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PubMed1999

A technique for rigid fixation of methyl methacrylate cranioplasty: the vault-locking method.

BACKGROUND: Current treatment of difficult to reach lesions of the central nervous system favors extensive bone removal for improved visualization and access with minimal brain retraction. Particularly in the posterior fossa, bone is often removed piecemeal, and a standard craniotomy flap is not always available for simple reattachment. Cranioplasty with methyl methacrylate is used to provide cosmesis and neural protection. A method for the fixation of methyl methacrylate cranioplasty is described, and the results of technique application in 30 patients during a 14-month period are reported. METHODS: A series of notches are burred in the cancellous margin of the surrounding cranium, preserving the inner and outer tables. Methyl methacrylate is applied to the defect. Overflow of methyl methacrylate into the notches assures solid fixation. The resultant construct resembles the locking mechanism of a bank vault. No mesh, wire, or miniplates are required. Prolene buttresses may be placed through the outer table of the notches to identify their location, should removal of the plasty be required. Removal of the outer table over the notches facilitates rapid removal. RESULTS: Solid plasty and good cosmesis occurred in all patients. There were no infections or complications related to this technique. CONCLUSIONS: Firm fixation, molding and hardening in situ, and technical ease are potential advantages over established methods of cranioplasty.

Adult↗
PubMed1997

Post-cranioplasty cerebrospinal fluid hydrodynamic changes: magnetic resonance imaging quantitative analysis.

The syndrome of the trephined has been described in many patients with cranial defects as an indication for cranioplasty. Cerebral blood flow changes, the effect of the atmospheric pressure on the brain, as well as cerebrospinal fluid hydrodynamic changes have been postulated as the possible reasons for this syndrome. Using dynamic phase-contrast magnetic resonance imaging we measured arterial, venous, and cerebrospinal fluid flow into and out of the skull, before and after cranioplasty in one patient whose bone flap was removed because of osteomyelitis. We report significant changes in the oscillatory CSF flow after cranioplasty. A moderate increase in venous outflow as well as a two-fold increase in craniocaudal cerebrospinal fluid systolic flow velocity was measured after the skull closure. The changes in the cerebrospinal fluid oscillatory flow at the level of the craniovertebral junction could reflect changes in the compliance of the craniospinal system produced by closure of the cranial defect.

Adult↗
PubMed2001

Cranioplasty: why throw the bone flap out?

Patients who undergo decompressive craniectomy for intracranial hypertension often require interval cranioplasty. Many cranioplasty agents are currently in use. The authors suggest that storage of the patient's own bone flap in the subcutaneous tissue of the abdominal wall, is a safe, efficacious and cost-effective alternative to use of synthetic cranioplasty materials.

Abdominal Muscles↗
PubMed2003

Spring-mediated cranioplasty compared with the modified pi-plasty for sagittal synostosis.

The aim of this study was to compare the safety, morphological outcome, and degree of parental satisfaction of the new spring-mediated cranioplasty with those of the modified pi-plasty in the management of sagittal synostosis. Ten patients with non-syndromic sagittal synostosis treated with the spring-mediated cranioplasty were followed prospectively. A control group of 10 sex-matched patients operated on with the modified pi-plasty procedure was chosen. Cephalometric radiographs were obtained preoperatively and postoperatively at 1 year of age. Cephalic index, axial width ratio, length ratio, width ratio and height ratio were used as objective measures of outcome. Parents were sent a questionnaire to obtain a subjective aesthetic assessment of outcome. Significantly less blood replacement was required (p = 0.003), and shorter duration of postoperative anaesthesia (p = 0.030) and postoperative hospital stay (p = 0.013) were found in the spring-mediated cranioplasty group. There were no complications or deaths in either group. Also significant was the inter-group difference in the postoperative change in the height ratio (p = 0.030), the most change being seen in the spring group. The change in the subjective parental aesthetic evaluation of skull shape was significant in both groups. In conclusion, the spring-mediated procedure was morphologically more effective than the modified pi-plasty procedure in the management of sagittal synostosis with the additional benefits of less blood transfusion needed and shorter duration of hospital stay.

Cephalometry↗
PubMed1981

Split-rib cranioplasty.

Cranioplasty using a synthetic material is less than ideal, especially if there is a history of infection at the defect site. Split-rib cranioplasty is a practical approach even in patients with a positive history of infection at or around the defect. We briefly review the historical background of split-rib cranioplasty and report our experience with this procedure in 12 patients. Forty-two pieces of rib, with an average length of 13 cm. were used for reconstruction. We had only 1 complication-a pneumothorax following removal of the rib graft. The follow-up period ranged from three to thirty-six months. All patients had complete regeneration of the donor rib and solid protection of the brain.

Adolescent↗
PubMed1998

Split calvarial graft cranioplasty for the prevention of headache after retrosigmoid resection of acoustic neuromas.

OBJECTIVE: This study describes the technique and efficacy of split calvarial graft cranioplasty for the reconstruction of retrosigmoid/suboccipital defects following surgery for acoustic neuromas. STUDY DESIGN: A prospective study of the technique of split calvarial graft cranioplasty, its postoperative healing, and incidence of postoperative headache. METHODS: The technique requires splitting of the craniotomy bone flap into outer and inner table bone grafts. The combination of both bony grafts allows the coverage of a wider area of posterior fossa dura. This technique was used in 18 patients. All patients were followed for a minimum of 6 months. Eleven of 18 patients were followed for 1 year or longer. Four patients had three-dimensional computed tomography of their skull and area of split calvarial bone graft. RESULTS: One of 18 patients had a persistent disabling headache at 1 year postoperatively. A natural contour of the retrosigmoid area was achieved in all patients. Three-dimensional computed tomography scan, obtained 6 months postoperatively, showed total coverage of the retrosigmoid area and fusion of the bone flap to the surrounding skull. CONCLUSION: The technique of split calvarial grafting of posterior fossa defects is a feasible, safe, and effective way of separating the nuchal musculature and posterior fossa dura. The technique also allows the restoration of the contour and bony covering of the retrosigmoid area. The technique is a simple alternative to other types of cranioplasties aimed at reducing the incidence of postoperative headache in patients with acoustic neuromas.

Craniotomy↗
PubMed1996

Acrylic cranioplasty using miniplate struts.

OBJECTIVE: Cranioplasty using acrylic is a common procedure in patients with cranial defects secondary to trauma, infection, or tumor. The limitations of this technique include poor adherence of the acrylic to surrounding bone and difficulty in achieving a proper cosmetic contour in complicated cranial defects, especially those involving the orbital rim. The authors have been continually developing techniques of cranioplasty. METHODS: Ten consecutive cranioplasties were performed over the past 5 years using this new technique. TECHNIQUE: The authors describe a technique using miniplates as struts to which the acrylic is applied using a "reinforced concrete" principle. RESULTS/CONCLUSION: All patients achieved excellent cosmetic results with no complications. This technique allows contour of the repair site while the acrylic is curing and provides a more resilient resulting prosthesis.

Bone Cements↗
PubMed1997

Acrylic cranioplasty with alginate molding: technical note.

OBJECTIVE: Acrylic cranioplasty for cranial defects is a common neurosurgical procedure that is performed when the original bone flap becomes infected or is unusable for other reasons. We developed a simple technique to produce a complete copy of the original bone flap from acrylic, using alginate impression material as a mold. METHODS: Alginate impression material was used to form a mold of the patient's original bone flap. Methylmethacrylate was then placed inside the mold to create an exact duplicate of the bone flap. The acrylic flap was sterilized with gamma irradiation and used for cranioplasty. Two patients who had cranial defects secondary to infections of their craniotomy bone flaps underwent cranioplasty with this technique. RESULTS AND CONCLUSION: A perfect copy of the patient's original bone flap was easily and quickly created with this technique, and excellent cosmetic results were obtained. Operative time was shortened because the prosthesis was preformed before the operation. This technique can also be used to mold large or complex cranial defects as long as the original bone flap is available and there is no major cranial remodeling around the defect.

Alginates↗
PubMed2003

Assessment of the effects on growth of porous hydroxyapatite granule cranioplasty in the immature guinea pig craniofacial skeleton.

The immature guinea pig was used to study the effects on growth of porous granular hydroxyapatite used as an onlay cranioplasty and inlay cranioplasty to reconstruct full-thickness cranial defects in a growing craniofacial skeleton. Forty Hartley guinea pigs, 20 immature animals and 20 mature animals, were divided into four groups each containing five mature and five immature animals. The mature animals served as controls. Group I underwent elevation and replacement of the parietal periosteum. Group II underwent placement of hydroxyapatite between periosteum and parietal bone. Group III underwent elevation and replacement of autogenous bone flap after the formation of a 1 x 1-cm craniectomy defect in the parietal skull. Group IV underwent elevation of a 1 x 1-cm parietal craniectomy and reconstruction of the defect with hydroxyapatite granules placed between the dura and periosteum. Immature animals were killed at maturity at 3.5 months and mature animals were killed 2.5 months postoperatively. Macroscopic examination of the operative field, transverse and longitudinal cephalometric measurements, and histological sections encompassing the operative sites were compared. Macroscopically, all reconstructed operative sites were fully incorporated into the cranium. Histological staining of the sectioned operative site revealed no hydroxyapatite migration through the cranial bone or dura. No inflammatory or foreign body reaction was evident in the subcutaneous tissue, periosteum, or dura. No statistically significant cephalometric intergroup or intragroup differences were found at the conclusion of the study. The results of this study indicate that a granular porous form of hydroxyapatite may be used as an onlay or inlay cranioplasty in the immature guinea pig craniofacial skeleton without evidence of dural inflammation, granule migration, or growth restriction or retardation.

Age Factors↗
PubMed1995

Reduction cranioplasty.

Reduction cranioplasty can greatly improve the quality of life for selected patients with severe macrocephaly and can significantly diminish some of the difficulties in the long-term chronic care of others. Because of differences in age, cranial morphology and surgical goals, the surgical plan must be tailored to the individual patient. Three techniques for reduction cranioplasty, with the advantages and disadvantages of each, are described. Four patients, representing the spectrum of severe macrocephaly and also the problems associated with reduction cranioplasty, are presented. Surgical indications, tactical considerations and risks are discussed.

Adolescent↗
PubMed2006

Early combined cranioplasty and programmable shunt in patients with skull bone defects and CSF-circulation disorders.

OBJECTIVE: This study assesses the clinical outcome after early combined cranioplasty (own frozen bone) and shunt implantation (Codman-Medos programmable VP shunt) in patients with skull bone defects and cerebrospinal fluid (CSF) circulation disorders. METHOD: Medical records were reviewed retrospectively for the last 100 patients with CSF disorders after trauma or subarachnoid hemorrhage (SAH), who previously underwent decompressive craniotomy owing to therapy-resistant brain swelling. Patients treated with early (5 to 7 weeks after injury) combined cranioplasty and shunt implantation were analysed and a follow-up for the survivors was obtained. RESULTS: In 60 patients with a daily CSF external drainage over 150 ml and dilated ventricles in CT scan, a programmable VP shunt was implanted simultaneously with the cranioplasty within 5.1 weeks after decompression. The neurological condition 6 months later was good (independent patients) in 39 cases (65%); 12 patients (20%) survived with a severe disability; three patients (5%) remained in a persistent vegetative state and only six patients (10%) died. There were few complications: bone or shunt infection (three cases), post-operative intracranial bleeding (one case), transitory neurological impairment after bone reimplantation (two cases), bone resorption (two cases) and shunt dysfunction (three cases). CONCLUSION: The early reimplantation of the patient's own skull bone combined to the employment of a programmable shunt system allowed us a dynamic adjustment of the intracranial pressure (ICP) changes. The combined treatment reduced the number of required surgical procedures, complications and unsatisfactory patient outcomes.

Adult↗
PubMed2004

Vancomycin ointment for MRSA infection at a cranioplasty site.

OBJECTIVE: To report a case illustrating therapeutic success with long-term topical application of aseptic vancomycin ointment to treat methicillin-resistant Staphylococcus aureus (MRSA) infection at a cranioplasty site. CASE SUMMARY: A 63-year-old Japanese woman underwent evacuation of a subdural hematoma complicated by subarachnoid hemorrhage. Subsequent craniotomy for clipping and external decompression of an aneurysm of the neck was followed by cranioplasty using an autologous bone graft. The graft became infected with MRSA, which responded to intravenously infused vancomycin. The graft was then replaced with a ceramic implant. The implant site became reinfected with MRSA. Vancomycin infusion failed on this occasion, despite a favorable in vitro sensitivity test. After obtaining patient consent, investigative treatment was begun using long-term aseptic application of vancomycin 2.5% ointment, resulting in control of the infection and negative cultures. DISCUSSION: The care of an infection at the site of cranioplasty with a ceramic artificial bone implant is difficult. Our patient's infection resolved with the use of vancomycin ointment. In this case, blood concentrations of vancomycin remained below detectable levels, and no adverse effects resulted from application of vancomycin ointment. CONCLUSIONS: Topical administration of vancomycin was more effective than systemic administration in the treatment of our patient's MRSA skull implant infection. No adverse effects from topical treatment were encountered over 3 years.

Administration, Topical↗
PubMed1999

Reduction cranioplasty for macrocephaly. Two case reports.

Multi-stage reduction cranioplasty was performed on two children with severe macrocephaly secondary to hydrocephalus. One patient underwent a four-stage operation, and the other underwent a two-stage operation. The postoperative course of both patients was uneventful. Reduction cranioplasty improved quality of life for both patients, and good cosmetic results were achieved. Reduction cranioplasty is effective for the treatment of macrocephaly, and multi-stage surgery can reduce the associated risks.

Agenesis of Corpus Callosum↗
PubMed2001

Dynamic cranioplasty for brachycephaly in apert syndrome: long-term follow-up study.

OBJECT: Brachycephaly is a characteristic feature of Apert syndrome. Traditional techniques of cranioplasty often fail to produce an acceptable morphological outcome in patients with this condition. In 1996 a new surgical procedure called "dynamic cranioplasty for brachycephaly" (DCB) was reported. The purpose of the present study was to analyze perioperative data and morphological long-term results in patients with the cranial vault deformity of Apert syndrome who were treated with DCB. METHODS: Twelve patients have undergone surgery performed using this technique since its introduction in 1991 (mean duration of follow-up review 60.2 months). Eleven patients had bicoronal synostosis and one had a combined bicoronal-bilambdoid synostosis. Perioperative data and long-term evolution of skull shape visualized on serial cephalometric radiographs were analyzed and compared with normative data. Changes in mean skull proportions were evaluated using a two-tailed paired-samples t-test, with differences being considered significant for probability values less than 0.01. The mean operative blood transfusion was 136% of estimated red cell mass (ERCM) and the mean postoperative transfusion was 48% of ERCM. The mean operative time was 218 minutes. The duration of stay in the intensive care unit averaged 1.7 days and the mean hospital stay was 11.8 days. There were no incidences of mortality and few complications. An improvement in skull shape was achieved in all cases, with a change in the mean cephalic index from a preoperative value of 90 to a postoperative value of 78 (p = 0.000254). CONCLUSIONS: Dynamic cranioplasty for brachycephaly is a safe procedure, yielding high-quality morphological results in the treatment of brachycephaly in patients with Apert syndrome.

Acrocephalosyndactylia↗
PubMed2004

Failure of autologous bone-assisted cranioplasty following decompressive craniectomy in children and adolescents.

OBJECT: The authors have routinely performed primary autologous cranioplasty to repair skull defects after decompressive craniectomy. The high rates of subsequent bone resorption occurring in children prompted this study. METHODS: In an institutional review, the authors identified 40 (32 male and eight female) children and adolescents ranging from 4 months to 19 years of age in whom autologous cranioplasty was performed after decompressive craniectomy. The defect surface area ranged from 14 to 147 cm2. In all cases, the bone was fresh frozen at the time of the decompression. Symptomatic bone resorption subsequently occurred in 20 children (50%) in all of whom reoperation was required. The incidence of bone resorption significantly correlated with an increased skull defect area (p < 0.025). No significant correlation was found with age, sex, or anatomical location of the skull defect, number of fractured bone fragments, presence of a shunt, cause for decompressive craniectomy, method of duraplasty, or interval between the craniectomy and the cranioplasty. Reoperation to repair the resorbed autologous bone was performed 2 to 76 months after the initial procedure. CONCLUSIONS: The use of autologous bone to reconstruct skull defects in pediatric patients after decompressive craniectomy is associated with a high incidence of bone resorption. The use of autologous bone should be reevaluated in light of the high rate of reoperation in this pediatric population.

Adolescent↗
PubMed2001

[Cranioplasty for isolated trigonocephaly with developmental disorder].

We reported 50 cases of mild to moderate trigonocephaly (most isolated type) treated by cranioplasty. All of them had clinical symptoms such as severe hyperactivity, speech delay, inability to communicate with others, self-mutilation (head banging), irritability, temper tantrum and mental retardation. Pre-operative CT scan and MRI showed no abnormal findings in the brain except for constricted frontal lobes. The 3 D-CT scan showed the most important diagnostic findings: a ridge of the metopic suture and narrow anterior fossa. TcECD SPECT was performed on 43 patients, and demonstrated in 31 cases some degree of decreased cerebral blood flow (CBF), mainly in the bilateral frontal lobes. Post-operatively, most patients improved to some degrees. The results were compared to those of trigonocephaly patients without cranioplasty. The operated group showed better improvement in the above clinical symptoms, especially, hyperactivity, indifference to others, understanding of verbal communication, self-mutilation, irritability and temper tantrum. The post-operative SPECT represented the increased CBF in 30 out of the 31 cases. MRI and CT scan revealed expanded frontal lobes. Thus, cranioplasty may alleviate the symptoms of patients with mild to moderate trigonocephaly and developmental disorders.

Cerebrovascular Circulation↗
PubMed2002

[Cranioplasty using autogenous bone cryopreserved with dimethylsulfoxide (DMSO)].

It is generally agreed that the autogenous bone flap which has been removed at the time of external decompression would be superior to any artificial material if it can be used in cranioplasty. Cranioplasty using autogenous frozen bone graft has been reported and showed good results except for infection and severe bone absorption. We conducted 39 cases of cranioplasty with cryopreserved autogenous bone in the presence of 10% of Dimethylsulfoxide (DMSO), which has been reported as a cryoprotective agent. Although no remarkable histological effects have been recognized in frozen bone with or without DMSO, we have obtained excellent clinical results without bone absorption in 24 of the cases. These results suggest that DMSO is helpful for frozen bone preservation.

Adult↗
PubMed1992

[Cranioplasty of extensive defects of the cranial vault bones using a "Codubix" prosthesis].

In the years 1980-1987 in the Neurosurgery Department, Medical Academy in Lódź in 21 patients aged 12 to 59 years covering of cranial vault bone defects over 100 cm2 of area was done using of cranioplasty polypropylene-polyester knitted fabric Codubix. The size of the implanted prostheses was from 100 to 430 cm2. The time from bone defect occurrence to cranioplasty was from 4 weeks to 18 years. Cranial defects resulted from treatment of trauma complications in 10 cases, treatment of intracranial tumours in 7, aneurysms in 2 and intracranial infections in 2 cases. The follow-up after cranioplasty was from 3 to 10 years. In 18 cases (85.7%) good and very good therapeutic results were obtained. Three patients required removal of prosthesis because of purulent complication, in 2 of these cases high risk of infection was present before the operation. Codubix prosthesis was particularly useful for filling giant of cranial bones.

Adolescent↗