title: Reconstructive approach to hostile cranioplasty: A review of the University of Chicago experience.
abstract: BACKGROUND
  Hostile sites for cranioplasty occur in patients with a history of radiation, infection, failed cranioplasty, CSF leak or acute infection. We review our series of autologous cranioplasties and present an approach to decision-making for reconstructing these complex defects.
  
  
  METHODS
  Patients with cranioplasty of a hostile cranial site at the University of Chicago between 2003 and 2012 were identified. They were stratified into three groups: chimeric free flap with vascularized bone (the vascular group), non-vascularized bone with local coverage (the non-vascular group) and non-vascularized bone with free flap (the mixed group). The primary outcome measure was a major complication in the year following cranioplasty, identified by flap or bone graft failure.
  
  
  RESULTS
  We reviewed 33 cases; 14 "vascular", 13 "non-vascular", and 8 "mixed". There was no difference in flap or bone graft failure rates, which were 7% (1/14) for the vascular group, 8% (1/13) for the non-vascular group, and 0% for the mixed group (p = NS). Overall complication rate was statistically different between the three groups (p = 0.01). The non-vascular group had the lowest complication rate (31%). Based on our data we developed an assessment score (The University of Chicago CRAnial Severity Score of Hostility, CRASSH) for patient and treatment stratification.
  
  
  CONCLUSIONS
  Vascularized, non-vascularized and mixed reconstructive methods can be used successfully in these challenging situations. We offer the CRASSH to aid in aligning patients with the most appropriate autologous reconstruction method for their hostile cranial sites.
authors.affiliation: Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, USA.
authors.forename: Abigail J
authors.initials: AJ
authors.lastname: Fong
authors.affiliation: Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, USA.
authors.forename: Benjamin T
authors.initials: BT
authors.lastname: Lemelman
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, USA.
authors.forename: Sandi
authors.initials: S
authors.lastname: Lam
authors.affiliation: Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, USA.
authors.forename: Grant M
authors.initials: GM
authors.lastname: Kleiber
authors.affiliation: Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, USA. Electronic address: rreid@surgery.bsd.uchicago.edu.
authors.forename: Russell R
authors.initials: RR
authors.lastname: Reid
authors.affiliation: Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, USA.
authors.forename: Lawrence J
authors.initials: LJ
authors.lastname: Gottlieb
mesh_terms: D000046:Academic Medical Centers; D000293:Adolescent; D000328:Adult; D000368:Aged; D016025:Bone Transplantation / Q000379:methods*; D065634:Cerebrospinal Fluid Leak / Q000453:epidemiology; D002641:Chicago / Q000453:epidemiology; D005260:Female; D058752:Free Tissue Flaps / Q000098:blood supply*; D006085:Graft Survival; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008581:Meningitis / Q000453:epidemiology; D008875:Middle Aged; D010019:Osteomyelitis / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology; D011878:Radiotherapy / Q000009:adverse effects; D012189:Retrospective Studies; D012886:Skull / Q000098:blood supply* / Q000601:surgery*; D013530:Surgical Wound Infection / Q000453:epidemiology; D055815:Young Adult
keywords: Cranial defect; Cranial reconstruction; Cranioplasty; Hostile cranium; Non-vascularized bone; Vascularized bone