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PubMed2000

A new technique for cranioplasty with L-shaped titanium plates and combination ceramic implants composed of hydroxyapatite and tricalcium phosphate (Ceratite).

OBJECTIVE: The use of hydroxyapatite-based ceramics for cranioplasties has recently increased in Japan, because of the good cosmetic outcomes, biocompatibility, strength, osteoconductive properties, and lack of risk of disease transmission associated with these materials. However, miniplate fixation has not been possible for ceramic implants. We describe a new technique for miniplate fixation of ceramic implants. METHODS: Combination ceramic implants composed of hydroxyapatite and tricalcium phosphate (Ceratite; NGK Spark Plug Co., Aichi, Japan) were used for cranioplasties. A slot and a pair of holes were cut in each Ceratite implant, for use as a fixation unit. We have also developed a new L-shaped titanium plate (HOMS Engineering Inc., Nagano, Japan) that fits into the fixation unit. We first insert an L-shaped titanium plate through the slot from the back surface of the Ceratite implant. We then bend the plate outward at the front surface of the Ceratite implant and fix it to the cranium of the patient with titanium screws. The Ceratite implant is usually firmly fixed to the cranium of the patient with three L-shaped titanium plates. RESULTS: Using L-shaped titanium plates and Ceratite implants, we successfully performed cranioplasties for seven patients with cranial defects resulting from external decompression craniotomies. The Ceratite implant exactly fit the bone window for each patient. Surgical maneuvers were simple and easy for all patients, permitting shorter operating times. All Ceratite implants were firmly fixed, and no postoperative infections have occurred. CONCLUSION: Our new technique for cranioplasty is simple and allows rigid fixation of Ceratite implants.

Adolescent↗
PubMed2001

Successful use of rib grafts for cranioplasty in children.

Numerous materials are available for use in cranioplasty including bone, plastics and metals. Rib grafts as a construct for cranial reconstruction offer several advantages: autologous bone source, a formable platform, low infection, regeneration at the donor site and high fusion rates. Criticism of rib graft cranioplasty includes scarring and pain at the donor site, irregular contour at the graft site and graft reabsorption. Since 1988, we have performed rib autograft cranioplasty on 13 patients. Seven females and 6 males combined for an average age of 6 years (11 months to 20 years) at the time of surgery. The mean follow-up from surgery is 27 months (2-48 months), with 11 subjects having at least 12 months. The commonest reasons for cranial reconstruction were: post-traumatic calvarial defect (n = 4), defect from previous craniotomy (n = 3), "growing" skull fracture (n = 2), and defect from previous encephalocele closure (n = 2). Mean defect size was 41 cm(2) (8-144 cm(2)) and average number of ribs harvested was 1.75 (1-3). Simple rib cranioplasty had a mean time in the operating room of 6 h and 30 min. No donor site complications were noted (pneumothorax, significant post-operative pain) and no post-operative infections were encountered. Excellent cranial contour was achieved in each of the 11 patients followed for a minimum of 12 months. One subject required staged reconstructive procedures owing to the size of the defect.

Adolescent↗
PubMed1997

Methyl methacrylate cranioplasty in children: long-term results.

The long-term outcome of 75 children who underwent methyl methacrylate cranioplasty over a 15-year period is presented. Forty-two patients underwent cranioplasty for posttraumatic skull defects and 33 for nontraumatic causes. Within 8 years following initial cranioplasty procedure, a total of 17 (23%) complications occurred. Several factors correlated with the development of complications, including postoperative radiotherapy, the size of the defect, involvement of the frontal sinus, and the presence of prior infection. The authors currently recommend avoiding methyl methacrylate cranioplasty in selected patients who have received postoperative radiation therapy, in patients with large cranial defects, involvement of the frontal sinus, or any history of prior infection.

Acrylic Resins↗
PubMed1994

Neurological recovery after cranioplasty.

A patient who sustained a gunshot wound to the head was successfully treated with acute neurosurgical intervention. Six months after the injury, cranioplasty was used to repair a large skull defect. After cranioplasty, the patient developed significant improvement in motor function in his left upper extremity, which had been plegic after his injury. Although the mechanism of neurological recovery after cranioplasty is controversial, the occurrence of such improvement may be a sufficient indication for cranioplasty in certain patients.

Adult↗
PubMed1995

Impact of cranioplasty on headache after acoustic neuroma removal.

We reported previously the incidence of headache after the retrosigmoid removal of an acoustic neuroma as 23% at 3 months, declining to 9% at 2 years after surgery. In an attempt to reduce the incidence and the severity of these headaches, we made one change in our surgical procedure, which was to perform a cranioplasty with methyl methacrylate. Twenty-four patients underwent the cranioplasty and were followed for at least 3 months postoperatively. These patients were matched to 24 patients who did not undergo a cranioplasty. We found a 4% incidence of headache in the cranioplasty group and a 17% incidence in the matched group. No complications were related to this change in our procedure.

Adult↗
PubMed1994

Imaging after titanium cranioplasty.

Titanium cranioplasty has been used in our unit for reconstruction of cranial defects following trauma, tumour resection and bone loss due to postcraniotomy infection. It has previously been assumed that imaging to assess recurrence of disease progression after cranioplasty would be severely compromised in the presence of metallic material. Titanium is a non-ferrous metal of low atomic number, which is relatively radiolucent and allows exceptionally clear images to be obtained without significant degradation of image quality, on CT and magnetic resonance (MR) imaging. Cases are presented that demonstrate the use of CT contrast cisternography and MR imaging after titanium cranioplasty. On the basis of its strength, biocompatibility and excellent handling characteristics, allied to its suitability for all post-operative imaging techniques, we conclude that titanium plate is the material of choice for cranioplasty.

Brain Diseases↗
PubMed1989

[Split rib cranioplasty].

Presented are an operative technique and clinical indications for split rib cranioplasty, and the results of its practical application. This technique was applied to 6 patients, in five of whom infection after previous cranioplasty had been noted before split rib cranioplasty. Two patients out of the 5 had been suffering from inveterate and repetitive postoperative infections; one patient had been operated on twice and the other three times, respectively. Operative results were excellent without serious and/or infectious complications, except initially in one patient who presented hemothorax after rib harvest. This method can be applied for those who have extensive defect of the skull or who need additional reconstruction using split rib graft because of infectious complications after previously performed cranioplasty. This technique also has the following advantage; cranial contour is easy to reconstruct and good cosmetic results can be expected.

Adult↗
PubMed1985

[Effects of cranioplasty on neurological function and cerebral blood flow].

The authors present a review of their experience of cranioplasty in cases showing of skull defects. Forty recent case reports were retained out of a total of 125 cases and of these, 15 showed neurological deficiency prior to cranioplasty. In 7 out of these 15 cases cranioplasty appeared to have no effect, but in the 8 remaining cases, an improvement in the neurological condition was observed. In connection with these clinical observations, a recent study of a small group of patients with skull defects used the Xenon 133 inhalation method to investigate cerebral blood flow. In all cases these was a significant postoperative improvement in cerebral blood flow. The rate varying from 15 to 30% and this improvement was even observable in the case of small skull defects of the order of 10 cm2. The mechanism giving rise to such improvements is discussed; it may be related to cerebral hemodynamic normalization after skull restoration. The improvement in cerebral blood flow brought about by cranioplasty in all the cases studied suggests that this technique may be important not only for simple skull repair but also to improve neurological function.

Cerebrovascular Circulation↗
PubMed1984

[Alumina ceramic (Bioceram) as the cranioplastic material--experimental study and application in cranioplasty].

External decompression is an effective treatment for acute intracranial hypertension, but the repair of cranial defect by cranioplasty is necessary sooner or later. Various materials have been used for cranioplasty, such as bone, metallic materials and methyl methacrylate. Alumina ceramic (Bioceram), which is known to be extremely compatible with tissues, has already been used in the operations of not only orthopedic and oral surgery but also neurosurgery such as transsphenoidal surgery and anterior cervical fusion. At first, we implanted pieces of ceramic and small titan shield in the parietal bone of mongrel dogs. In this experimental study, tissue compatibility and osteogenesis are investigated in each case. The new bone formation was observed macroscopically and histologically around the ceramic pieces, but there were no osteogenic changes around the titan shields. Then ceramic plates, which were designed just as patients' own bone flaps, and titan shields were used for cranioplasties after decompression surgery, and compared clinically and histologically. The ceramic plate is superior than the titan shield in its strength, tissue-compatibility and excellent fit for cranial defect compared with the titan shield. There was no tissue reaction such as subgaleal fluid collection just as seen in the application of acryl resin. We believe that Alumina ceramic (Bioceram) is a good material for cranioplasty.

Aluminum↗
PubMed1995

Implants for cranioplasty.

As long as there have been skull defects, there has been a recognized need to cover them in some way. Cranioplasty is the surgical correction of skull defects. The two major purposes of performing a cranioplasty are to protect the brain and to provide reasonable cosmesis. The two physical requirements of the implant are strength and malleability. Originally, foreign materials such as precious metals were used. Autogenous bone grafts have also achieved successful results. Over the past quarter-century, the popularization of acrylics and radiolucent metals has favored them over bone because of their ease of use, the absence of need to harvest donor bone, and, particularly, bone's tendency to resorb or scar. Yet foreign materials can cause excessive inflammation, producing a synovial membrane at the interface between the host bone and cranioplasty construct, increasing the risk of infection. Currently, hydroxyapatite-based ceramics, which may induce bone growth into the implant, are increasingly being used. Future applications will include antibiotic-impregnated implants and computer-generated models to improve the precision of cranioplasty fit and cosmesis.

Biocompatible Materials↗
PubMed2004

Cranioplasty in children.

OBJECTIVE: The objective was to assess the outcome and complications associated with different cranioplasty implant materials in children. MATERIALS AND METHODS: A retrospective review was conducted of 28 consecutive cranioplasties carried out on 24 children between 1994 and 2001 (age range, 9 months to 15 years; minimum follow-up 18 months). The indications were: defect from previous craniectomy for trauma, tumour, infection or evacuation of haematoma (n=21), intradiploic dermoid cysts (n=2), growing fractures (n=4) and residual bony defect following craniofacial reconstruction (n=1). The materials used were: patient's craniectomised bone flap (n=16), split calvarial graft (n=8), acrylic (n=3) and titanium (n=1). All patients were assessed for bony fixation, cosmesis, wound healing and flap infection. RESULTS: There was no mortality and 18% morbidity (n=5: 3 infected flaps, 1 sterile wound dehiscence and 1 sterile wound discharge; overall infection rate 10%). Out of the 14 patients who had their own craniectomised bone flaps implanted initially, 3 became infected (2 in patients with bilateral defects) necessitating flap removal. Two of these were successfully re-implanted. No donor or recipient bone flap complications were seen in the 8 split calvarial grafts, wound discharge was seen in 1, requiring wound toilet. No complications were seen with acrylic or titanium cranioplasties. CONCLUSION: In this series, the use of the patients' own craniectomised flap had a low infection rate, and was mainly seen in patients who had bilateral flaps re-implanted soon after removal. There were no complications arising from the use of split calvarial and allograft material. Use of autologous implant material should be preferred whenever possible due to obvious resource and biological advantages, and can even be re-implanted if infected.

Adolescent↗
PubMed2000

Advances in cranioplasty with osteoinductive biomaterials: summary of experimental studies and clinical prospects.

The surgical repair of large calvarial defects is still a challenge for craniofacial surgeons. Since the discovery of bone growth factors, numerous studies have confirmed the interest of osteoinduction for bone repair. We summarize the findings of experimental and clinical trials carried out with composite bone substitutes. The triple mixture of TGF-beta 1, fibrin glue, and natural coral has proven effective in repairing rabbit skull defects. The same preparation was also efficient for a cranioplasty in two of three patients, age being a limiting factor. The adjunction of bone morphogenetic protein to autologous bone marrow was shown to be a potentiating factor in a rat cranioplasty model, but the combination of fibrin glue and bone marrow on a natural coral carrier was unable to achieve bone repair in children aged 6 years. Although the series were limited, stability and asepsis were important factors in promoting bony ingrowth. Cranioplasties with osteogenic biomaterials may be good option, but the most adequate dose of growth factor should be determined.

Adolescent↗
PubMed1997

Long-term follow up of a growing skull fracture treated by dura and cranioplasty with artificial dura mater and methylmethacrylate.

We report the long-term follow up of a growing skull fracture treated by duraplasty and cranioplasty with artificial dura mater and methylmethacrylate. The patient had undergone duraplasty and cranioplasty 19 years earlier at the age of 1 year and 11 months old. We examined the growth of the skull and the long-term adaptation between his own skull and methylmethacrylate 19 years after cranioplasty.

Adolescent↗
PubMed2002

Neurocognitive assessment before and after cranioplasty.

OBJECTIVE: This paper addresses the possible value of neurocognitive tests on the evaluation of patients before and after cranioplasty for large cranial defects. METHODS: In a single patient with a large corrected cranial defect a detailed neurocognitive analysis was performed utilizing the EXIT interview and Cognistat before and after surgery. Planning and development of the surgical prosthesis were based on the pre-operative reconstruction of the head CT and on pre-operative pictures of the patient. Xenon-CT anatomical and quantitative cerebral blood flow (CBF) analysis was performed before and periodically after cranioplasty. FINDINGS: A significant improvement in major cognitive functions was observed after surgery. INTERPRETATION: Cognistat is a detailed neuropsychological battery that permits a better assessment of patients in diverse neurological conditions. The EXIT interview gives a better rapid assessment of cognition not provided by other methods, such as the mini-mental status examination (MMSE). The utilization of these techniques permits a better understanding of long-term outcomes for patients with diverse neurological conditions, including post-cranioplasty patients.

Adult↗
PubMed1996

A new method of acrylic cranioplasty.

BACKGROUND: Previous acrylic cranioplasty techniques have relied on wire or suture fixation of the acrylic to the skull. A new methyl methacrylate cranioplasty technique, using acrylic with titanium plating, is described. METHODS: Titanium plates were bent into a "Z" shape and attached to the skull at the perimeter of the skull defect, extending into the defect. The acrylic was then poured into the defect and held in place during setting with a sheet of plastic. The plates are thereby embedded in the acrylic. RESULTS: Standard methyl methacrylate and titanium plates and screws were used to perform a new method of cranioplasty. CONCLUSIONS: A rigid, form-fitting, aesthetic construct can be easily and quickly created. This technique also offers the benefit of allowing secondary craniotomy, if necessary.

Humans↗
PubMed1993

Repair of cranial defects with teflon: a method of cranioplasty in monkeys.

Magnetic resonance imaging demonstrated the need for cranioplasty in experimental neurobehavioral studies with non-human primates. Postoperatively temporal lobes showed substantial deformation of the neocortex due to pressure from the overlying muscle. A new method of cranioplasty using teflon to cover a cranial defect has been developed. Teflon is easily shaped and fitted into place. This method is safe, allows for the natural shape of the brain, provides protection, and is compatible with imaging techniques. Cranioplasty with teflon should be considered whenever craniotomy is necessary for accessing the brain.

Animals↗
PubMed2005

[Free temporoparietal osteomuscular flap for cranioplasty].

PURPOSE: Advances in composite materials for craniofacial reconstruction surgery has tended to limit indications for osteomuscular free flaps which nevertheless must be used for certain septic patients. The purpose of this report was to illustrate the usefulness of the free temoroparietal osteomuscular flap in this particular situation. CASE REPORT: A 47-year-old man underwent surgical repair of an aneurysm of the anterior communicating artery complicated by acute hydrocephaly treated by external then ventriculoperitoneal bypass. The fronto-pteryonal approach was used. The early postoperative period was complicated by osteitis of the cranial piece requiring revision. The revision procedure, performed at the end of the septic period, involved cranioplasty with acrylic cement. Recurrent infection contraindicated any new attempt for prosthetic repair. The patient was treated with a controlateral free temporoparietal osteomuscular flap to achieve cranioplasty. The postoperative period was uneventful with no infection and satisfactory healing. Flap vitality was very satisfactory. The patient's neurological status improved and no further complication developed. DISCUSSION: In certain therapeutic situations, several diffent techniques may be required to overcome postoperative complications or manage particularly difficult cases. A free osteomuscular flap can be a useful alternative for cranioplasty. This technique is rarely used but can offer an optimal solution in selected patients, particularly for second intention revision after failure of prosthetic repair.

Acrylic Resins↗
PubMed1999

Functional outcome and the effect of cranioplasty after retromastoid craniectomy for microvascular decompression.

BACKGROUND: While the efficacy of retromastoid craniectomy for microvascular decompression for hyperactive cranial nerve syndromes is well established, there is no real information regarding the functional outcome of these operations. The purpose of this retrospective questionnaire study is to assess functional outcome regarding presence and duration of postoperative headache, incisional pain, and the time to return to normal activity in patients undergoing retromastoid craniectomy for microvascular decompression. The effect of closure with bone chips or cranioplasty in the defect upon these functional outcomes was studied, as was the influence of the particular nerve that was the object of decompression. METHODS: Four-hundred and ninety-five consecutive patients were contacted and 320 (65%) returned questionnaires with enough information to be suitable for analysis. RESULTS: The incidence of postoperative headache was initially 60.1%, dropping to 28.8% at 1 month and 16.8% at 6 months. Incisional pain likewise declined with time, noted in 25.8% at 1 month and only 13.1% at 6 months. Use of a cranioplasty made no significant difference in influencing either postoperative headache or incisional pain, nor was the nature of the procedure a significant factor. CONCLUSION: Twenty-five percent of patients resumed normal activity by 3 weeks, 50% by 1 month, and 90% by 3 months. Overall, 98% of patients responding reported returning to normal activity. Therefore, although there is an incidence of postoperative headache and incisional pain, these decrease with time and do not seem to interfere with the return to normal activity, nor are they affected by placement of a cranioplasty or the nature of the operation.

Activities of Daily Living↗