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Vol. 26. Num. 3.May - June 2015
Pages 105-156
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Vol. 26. Num. 3.May - June 2015
Pages 105-156
Clinical Research
DOI: 10.1016/j.neucir.2014.10.001
Cranioplasty after decompressive craniectomy. A prospective series analyzing complications and clinical improvement
Craneoplastia tras craniectomía descompresiva. Serie prospectiva analizando complicaciones y mejoría clínica
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Igor Paredesa,
Corresponding author
, Ana María Castaño-Leóna, Pablo M. Munarriza, Rafael Martínez-Pereza, Santiago Cepedaa, Rosa Sanzb, José F. Aléna, Alfonso Lagaresa
a Neurosurgery Department, University Hospital 12 de Octubre, Madrid, Spain
b Anesthesiology Department, University Hospital Infanta Leonor, Madrid, Spain
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Table 1. Relation between the occurrence of a complication and the underlying pathology and between the occurrence of clinical objective improvement and the underlying pathology.
Table 2. Relation between the occurrence of a complication and the implant material and between the occurrence of clinical objective improvement and the implant material. PEEK: polyetheretherketone.
Table 3. Relation between the occurrence of clinical objective improvement and the side and type of decompressive craniectomy and between the occurrence of complications and the side of the decompressive craniectomy.
Table 4. Literature review of factors related to complications after cranioplasty. Odds ratio and confidence intervals are presented as published or calculated from the raw data when possible.
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Abstract
Background

Cranioplasty is carried out for cosmetic reasons and for protection, but it may also lead to some neurological improvement after the bone flap placement. Complications of cranioplasty are more frequent than expected for a scheduled neurosurgical procedure. We tried to identify factors associated with both complications and improvement after cranioplasty.

Methods

We prospectively studied the cranioplasties performed in our hospital from November 2009 to November 2013. Patients whose initial reason for bone removal was tumor infiltration were excluded. Demographic, clinical and radiological data were collected. The NIH Stroke Scale and Barthel Self-Care Index scores were obtained both before and within 72h after cranioplasty. The outcome measures were the occurrences of complications and clinical improvement.

Results

Fifty-five cranioplasties were performed. The material used for the cranioplasty was autologous bone in 42 cases, polyetheretherketone (PEEK) in 7 and methacrylate in 6. The average size of the bone defect was 69.5 (19.5–149.5)cm2. The time elapsed between decompressive craniectomy and cranioplasty was 309 (25–1217) days. There were 10 complications (7 severe and 3 mild), an 18.2% complication rate. Statistically significant risk factors of complications were identified as a Barthel ≤70 (Odds ratio [OR] 22; 2.5–192; P=0.005), age over 45 years (OR 13.5; 1.5–115; P=0.01) and early surgery (≤85 days; OR 8; 1.69–37.03, P=0.004). After multivariate analysis, Barthel ≤70 and age over 45 years remained independent predictors of complications. Twenty-two (40%) of the 55 patients showed objective improvement. Early surgery (<85 days) increased the likelihood of improvement (OR 4.67; 1.05–20.83; P=0.035). Larger bone defects seemed to be related with improvement, but differences in defect size were not statistically significant (75.3 vs 65.6cm2; P=0.1).

Conclusions

The complication rate of cranioplasty is higher than for other elective neurosurgical procedures. Older age, poorer functional situation (worse Barthel index score) and early surgery (≤85 days) are independent risk factors for complications. However, cranioplasty produces clinical benefits beyond protection and esthetic improvement. Earlier surgery and larger bone defects seem to increase the likelihood of clinical improvement.

Keywords:
Decompressive craniectomy
Trephine syndrome
Cranioplasty
Complications
Clinical improvement
Timing
Resumen
Antecedentes

La craneoplastia es un procedimiento que se realiza por motivos estéticos y de protección, pero que además puede producir cierta mejoría neurológica tras la reposición del colgajo óseo. Las complicaciones del procedimiento son más frecuentes de lo esperado para un procedimiento neuroquirúrgico programado. Se han tratado de identificar los factores asociados tanto a la aparición de complicaciones como de mejoría neurológica.

Métodos

Se han analizado prospectivamente las craneoplastias realizadas en nuestro centro desde noviembre del 2009 hasta noviembre del 2013. Los pacientes sometidos a craniectomía descompresiva (CD) por infiltración tumoral no fueron incluidos. Se recogieron datos demográficos, clínicos y radiológicos. La escala NIHSS y Barthel fueron medidas en cada paciente antes y dentro de las primeras 72h tras la cirugía. Las medidas «resultado» fueron la aparición de complicación y/o mejoría clínica.

Resultados

Se realizaron 55 craneoplastias. El material utilizado para las plastias fue el propio hueso en 42 casos, PEEK en 7 y metacrilato en 6. El tamaño medio del defecto óseo fue de 69,5 (19,5–149,5)cm2. El tiempo medio transcurrido desde la CD hasta la plastia fue de 309 (25–1.217) días. Hubo 10 complicaciones (7 graves, 3 leves), lo que supone una tasa de complicaciones del 18,2%. Una puntuación de Barthel ≤70 (OR: 22; 2,5–192; P=0,005), la edad por encima de 45años (OR: 13,5; 1,5–115; P=0,01), y la cirugía temprana (≤85días, OR: 8; 1,69–37,03, P=0,004) fueron identificados como factores de riesgo estadísticamente significativos de la aparición de complicaciones. Tras el análisis multivariante, el Barthel ≤70 y la edad mayor de 45años permanecieron como predictores independientes de complicaciones. Veintidós (40%) de 55 pacientes presentaron mejoría clínica objetiva. La cirugía temprana (<85 días) aumentó la probabilidad de mejoría (OR: 4,67; 1,05–20,83; P=0,035). El mayor tamaño de defecto óseo parece relacionarse con la aparición de mejoría, pero las diferencias en tamaño entre los que mejoraron y los que no, no resultó estadísticamente significativa (75,3 vs 65,6cm2, P=0,1).

Conclusiones

La tasa de complicaciones de la craneoplastia es mayor que la de otros procedimientos neuroquirúrgicos electivos. Una edad mayor, una peor situación funcional (entendido como peor puntuación en la escala Barthel) y la cirugía temprana (menos de 85días) son factores de riesgo de complicación. Por otro lado, la craneoplastia produce un beneficio clínico más allá de la protección y la mejoría estética. La cirugía temprana y los defectos óseos mayores parecen aumentar la probabilidad de mejoría clínica.

Palabras clave:
Craniectomía descompresiva
Síndrome del trefinado
Craneoplastia
Complicaciones
Mejoría clínica
Timing

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