and memory. There are 2 lists, A and B, consisting of 15 words each. The number of words recalled correctly in the immediate recall (RAVLT-IR) trial, delayed recall (RAVLT-DR) trial, and the recognition trial will form the memory score.28

Digit Span Test

The Digit Span Test (DST) is a subtest of the PGI Memory Scale, which is an Indian adaptation of the Wechsler Memory Scale, and it measures auditory attention and working memory. The score will be the maximum number of digits recalled correctly.24

Digit Symbol Substitution Test

The Digit Symbol Substitution Test (DSST) is a test of mental speed, which requires motor persistence, sustained attention, and response speed. Rapid information processing is required to substitute the symbols accurately and quickly.36

For each test the raw scores obtained were compared with normative data for the respective tests and then were converted into either percentiles or Z scores. The patients scoring below the 15th percentile or below 1.5 SD were considered to have significant impairment in that specific domain.

99mTc-ECD Brain SPECT Imaging

All the patients underwent technetium-99m ethyl cysteinate dimer (99mTc-ECD) brain SPECT imaging. After intravenous administration of the radiotracer (mean 700 MBq), brain SPECT acquisition started at 0.5–1 hour by using a dual-head SPECT gamma camera (Symbia T16, Siemens). The SPECT data were acquired over a 360° rotation (circular orbit) in 128 projections (20 seconds/projection) in a 128 × 128 matrix with a zoom factor of 1.5. The acquired SPECT data were then reconstructed using an iterative reconstruction algorithm and Butterworth smoothing filter. Subsequently, the reconstructed data were displayed in 3 planes (axial, sagittal, and coronal) for visual localization and interpretation of the lesions demonstrating focal and abnormal uptake of the radiotracer. The SPECT data were analyzed using SCENIUM dedicated software for regional analyses of brain projections. The minimum cerebral perfusion was calculated by the SCENIUM dedicated application in the syngo (Molecular Imaging) application for regional analyses of brain projections. This application measures minimum, maximum, and mean perfusion within each lobe or region. The ratio of minimum perfusion of all lobes was calculated and compared with postcranioplasty results. A change in ratio by even 1% was considered an improvement.34

All the assessments were performed at 2 time points, first at 1 week prior to cranioplasty and then at 3 months after cranioplasty. The cohort of patients was also divided into 2 groups according to the time interval between craniotomy and cranioplasty: Group 1 (early—patients subjected to cranioplasty within 6 months); and Group 2 (late—patients subjected to cranioplasty after 6 months).

The data were analyzed using SPSS 21 (IBM). The data for categorical and continuous variables have been presented as frequency (percentage) and mean (SD), respectively. The quantitative data were analyzed using either the paired t-test or Wilcoxon signed-rank test (data not normally distributed) to compare the changes in pre- and postperfusion (SPECT scans) and cognitive tests. All analysis was 2-tailed and the level of significance was taken as p ≤ 0.05.

Results

Assessments performed prior to cranioplasty showed that all patients had recovered from their head injury and had a GCS score of 15. Regarding global outcome, 9 (26.5%) patients had a GOS score of 5, and 25 (73.5%) patients had a GOS score of 4. Three patients had visual acuity impairment and 10 had motor weakness (MRC Grade 4/4+). The mean perfusion ratios precranioplasty were 0.673 ± 0.448 in frontal lobes, 1.09 ± 0.535 in parietal lobes, 0.79 ± 0.597 in occipital lobes, 0.766 ± 0.369 in temporal lobes, and 0.949 ± 0.338 in basal ganglia. On preoperative cognitive assessment, the patients whose scores were in the impaired range were 78.8% in the DSST, 84.8% in the TMT-A, 86.2% in the TMT-B, 70.6% in the DST, 61.8% in the COWAT, 94.1% in the RAVLT-IR, and 88.2% in the RAVLT-DR.

At postcranioplasty assessment all 34 patients had a GOS score of 5. The mean perfusion ratios postcranioplasty were 0.798 ± 0.374 in frontal lobes, 0.999 ± 0.174 in parietal lobes, 0.869 ± 0.340 in occipital lobes, 0.673 ± 0.214 in temporal lobes, and 0.826 ± 0.179 in basal ganglia. With regard to cognitive functioning, the number of patients falling in the impaired range decreased to 42.4% in the DSST, 57.6% in the TMT-A, 60% in the TMT-B, 14.7% in the DST, 44.1% in the COWAT, 55.9% in the RAVLT-IR, and 55.9% in the RAVLT-DR.

The comparison between pre- and postassessment values revealed significant improvement in global functioning (GOS). The patients having impairment in visual acuity and motor weakness also showed complete improvement. With regard to CBP, only 2 (6%) patients did not show improvement in any of the lobes, whereas the remaining 32 (94%) showed improvement in 1 or more lobes (Figs. 14). The maximum number of patients had improvement in frontal lobe (21) and occipital lobe (20). Fourteen patients showed improvement in the parietal lobe and 11 each in the temporal lobe and basal ganglia. The comparison between pre- and postassessment values revealed statistically significant differences only in the occipital lobe and basal ganglia. There was an increase in the brain perfusion scores in the occipital lobe and a decrease in the basal ganglia. Although there was an increase in the brain perfusion ratio following cranioplasty in the frontal lobe and a decrease in the temporal and parietal lobes, the differences were not statistically significant. A trend of improvement (change of scores ± 1 SD) from pre- to postcognitive assessments was observed in 35.3%–90.9% of patients, including those who were still in the impaired range. The maximum improvement (90.9%) was observed in DSST, a measure of information processing speed, and minimum improvement (35.3%) was seen in the COWAT, a measure of phonemic fluency. Only 1 patient showed deterioration in performance on the DST, a measure of attention (Table 1). The results of the paired t-test or Wilcoxon signed-rank test indicated a significant difference in all the domains of cognitive functioning (Table 2).

FIG. 1.
FIG. 1.

A: Transaxial CT image showing right craniotomy defect. B and C: Transaxial and sagittal brain SPECT images of a patient with right craniotomy showing perfusion defect in frontal, parietal, and occipital lobes. D and E: Postcranioplasty SPECT images of the same patient showing improvement in perfusion in the respective lobes. Arrows designate the site of craniotomy and the perfusion defects. Figure is available in color online only.

FIG. 2.
FIG. 2.

A: Transaxial CT image obtained in a patient with a left craniotomy defect. B: Transaxial brain SPECT of the same patient showing a decrease in CBP in left frontal, parietal, and occipital lobes. C: Postcranioplasty SPECT suggestive of improvement in cerebral perfusion. Arrows designate the site of craniotomy and the perfusion defects. Figure is available in color online only.

FIG. 3.
FIG. 3.

A: Transaxial CT image showing right craniotomy defect. B and C: Precranioplasty SPECT of patient with right craniotomy defect. D and E: Postcranioplasty SPECT showing marked improvement in CBP in occipital lobe in the same patient. Arrows designate the site of craniotomy and the perfusion defects. Figure is available in color online only.

FIG. 4.
FIG. 4.

A: Transaxial CT image of patient with left craniotomy defect. B and C: Postcranioplasty SPECT (C) of the same patient showing ipsilateral and contralateral improvement in CBP, as compared with the precranioplasty SPECT (B). Arrows designate the craniotomy and perfusion defects. Figure is available in color online only.

TABLE 1.

Neuropsychological status of patients following cranioplasty

TestNo.*No. w/Status (%)
ImprovementNo ChangeDeterioration
TMT-A3315 (45.5)18 (54.5)0
TMT-B3023 (76.7)7 (23.3)0
DSST3330 (90.9)3 (9.1)0
DST3422 (64.7)11 (32.4)1 (2.9)
COWAT3412 (35.3)22 (64.7)0
RAVLT-IR3425 (73.5)9 (26.5)0
RAVLT-DR3428 (82.4)6 (17.6)0

Numbers vary because tests could not be administered in all patients.

TABLE 2.

Comparison of neuropsychological test results pre- and postcranioplasty

TestPrecranioplastyPostcranioplastyp Value
No.*MeanSDMeanSD
TMT-A3388.8744.3056.6027.180.001
TMT-B29255.93154.79133.5874.410.001
DSST33508.39211.92346.45149.510.001
DST348.382.0510.412.210.001
RAVLT-IR346.413.189.352.760.001
RAVLT-DR346.053.219.552.830.001
COWAT343.882.485.392.560.001

Numbers vary because tests could not be administered in all patients. Regarding the discrepancy in number of patients for TMT-B in Tables 1 and 2; 1 of the 30 patients had a significant number of errors and could not complete the test in the precranioplasty assessment. Hence he was considered to be impaired on preassessment. However, the score was not entered in the analysis because the patient could not complete the test. He could complete the test without errors in the postcranioplasty assessment; therefore the paired t-test was computed for 29 patients.

Because the time lapse between craniectomy and cranioplasty could contribute to the cognitive changes over time, hence the performance in 2 groups, the early cranioplasty group and the late cranioplasty group, was also compared. Both groups were comparable in terms of age, sex, education, severity of injury, and GOS score, but significantly different with regard to interval between craniectomy and cranioplasty. Prior to cranioplasty, the late group comprised more patients having impairment on the TMT-A, TMT-B, and DSST, whereas the early group comprised more patients having impairment on the RAVLT-IR, RAVLT-DR, and COWAT, but the differences were not statistically significant except for TMT-A. Postcranioplasty, significant improvement was observed in all cognitive domains for both the groups; however, the recovery was better in the early cranioplasty group (Table 3).

TABLE 3.

Frequency and percentages of patients falling into the impaired range: early versus late cranioplasty

TestNo. of Patients Impaired (%)
PrecranioplastyPostcranioplasty
EarlyLateEarlyLate
TMT-A*14 (73.7)14 (100.0)9 (47.4)10 (71.4)
TMT-B*13 (76.5)12 (100.0)7 (38.9)11 (91.7)
DSST*13 (68.6)13 (92.9)5 (26.3)9 (64.3)
DST14 (70.0)10 (71.4)2 (10.0)3 (21.4)
COWAT13 (65.0)8 (57.1)8 (40.0)7 (50.0)
RAVLT-IR20 (100.0)12 (85.7)11 (55.0)8 (57.1)
RAVLT-DR18 (90.0)12 (85.7)11 (55.0)8 (57.1)

Tests could not be administered in all patients (see also Tables 1 and 2): the TMT-A and DSST could not be administered in 1 patient in the early precranioplasty and early postcranioplasty groups. The TMT–B could not be administered in 3 patients in the early precranioplasty group, in 2 patients in late precranioplasty group, and in 2 each in the early and late postcranioplasty groups.

Discussion

In the present study we have demonstrated that the restorative cranioplasty improves the neurological status, cognitive functions, and CBP. This strengthens the hypothesis that decompressive craniectomy can cause alteration not only in CSF dynamics but that it also causes dysfunction of the cerebrum, leading to neurological and cognitive symptomatology.

Regarding the results of brain SPECT, our study showed that the majority of patients had improvement in CBP in both frontal and occipital lobes following cranioplasty, but the paired t-test revealed a significant difference only in the occipital lobe. A decrease in the mean perfusion of parietal and temporal lobes was observed that may be due to redistribution of blood to frontal and occipital lobes, which showed an increase in perfusion.

The results revealed a significant improvement in global functional outcome after cranioplasty. Prior to cranioplasty, the majority of patients had a GOS score of 4, which improved to a GOS score of 5 after cranioplasty. These findings were supported by the study done by Chibbaro et al.,8 who concluded that cranioplasty is helpful not only for cerebral protection but also for a patient's functional outcome. Suzuki et al.33 studied the cerebral blood flow (CBF) with dynamic CT scanning in patients undergoing cranioplasty. They concluded that improvement in a patient's neurological outcome might be due to an increase in bilateral CBF. Yoshida et al.40 were the first to study cognitive improvement in 7 patients with large cranial defects, and correlated their findings with CBF and metabolism by using stable 133Xe CT and 31P MR spectroscopy. Winkler et al.37 showed that cranioplasty resulted in a significant increase in the cerebral metabolism in both hemispheres, as measured by PET in 12 patients and CBF reactivity with transcranial Doppler and concluded that cranioplasty appears to affect postural blood flow regulation. Chibbaro et al. also demonstrated improvement in CBF and glucose uptake in both hemisphered by transcranial Doppler and 18FDG-PET in 100% of patients.

The results also revealed significant differences in all the cognitive tests performed pre- and postcranioplasty, indicating significant improvement in the functions of frontal and temporal lobes. Regarding the frontal lobe functions, significant improvement was observed in the DSST, a measure of information processing speed, and also on the TMT-B, which requires executive control— specifically flexibility of thinking and greater demand for working memory and attention (DST), respectively. However, not much improvement was observed in results of the COWAT, a measure of phonemic fluency. Chibbaro et al.8 also reported positive outcome on measures of frontal lobe functions (Frontal Assessment Battery) in 91% of patients. With respect to memory, a function of temporal lobe improvement was observed in both immediate and delayed recall. The significant cognitive improvement in the present study has been supported by a number of investigators. The case series study of 4 patients by Di Stefano et al.12 showed remarkable improvement in cognitive outcome after cranioplasty. Agner et al.2 presented significant improvement in the regional CBF as measured by Xe-CT along with neuropsychological scores. Cognistat scores showed an improvement of 48.3% (assess different cognitive abilities), and Executive Interview showed an improvement of 32.95% (assesses executive functions) postcranioplasty. In a case report by Coelho et al.,9 significant improvements in various cognitive tests were demonstrated in the task of verbal fluency, episodic memory, audio-verbal learning, information processing speed, and visual-constructive functions. There were comparable results reported by Winkler et al.,37 who reported that of their 13 patients, 7 (53%) showed improvement in cognitive functions (not quantified) after cranioplasty.

A question may arise whether these changes were attributable to cranioplasty or if they could be due to the time lapse between craniectomy and cranioplasty. The comparison of the precranioplasty assessment of both the early and late cranioplasty group was suggestive of slow recovery or deterioration of executive functions and psychomotor speed. Memory and verbal fluency may be prone to early recovery, as indicated by the lower number of impaired patients in the late cranioplasty group. But no definite conclusions could be made unless assessed at different time points. The trend of improvement was present in both the groups, although in general the early group had better recovery of cognitive functions. Beauchamp et al.5 also opined that early cranioplasty is better and should be performed as soon as brain edema gets resolved. Di Stefano et al.11 also stated that the majority of neurocognitive changes tend to be maximum initially and then decline gradually, and that cranioplasty hastens the recovery even though the improvement may be masked by an ongoing spontaneous recovery process. There is no agreement in the literature with regard to optimal timing for cranioplasty, although early intervention has been recommended.

The overall findings suggested a significant improvement in neurological and cognitive functioning, which could be possible due to an improvement in the hemodynamic patterns in both cerebral hemispheres. It is suggested that every cranial defect allows direct transmission of atmospheric pressure into the intracranial contents; i.e., affecting CBP. Before cranioplasty the entire cerebral perfusion in both hemispheres was affected in the same manner by intracranial pressure through the affected area. When the brain perfusions were compared after cranioplasty, they were found to be increasing.

Conclusions

The findings of the present study showed clear evidence that cranioplasty triggers relevant neurological, functional, and cognitive improvement in addition to cosmetic corrections. The probable mechanism of this is improvement in perfusion of the underlying brain as depicted by brain SPECT. These possibilities should serve as a reminder to rehabilitation clinicians to give serious consideration to prompt performance of cranioplasty during the time allotted for rehabilitation of the patients.

Acknowledgments

I express my extreme pleasure in acknowledging the contributions of all who have been instrumental in the successful completion of this work. I would like to thank Ms. Sarika, Medical Physicist and Radiation Safety Officer, and Ms. Kusum Chopra, the statistician, for their help.

Disclosures

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

Author Contributions

Conception and design: Gupta, Mohanty. Acquisition of data: Shahid. Analysis and interpretation of data: Gupta, Mohanty, Singla, Mittal. Drafting the article: Shahid. Critically revising the article: Gupta, Mohanty, Singla. Reviewed submitted version of manuscript: Gupta, Mohanty, Singla. Approved the final version of the manuscript on behalf of all authors: Gupta. Statistical analysis: Mohanty. Administrative/technical/material support: Gupta, Mohanty. Study supervision: Gupta, Mohanty.

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Article Information

Correspondence Sunil Kumar Gupta, Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Secto 12, Chandigarh 160012, India. email: drguptasunil@gmail.com.

INCLUDE WHEN CITING Published online March 3, 2017; DOI: 10.3171/2016.10.JNS16678.

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

© AANS, except where prohibited by US copyright law.

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Figures

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    A: Transaxial CT image showing right craniotomy defect. B and C: Transaxial and sagittal brain SPECT images of a patient with right craniotomy showing perfusion defect in frontal, parietal, and occipital lobes. D and E: Postcranioplasty SPECT images of the same patient showing improvement in perfusion in the respective lobes. Arrows designate the site of craniotomy and the perfusion defects. Figure is available in color online only.

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    A: Transaxial CT image obtained in a patient with a left craniotomy defect. B: Transaxial brain SPECT of the same patient showing a decrease in CBP in left frontal, parietal, and occipital lobes. C: Postcranioplasty SPECT suggestive of improvement in cerebral perfusion. Arrows designate the site of craniotomy and the perfusion defects. Figure is available in color online only.

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    A: Transaxial CT image showing right craniotomy defect. B and C: Precranioplasty SPECT of patient with right craniotomy defect. D and E: Postcranioplasty SPECT showing marked improvement in CBP in occipital lobe in the same patient. Arrows designate the site of craniotomy and the perfusion defects. Figure is available in color online only.

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    A: Transaxial CT image of patient with left craniotomy defect. B and C: Postcranioplasty SPECT (C) of the same patient showing ipsilateral and contralateral improvement in CBP, as compared with the precranioplasty SPECT (B). Arrows designate the craniotomy and perfusion defects. Figure is available in color online only.

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