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Subdural temperature recordings under hardening methyl-methacrylate cranioplasties of varying sizes but standard thickness were analyzed. If 29.7 degrees C saline irrigations are used during hardening, the subdural temperature rises no more than 0.55 degrees C. The conclusion is that letting methyl-methacrylate harden in situ during cranioplasty is safe provided 29.7 degrees C saline irrigation is utilized.
Although almost all infants suffering chronic subdural hematomas (CSDH) are successfully treated by established methods such as a subdural puncture, burr holes and shunting procedures, infantile CSDH with progressive craniocerebral disproportion requires a special therapeutical regimen. Clinical efforts such as reduction cranioplasty have been made as a treatment for these cases. This is a case report of a 9-month-old male infant with an intractable CSDH, bilateral and large, and subsequent brain atrophy caused by traumatic head injury. Excellent results were obtained by a modified reduction cranioplasty. In brief, the patient was supine-positioned with a 20-degree flexion of the head in an attempt to obtain a large operative field. Bicoronal skin incision was combined with an additional linear one on the midline (T-shaped incision). Bilateral frontoparietal craniotomy with periosteum was made to keep the midline bony bridge overlying the superior sagittal sinus (SSS). The resulting extensive dural opening allowed complete evacuation of the subdural hematoma. Thereafter, the anterior part, ca. 4cm in width, of the bony bridge was removed in order to make the remaining bone able to be manipulated and connected to the frontal bone. Prior to this stage, SSS close to the crista galli was ligated and cut with the falx to avoid postoperative kinking. The dura mater was sutured so as not to leave an excessive subdural space. The bone flaps were trimmed to complete a good-shaped reconstruction. Finally, the excessive scalp was removed because the original scalp was too large for the reconstructed skull.(ABSTRACT TRUNCATED AT 250 WORDS)
We present our clinical experience in cranioplasty with autograft as follows: conchal cartilage for losses up to 2 cm2, outer table grafts for defects up to 100 cm2, and, for larger defects still, split rib grafts, which may be combined with outer table grafts. We conclude that autograft is superior to alloplastic material in cranioplasty.
A case of intracranial epidural abscess, 20 years after allograftic cranioplasty was presented. The abscess was caused by bacterial implantation after a minor stab wound of the scalp over the cranioplastic plate. It seemed quite rare that the intarcranial abscess occurred 20 years after an allograftic cranioplasty.
The work deals with "delayed" cranioplasty in children with severe craniocerebral trauma employing a bone graft preserved under the skin or fascia of the thigh. On grounds of a morphological examination of bone grafts the most favourable terms for performing cranioplasty are indicated.
Fronto-orbital deformities secondary to trauma, infection, or surgery create a difficult problem for the reconstructive surgeon. The location of the deformity is particularly critical because it involves the most visible part of the face. Since the skull is rarely able to produce bony regeneration over large areas, numerous alloplastic materials have been used to repair these defects. Complications with these materials are commonplace. Autogenous bone has been used with good results and avoids many of the problems inherent to the use of foreign materials. Rib, scapula, and iliac crest may be used, but they require a separate incision and often provide less than satisfactory cosmetic results. We describe a technique of cranioplasty utilizing split calvarium for repair of frontal bone defects. Cosmesis is excellent, morbidity is minimal, and only one incision is necessary.
Although pediatric neurosurgeons traditionally have been trained to perform a sagittal synostectomy for the treatment of sagittal synostosis, numerous articles advocating modifications of this procedure or more complex cranial vault reconstructions point our the inadequacies of strip craniectomy in providing optimal short- and long-term cosmesis. This review addresses the major arguments for and against performing complex cranioplasties for sagittal synostosis, as well as issues regarding timing of surgery, mortality and morbidity, increased need for blood transfusion, and increased expense. The authors support the contention that for the majority of infants with sagittal synostosis, complex calvarial vault reconstruction provides a better outcome with little increase in operative risk.
Two cases of massive osteolysis involving the cranial vault are presented. Unlike disappearing bones in other regions, it is vital to protect the brain from injury by performing cranioplasty once the bone loss has reached a reasonable extent. This appears to be the first report on surgical management in massive osteolysis of the skull. Long term follow-up results are given. The diagnosis and differentiation from related conditions are discussed.
The authors studied the changes in neurological signs and cerebral circulation by using dynamic CT scans before and after cranioplasty in six externally decompressed patients. Five of the 6 patients showed some improvements in neurological signs. The results of the dynamic CT scans in 6 cases suggested that increases of bilateral cerebral blood flow may play a role in their neurological improvement.
The results of a total of 25 cranioplasties are reported. In 10 patients, a reinforced acrylic prosthesis was utilized. In the remaining 15 cases, the patient's own autoclaved bone flap was re-implanted. Six of these bone flaps were autoclaved to kill tumour cells, and was re-implanted during the same surgical procedure. In the remaining 9 patients, the flaps were removed to allow brain swelling, preserved in a freezer and re-implanted several months later. All the prostheses and re-implanted flaps were accepted by the patients without complications such as infections or resorption, and with cosmetically satisfying results. The tumour infiltrated flaps remained tumour free for the entire period of observation.
A modification of Galicich and Hovind's method of cranioplasty is described. The prosthesis is not made on a side-table in the operation theatre. Steel wire mesh is fastened to the edge of the bone defect with stainless wires passed through drill holes. Acrylic mixture is then poured over the mesh and is cooled with saline. The technique has its main advantage in simplicity, and the result is cosmetically and functionally satisfactory.
Hemispherectomy has had excellent results in treating drug-resistant seizures of infantile hemiplegia, except for the vulnerability of the remaining hemisphere. The hemispherectomy cavity has been considered responsible for early and late complications. Modified techniques have been widely performed and are not without complications. CNS hemosiderosis is probably not the only explanation; the craniocerebral disproportion following the surgery, the shunt effect and low pressure of the cavity should also be taken into account. Splinting the remaining hemisphere to avoid its dislodgment could be important. One of our patients who suffered a series of complications hitherto unreported in the literature was eventually treated with a filling-reduction cranioplasty. The rationale for the technique can be inferred from the literature reviewed in the article. Our technique is validated by a follow-up of 28 years since the hemispherectomy and 13 years since treatment for complications.
In order to treat syringomyelia associated with adult type Chiari malformation, the authors developed a method of expansive suboccipital cranioplasty (ESC) that involves enlarging the small posterior fossa to obtain a sufficient flow of cerebrospinal fluid (CSF). The relative effectiveness of ESC with the obex plugged and not plugged was also examined, as well as other factors influencing the operative results. Twenty patients without arachnoid adhesion at the major cistern underwent ESC without opening the arachnoid membrane at the major cistern. After surgery, all improved with no recurrence and CSF flow study using magnetic resonance (MR) imaging showed significant improvement of the flow at the major cistern. Another 20 patients without arachnoid adhesion also underwent ESC but with obex plugging. Sixteen improved and one displayed only temporary improvement with recurrent syringomyelia due to postoperative arachnoid adhesions. The remaining three showed no change in spite of shrinkage of the syrinx on postoperative MR imaging. These three patients had displayed pre-operative symptoms over an approximately 10-year period involving almost the entire axial plain of the spinal cord, and presented a large syrinx before surgery. In 4 patients with arachnoid adhesions, all required intra-arachnoid procedures in addition to ESC. Intra-arachnoid procedures are not necessary to facilitate restoration of CSF flow in patients without arachnoid adhesions, because ESC can release the CSF flow blockage in the major cistern even without plugging of the obex. An associated arachnoid adhesion at the major cistern or a long-standing syringomyelia with irreversible damage of the spinal cord results in a poor operative prognosis. When posterior fossa surgery fails, insufficient decompression or postoperative arachnoid adhesions at the major cistern as the cause of treatment's failure should be evaluated by CSF flow studies using phase contrast MR imaging.
We present a case of reconstruction of severe aplasia cutis congenita. Initial treatment with silver sulphadiazine dressings failed and local scalp repair of the defect at age 3 months also failed to provide a stable reconstruction. At age 9 months the infant was experiencing increasing apparent hydrocephalus, shunt infection and brain herniation. The definitive reconstruction was performed with a split rib cranioplasty and a free latissimus dorsi muscle flap. The reconstruction was successful and the infant has a normal head shape and no neurological deficit 12 months postoperatively.
A technique has been described for fabrication of a cranioplasty prosthesis. The primary advantage of this technique is the duplication of the altered working cast. The technique also permits excellent reproduction of cranial contours and a positive seat of the prosthesis on the outer table of the skull. The disadvantage is the time involved in the duplicating procedure.
A review of the methods of cranioplasty has been presented. A method of prefabrication of an alloplastic cranial implant has been described as well as a review of 40 patients with whom this technique was used.
Cranioplasty represents a formidable challenge for neuro-surgeons, with a significant morbidity from both early and late wound infections. Polymethylmethacrylate (PMMA) is one of the most widely used materials in this setting. Despite the advantages of this material, such as ease of handling and inert biochemical properties, it is still a foreign body that is prone to infection. We present an animal model using a gentamicin-impregnated PMMA patch to assess the neurotoxicity as well as the efficacy of using this as an alternative material to lessen the infectious morbidity in this clinical setting. In part two of our experiment, we used a PMMA patch of similar weight and surface area in a physiological saline solution to determine the rate of gentamicin elution from the patch. The results obtained appear promising with no evidence of neurotoxicity and warrant further study to assess the clinical efficacy of PMMA in this setting.
INTRODUCTION: Aim of this experimental study was to assess the suitability of a new brushite calcium phosphate cement (chronOS Inject) for cranioplasty and to compare the results with a commercially available apatite calcium phosphate bone cement (Biobon). MATERIAL AND METHODS: A bilateral full-size craniotomy defect (23 mm in diameter) was created in the parietal bones of 18 adult Swiss Alpine sheep and filled with either chronOS Inject or Biobon. The observation intervals were 2, 4 and 6 months. Macroscopical, radiological, histological and histomorphometrical evaluations were performed. RESULTS: New bone formation was moderate and did not differ significantly between the biomaterials. Cement resorption occurred centripetally in the chronOS Inject group and proceeded significantly faster than the degradation process of Biobon. However, implantation of chronOS Inject was associated with a significantly higher rate of fibrous tissue formation. Cement resorption was mediated by macrophages in the chronOS Inject group, while osteoclasts were the predominant cell type involved in degradation of Biobon. Osteoblasts were found adjacent to residual cement in both groups. CONCLUSION: chronOS Inject demonstrated osteoconductive properties, good biocompatibility and superior bioresorbability but none of the cements proved suitable for filling large cranial bony defects due to the high rate of fibrous tissue formation and insufficient bony regeneration.