Cranioplasty after postinjury decompressive craniectomy: is timing of the essence?
BACKGROUND
The appropriate timing of cranioplasty after decompressive craniectomy for trauma is unknown. Potential benefits of delayed intervention (>6 weeks) for reducing the risk of infection must be balanced by persistent altered cerebrospinal fluid dynamics leading to hydrocephalus. We reviewed our recent 5-year experience in an effort to improve patient throughput and develop a rational decision making plan.


METHODS
A 5-year query (2003-2007) of our level I neurotrauma database. From 2,400 head injuries, we performed a total of 350 craniotomies. Of the 350 patients who underwent craniotomy for trauma, 70 patients (20%) underwent decompressive craniectomy requiring cranioplasty. Timing of cranioplasty, cranioplasty material, postoperative infections, and incidence of hydrocephalus were evaluated with logistic regression to study potential associations between complications and timing, adjusted for risk factors.


RESULTS
No specific time frame was predictive of hydrocephalus or infection, and logistic regression failed to identify significant predictors among the collected variables.


CONCLUSIONS
In our experience, the prior practice of delayed cranioplasty (3-6 months postdecompressive craniectomy), requiring repeat hospital admission, does not seem to lower postcranioplasty infection rates nor the need for cerebrospinal fluid diversion procedures. Our current practice emphasizes cranioplasty during the initial hospital admission, as soon as there is resolution on computed tomography scan of brain swelling outside of the cranial vault with concurrent clinical examination. This occurs as early as 2 weeks postcraniectomy and should lower the overall cost of care by eliminating the need for additional hospital admissions.
Beauchamp
Kathryn M
KM
Division of Neurosurgery, Rocky Mountain Regional Trauma Center, Denver Health Medical Center, Denver, Colorado 80304, USA. kathryn.beauchamp@dhha.org
Kashuk
Jeffry
J
Moore
Ernest E
EE
Bolles
Gene
G
Rabb
Craig
C
Seinfeld
Joshua
J
Szentirmai
Oszkar
O
Sauaia
Angela
A
D000328:Adult; D006259:Craniocerebral Trauma / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D016208:Databases, Factual; D056424:Decompressive Craniectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D015601:Injury Severity Score; D019586:Intracranial Hypertension / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D012886:Skull / Q000601:surgery*; D015996:Survival Rate; D016896:Treatment Outcome; D055815:Young Adult