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ORIGINAL ARTICLE
Year : 2013  |  Volume : 2  |  Issue : 2  |  Page : 189-192

The therapeutic effect of cranioplasty in severe head injuries: Report of two cases


1 Department of Neurosurgery, Strasbourg University Hospital, Strasbourg; Department of Neurosurgery, Lariboisere University Hospital, Paris, France
2 Private Neurosurgeon, (Associate University Arizona Medical Center), Paris, France
3 Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
4 Unité de Recherche Clinique Hôpital Universitaire Lariboisière - Fernand Widal, Paris, France
5 Department of Neurosurgery, Lariboisere University Hospital, Paris, France
6 Department of Neuroradiology, Lariboisere University Hospital, Paris, France
7 Department of ICU, Lariboisere University Hospital, Paris, France

Date of Web Publication13-Sep-2013

Correspondence Address:
Salvatore Chibbaro
Department of Neurosurgery, Strasbourg Hautepierre University Hospital, 1, Av Moliere, 67100 Strasbourg
France
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DOI: 10.4103/2277-9167.118124

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  Abstract 

Background: Aesthetic appearance and brain protection are the main indications for cranial reconstruction following decompressive craniectomy. Recently, few reports indicated that cranioplasty could also improve both, cognitive and functional status. Materials and Methods: A group of 20 patients were treated with decompressive craniectomy following closed head injury; among these patients, two of them (who represent the subject of the current investigation) had to undergo subsequent cranioplasty removal due to the development of local infection. All patients were evaluated by Glasgow outcome scale, frontal assessment battery and mini-mental state examination at 1 week before completion of the cranioplasty as well as 6 and 24 weeks following cranioplasty. Perfusion computed tomography scans were also performed (1 week before and 6 weeks after cranioplasty) as well as a trans-cranial Doppler 1 week before, and 6 and 24 weeks after. The two patients being the subject of this study were also clinically and radiologically evaluated after cranioplasty removal. Results: These two patients, who represent (not intentionally) two case control, showed a real clinical and cerebral perfusion improvement following repair of the skull defect followed by obvious clinical worsening after the skull flap had to be removed. Conclusion: Cranioplasty is likely not to have just a positive influence on cosmetic and protective features of the patients but also seem to improve both, cognitive and functional status by favorably influencing local and global brain hemodynamic and perfusion.

Keywords: Brain perfusion, cranioplasty, head injury, outcome of cranial reconstruction


How to cite this article:
Chibbaro S, Marsella M, Tigan L, Vicaut E, George B, Guichard JP, Vallee F, Kehrli P, Houssen K, Diemidio P, Keppi JJ. The therapeutic effect of cranioplasty in severe head injuries: Report of two cases. Indian J Neurosurg 2013;2:189-92

How to cite this URL:
Chibbaro S, Marsella M, Tigan L, Vicaut E, George B, Guichard JP, Vallee F, Kehrli P, Houssen K, Diemidio P, Keppi JJ. The therapeutic effect of cranioplasty in severe head injuries: Report of two cases. Indian J Neurosurg [serial online] 2013 [cited 2014 Apr 20];2:189-92. Available from: http://www.ijns.in/text.asp?2013/2/2/189/118124


  Introduction Top


Currently, recommendations for cranioplasty following decompressive craniectomy include brain protection and cosmetic reasons. [1],[2],[3],[4],[5]

Recently, however, some studies indicated that cranioplasty may improve patients functional and cognitive status due to a possible positive influence on brain hemodynamic and perfusion. [1],[2],[3],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16]

Because of the protective and stabilizing effects of a rigid skull, it seems logical to think that once a skull defect develops, the local and global brain hemodynamic and perfusion might be negatively influenced. In this study, the authors describe two patients showing a clear clinical improvement following skull defect repair as well as a clear clinical deterioration after cranioplasty removal due to infectious complications.


  Materials and Methods Top


This report describes two patients, selected in a group of 20 patients who suffered closed head injury and subsequently underwent decompressive craniectomy followed later on by cranioplasty. These two patients had to undergo synthetic flap removal due to infectious complications.

All patients were studied by brain perfusion computed tomography (CT) scan 1 week before and 6 weeks after cranioplasty as well as by trans-cranial Doppler which was performed also 24 weeks afterwards. Clinical, functional and cognitive status was assessed by Glasgow outcome scale, frontal assessment battery and mini-mental state examination 1 week before, and 6 and 24 weeks after cranioplasty. The two patients being the subject of this report were also clinically and radiologically evaluated after cranioplasty removal.


  Results Top


A global clinical improvement was recorded in these two patients following repair of the skull defect. However, these two patients had to undergo later on (at 8 and 10 weeks, respectively) to removal of the bone flap because of local infection resistant to antibiotics. Within 3 and 5 days, respectively, following removal of the flap it was noted that both patients developed a noticeable clinical deterioration; in addition we found very interesting that their cerebral perfusion (that improved after flap replacement), deteriorated following flap removal. Clinical outcome and investigations of these two patients are summarized in [Table 1], [Table 2] and [Table 3].
Table 1: Cerebral perfusion outcome by computed tomography of the two patients in the affected hemisphere

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Table 2: Trans‑cranial Doppler parameters/results

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Table 3: Clinical outcome

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  Discussion Top


Patients with severe traumatic brain injury often need decompressive craniectomy to treat raised Intracranial pressure (ICP) not responsive to common medical management (i.e., raising of the head of the bed, osmotic diuretics, etc.). Current indications for replacement of the bone flap remain brain protection and cosmetic reasons. [1],[2],[4],[5]

Recently, many studies have documented that cranioplasty seems to bear a positive influence on cerebral hemodynamic and metabolism; other studies have shown that early cranioplasty would limit complications as hydrocephaly and epilepsy and improve neurological outcome allowing faster recovery. [1],[2],[3],[4],[5],[6],[11],[13],[14],[16] We feel that the relevance of our report is based on the fact that the two cases that involuntarily represent two case control; as mentioned, these two patients requiring removal of the flap due to antibiotic resistant infection had enjoyed clinical and neurological improvement following bone flap replacement and suffered noticeable deterioration following the removal [see also [Table 1], [Table 2] and [Table 3] as well as [Figure 1], [Figure 2] and [Figure 3]. This view coincides with Yamaura, [4] who in 1977, reported that 30% of patients with depressed scalp flap (due to lack of a piece of the skull) causing obvious brain indentation improved after cranioplasty. Similar results have been widely described in literature. Sakamoto et al. [10] studied the syndrome of the sinking flap (SSSF), described as one of the causes of new neurological worsening after a large craniectomy, using dynamic xenon CT scan to evaluate cerebral blood flow (CBF). Although, the mechanism of SSSF remains still speculative, they felt it to be the results of the combined effects of atmospheric pressure, cerebrospinal fluid, and CBF changes. [17] The study of Sakamoto showed clear improvement of CBF in the SSSF following defect repair. Additionally and although, the physiopathology is still not fully understood, there is general acceptation that cranial reconstruction is useful for not only cerebral protection but also for improving the functional and neuro-cognitive outcomes. [18] These clinical data are supported by animal models as reported by Schaller et al.; [15] in fact, after performing a hemicraniectomy in rats Schaller found a clear reduction of cerebral metabolism of normal brain tissue. In addition, it was also highlighted the higher susceptibility of oxygen metabolism to perfusional disturbances by documenting the reduction of cerebral metabolic rate of oxygen (CMRO) to be larger than that of cerebral metabolic rate (CMR). Another very relevant feature to be considered is that the extracranial internal carotid artery flow is a global parameter of the brain perfusion; on the other hand, the middle cerebral artery (MCA) flow is representative of a large yet distinct cortical area. This means that MCA flow changes are markedly influenced by the location of the skull defect. Because of this, we speculate that patients who still retain auto-regulation of CBF also retain, following cranioplasty, of re-establishing a normal local and global brain hemodynamic and perfusion. Data of the present study showed how cranial reconstruction after decompressive craniectomy might improve local and global cerebral perfusion and clinical and neuro-cognitive status; this concept is also supported by the fact that removal of the flap worsened all the measurement parameters. It seems rather evident that cranioplasty, in these two patients, not only re-established brain protection but also was associated with a significant functional and hemodynamic recovery; on the other hand, these two patients, showed a deterioration of clinical, cognitive and brain perfusion parameters as soon as the bone flap was removed again.
Figure 1: (Patient 1) Brain computed tomography perfusion scan of right and left temporal area before left cranioplasty

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Figure 2: (Patient 1) Brain computed tomography perfusion scan of right and left temporal area after left cranioplasty showing a clear global perfusion improvement in the affected hemisphere as well as in the opposite side comparing to prior skull reconstruction

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Figure 3: (Patient 1) Brain computed tomography perfusion scan of right and left temporal area after left cranioplasty removal showing a clear global brain perfusion deterioration in the affected hemisphere as well as in the opposite side

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  Conclusion Top


The current report suggests that cranioplasty following traumatic head injury may improve the clinical status by ameliorating brain hemodynamic and perfusion; this is pointed by the fact that the two patients who had to have the flap removed immediately regressed. At this point, because of the small number of patients in the study further multi-center and larger trials are required to support our hypothesis.

 
  References Top

1.Chibbaro S, Tacconi L. Role of decompressive craniectomy in the management of severe head injury with refractory cerebral edema and intractable intracranial pressure. Our experience with 48 cases. Surg Neurol 2007;68:632-8.  Back to cited text no. 1
[PUBMED]    
2.Boström S, Bobinski L, Zsigmond P, Theodorsson A. Improved brain protection at decompressive craniectomy: A new method using Palacos R-40 (methylmethacrylate). Acta Neurochir (Wien) 2005;147:279-81.  Back to cited text no. 2
    
3.Dujovny M, Aviles A, Agner C, Fernandez P, Charbel FT. Cranioplasty: Cosmetic or therapeutic? Surg Neurol 1997;47:238-41.  Back to cited text no. 3
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4.Yamaura A, Makino H. Neurological deficits in the presence of the sinking skin flap following decompressive craniectomy. Neurol Med Chir (Tokyo) 1977;17:43-53.  Back to cited text no. 4
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5.Fodstad H, Love JA, Ekstedt J, Fridén H, Liliequist B. Effect of cranioplasty on cerebrospinal fluid hydrodynamics in patients with the syndrome of the trephined. Acta Neurochir (Wien) 1984;70:21-30.  Back to cited text no. 5
    
6.Chibbaro S, Fricia M, Vallee F, Beccaria K, Poczos P, Mateo J, et al. The impact of early cranioplasty on cerebral blood flow and metabolism and its correlation with neurological and cognitive outcome: Prospective multi-center study on 34 patients. Indian J Neurosurg 2012;1:17-22.  Back to cited text no. 6
  Medknow Journal  
7.Britt RH, Hamilton RD. Large decompressive craniotomy in the treatment of acute subdural hematoma. Neurosurgery 1978;2:195-200.  Back to cited text no. 7
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8.Clifton GL, Jiang JY, Lyeth BG, Jenkins LW, Hamm RJ, Hayes RL. Marked protection by moderate hypothermia after experimental traumatic brain injury. J Cereb Blood Flow Metab 1991;11:114-21.  Back to cited text no. 8
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9.DeWitt DS, Jenkins LW, Prough DS. Enhanced vulnerability to secondary ischemic insults after experimental traumatic brain injury. New Horiz 1995;3:376-83.  Back to cited text no. 9
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10.Sakamoto S, Eguchi K, Kiura Y, Arita K, Kurisu K. CT perfusion imaging in the syndrome of the sinking skin flap before and after cranioplasty. Clin Neurol Neurosurg 2006;108:583-5.  Back to cited text no. 10
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11.Segal DH, Oppenheim JS, Murovic JA. Neurological recovery after cranioplasty. Neurosurgery 1994;34:729-31.  Back to cited text no. 11
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12.Stula D. The problem of the "sinking skin-flap syndrome" in cranioplasty. J Maxillofac Surg 1982;10:142-5.  Back to cited text no. 12
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13.Suzuki N, Suzuki S, Iwabuchi T. Neurological improvement after cranioplasty. Analysis by dynamic CT scan. Acta Neurochir (Wien) 1993;122:49-53.  Back to cited text no. 13
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14.Yamaura A, Sato M, Meguro K, Nakamura T, Uemura K. Cranioplasty following decompressive craniectomy - Analysis of 300 cases (author's transl). No Shinkei Geka 1977;5:345-53.  Back to cited text no. 14
[PUBMED]    
15.Schaller B, Graf R, Sanada Y, Rosner G, Wienhard K, Heiss WD. Hemodynamic and metabolic effects of decompressive hemicraniectomy in normal brain. An experimental PET-study in cats. Brain Res 2003;982:31-7.  Back to cited text no. 15
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16.Chibbaro S, Di Rocco F, Mirone G, Fricia M, Makiese O, Di Emidio P, et al. Decompressive craniectomy and early cranioplasty for the management of severe head injury: A prospective multicenter study on 147 patients. World Neurosurg 2011;75:558-62.  Back to cited text no. 16
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17.Fodstad H, Ekstedt J, Fridén H. CSF hydrodynamic studies before and after cranioplasty. Acta Neurochir Suppl (Wien) 1979;28:514-8.  Back to cited text no. 17
    
18.Chibbaro S, Vallee F, Beccaria K, Poczos P, Makiese O, Fricia M, et al. The impact of early cranioplasty on cerebral blood flow and its correlation with neurological and cognitive outcome. Prospective multi-centre study on 24 patients. Rev Neurol (Paris) 2012;Doi: pii: S0035-3787 (12) 00936-8.10.1016/j.neurol. 2012.06.016. [Epub ahead of print] French.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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