scholarly journals Sinking Skin Flap Syndrome following Posttraumatic Hydrocephalus

2021 ◽  
Vol 2021 ◽  
pp. 1-8
Author(s):  
Ashish Chugh ◽  
Prashant Punia ◽  
Sarang Gotecha
Keyword(s):  
Decompressive Craniectomy ◽  
Postoperative Period ◽  
Skin Flap ◽  
Case Series ◽  
Bone Flap ◽  
Complication Rates ◽  
Review Of Literature ◽  
Trendelenburg Position ◽  
Vp Shunt ◽  
Shunt Occlusion

Introduction. Complications following craniotomy are not uncommon and Sinking Skin Flap Syndrome (SSFS) constitutes a rare entity that may present after a large Decompressive Craniectomy. Although the entity is widely reported, the literature mostly consists of case reports. Authors present a case series of three patients with review of literature highlighting the various factors which can prove therapeutic and can help in avoidance of complications. Materials and Methods. The study was conducted over a period of 3 years, from 2016 to 2019, and included 212 patients who underwent unilateral Decompressive Craniectomy (DC) for trauma in our institute. All 212 patients underwent a similar DC following a strict institutional protocol and the craniectomies were performed by the same surgical team. At total of 160 patients survived and elective cranioplasty was planned at a 3-month interval. Out of a total of 160 patients who survived, 38 developed hydrocephalus, 3 patients presented with hydrocephalus acutely and had to be shunted before cranioplasty and underwent ventriculoperitoneal (VP) shunting on the opposite side of craniectomy. All 3 of these patients developed SSFS and were the focus of this case series wherein review of literature was done with emphasis being laid on the salient features towards management of SSFS in such precranioplasty shunted patients. These 3 patients were treated via rehydration using normal saline (NS) till the Central Venous Pressure (CVP) equaled 8–10 cm of water, nursing in Trendelenburg position and shunt occlusion using silk 3-0 round bodied suture tied over a “C”-loop of VP shunt tube over clavicle. This was followed by cranioplasty within 2 days of presentation using a flattened, nonconvex artificial Polymethyl Methacrylate (PMMA) bone flap with central hitch suture taken across the bone flap and release of shunt tie in immediate postoperative period. The PMMA bone flap was made intraoperatively after measuring the defect size accurately after exposure of defect. 3D printing option was not availed by any patient considering the high cost and patients’ poor socioeconomic status. Results. Out of a total of 212 patients, thirty-eight patients (19%) developed posttraumatic hydrocephalus and out of 38, three presented with SSFS over the course of time. Two patients presented with hemiparesis of the side opposite to sunken flap while 1 other patient was brought by relatives in stuporous state. All 3 were subjected to VP shunt tie, rehydration, and cranioplasty using flattened artificial bone flap and showed gradual recovery in postoperative period without any complications. Conclusion. Various factors like nursing in Trendelenburg position, adequate rehydration, early cranioplasty after resolution of oedema, preoperative tying of VP shunt and its subsequent release in immediate postoperative period, use of flattened PMMA bone flaps, placement of a central dural hitch suture across the bone, and a preoperative central burr hole in the bone flap may accelerate healing and, in most cases, reversal of sensory-motor deficits along with reduction in complication rates.

scholarly journals Sinking skin flap syndrome in a patient with bone resorption after cranioplasty and ventriculoperitoneal shunt placement: illustrative case

2021 ◽  
Vol 2 (11) ◽  
Author(s):  
Camryn R. Rohringer ◽  
Taryn J. Rohringer ◽  
Sumit Jhas ◽  
Mehdi Shahideh
Keyword(s):  
Bone Resorption ◽  
Decompressive Craniectomy ◽  
Rare Complication ◽  
Skin Flap ◽  
Mass Effect ◽  
Neurological Status ◽  
Bone Flap ◽  
Illustrative Case ◽  
Vp Shunt

BACKGROUND Sinking skin flap syndrome (SSFS) is an uncommon complication that can follow decompressive craniectomy. Even less common is the development of SSFS following bone resorption after cranioplasty with exacerbation by a ventriculoperitoneal (VP) shunt. OBSERVATIONS A 56-year-old male sustained a severe traumatic brain injury and subsequently underwent an emergent decompressive craniectomy. After craniectomy, a cranioplasty was performed, and a VP shunt was placed. The patient returned to the emergency department 5 years later with left-sided hemiplegia and seizures. His clinical presentation was attributed to complete bone flap resorption (BFR) complicated by SSFS likely exacerbated by his VP shunt and the resultant mass effect on the underlying brain parenchyma. The patient underwent surgical intervention via synthetic bone flap replacement. Within 6 days, he recovered to his baseline neurological status. LESSONS SSFS after complete BFR is a rare complication following cranioplasty. To the authors’ knowledge, having a VP shunt in situ to exacerbate the clinical picture has yet to be reported in the literature. In addition to presenting the case, the authors also describe an effective treatment strategy of decompressing the brain and elevating the scalp flap while addressing the redundant tissue, then using a synthetic mesh to reconstruct the calvarial defect while keeping the shunt in situ.

scholarly journals Cranioplasty following decompressive craniectomy – Analysis of complication rates and neurological outcomes: A single center study

2019 ◽  
Vol 10 ◽  
pp. 142 ◽  
Author(s):  
Saraj Singh ◽  
Rakesh Singh ◽  
Kapil Jain ◽  
Bipin Walia
Keyword(s):  
Decompressive Craniectomy ◽  
Complication Rate ◽  
Neurological Outcome ◽  
Simple Procedure ◽  
Surgical Techniques ◽  
Bone Flap ◽  
Intracerebral Hematoma ◽  
Complication Rates ◽  
Good Neurological Outcome ◽  
Second Surgery

Background:Cranioplasty is the surgical intervention to repair cranial defects in both cosmetic and functional ways. Despite the fact that cranioplasty is a simple procedure, it is still associated with a relatively high complication rate, ranging between series from 12% to 50%.Methods:The author did a prospective cohort study of patients from August 2015 to December 2017, who had undergone decompressive craniectomy followed by cranioplasty after 6 weeks at our institution. All patients were followed up to 6 months after cranioplasty and complications were recorded both by imaging and clinically. The complications were classified as minor (subgaleal collection, seizures) who did not require the second surgery and major (hydrocephalus, bone flap infection) who required the second surgery. To find out neurological outcome, Glasgow coma score (GCS) and Glasgow outcome scale extended (GOSE) were recorded at 1 month, 3 months, and 6 months.Results:Overall complication rate in this study was 22.4% (16/72). Subgaleal collection was the most common complication (5.6%), followed by hydrocephalus (4.2%), seizure (4.2%), bone flap infection (2.8%), intracerebral hematoma (2.8%), empyema (1.4%), and subdural hematoma (SDH) (1.4%). Of these, 8.4% (n= 6/72) were major complication (hydrocephalusn= 3, bone flap infectionn= 2, and SDHn= 1) which required the second surgery. GCS and GOSE were assessed preoperatively and in postoperative period at 1 month, 3 months, and 6 months. Both mean values of GCS and GOSE showed a significant improvement at 3 and 6 months after cranioplasty.Conclusion:Cranioplasty after decompressive craniectomy is associated with higher complication rate, but good neurological outcome after surgery always outweighs the complications.Key Message:Cranioplasty after decompressive craniectomy is associated with higher complication rate, but good neurological outcome after surgery always outweighs the complications. However, complications rate can be brought down by meticulous timing of cranioplasty in a patient of well-controlled comorbidities and precise surgical techniques. However, storing bone in bone bank is not an additional factor for any postcranioplasty complications which was considered previously.

scholarly journals Minimally invasive treatment for gynecomastia: ultrasound-guided vacuum-assisted excision – case series

Mastology ◽  
2020 ◽  
Vol 30 (Suppl 1) ◽  
Author(s):  
Henrique Lima Couto ◽  
Carolina Nazareth Valadares ◽  
Osmar Pellegrini ◽  
Shirley das Graças Ferreira ◽  
Julia Grichtolik Cantagalli Paiva
Keyword(s):  
Postoperative Period ◽  
Breast Tissue ◽  
Case Series ◽  
Complication Rates ◽  
Open Approach ◽  
Ultrasound Guided ◽  
Aesthetic Result ◽  
Postoperative Hematoma ◽  
Areolar Complex ◽  
Patient Reported

Introduction: Gynecomastia (GM) is the benign proliferation of breast tissue in men. Its prevalence is of up to 65% according to age. It can be unilateral or bilateral. The standard surgery is periareolar incision, even though it can lead to asymmetry (AS), anesthetic scar, retraction or necrosis of the nipple-areolar complex (NAC). The vacuum-assisted excision (VAE) is the alternative approach. Objectives: To describe the technique and results of ultrasound-guided VAE for GM. Methods: series of 7 cases of Simon I and II GM, submitted to US-guided VAE (10G needle and ENCOR® BD) between December 20, 2018, and October 26, 2019. The cases were assessed considering clinical, laboratory and imaging aspects with mammography (MMG) and US. The pre-surgical consent form was obtained. US-guided VAE was performed with a 3 mm incision, in the ambulatory, with local anesthesia (2% lidocaine) and no sedation, in the “fine precision” and “dense breast” modes, in order to leave a 1cm flap in the retroareolar region. At the end, a vacuum and/or manual drainage of the cavity was performed to reduce the postoperative hematoma (HMA). In the postoperative period, MMGs were performed 1 and 6 months after the VAE, and the revisions occurred on the 7th and 14th day, and the 1st, 2nd and 6th months. The patients wore vests for 30 postoperative days. The outcomes were good or excellent when the amount of residual breast tissue was minimum, and AS, retractions, necrosis, anesthetic scar or NAC deviation, absent. The patients filled out a form of satisfaction level and perception of the VAE. Results: Mean age was 26.7 years. Mean time of VAE was 28 minutes. The main complaint regarding VAE was aesthetic discomfort, followed by physical deformity. One patient presented with areola skin tear during the procedure. It was sutured and did not impact the aesthetic result. All patients and surgeons reported excellent or sufficient levels of satisfaction. There were no recurrences or re-approach in 6 months. There was no hemorrhage in the peri or postoperative period, with no open approach. No patient required sedation. They all had histology of GM. No cases of breast deviation, necrosis or NAC retraction, infection, AS our anesthetic scar. No patient reported changes in erection or breast sensitivity. They all presented with hemorrhagic suffusion and hematoma with spontaneous resolution in 30 days, without interfering in the outcome. No intervention or hematoma drainage was necessary in the postoperative period. Conclusion: US-guided VAE for GM is alternative to the conventional surgical treatment in Simon I and II cases, with good or excellent results. It presents low complication rates and high satisfaction rates. It is performed in the ambulatory, without intercurrences. Comparative studies of traditional surgery and VAE should be performed.

Evaluation of simultaneous cranioplasty and ventriculoperitoneal shunt procedures

2014 ◽  
Vol 121 (2) ◽  
pp. 313-318 ◽  
Author(s):  
Juneyoung Heo ◽  
Sukh Que Park ◽  
Sung Jin Cho ◽  
Jae Chil Chang ◽  
Hyung-ki Park
Keyword(s):  
Decompressive Craniectomy ◽  
Fluid Collection ◽  
Patient Characteristics ◽  
Defect Size ◽  
Complication Rates ◽  
Subdural Fluid Collection ◽  
Brain Swelling ◽  
Vp Shunt ◽  
Shunt Placement ◽  
Cranial Defect

Object Some patients with severe brain swelling treated with decompressive craniectomy may develop hydrocephalus. Consequently, these patients require cranioplasty and a ventriculoperitoneal (VP) shunt to relieve the hydrocephalus. However, there is no consensus as to the timing of the cranioplasty and VP shunt placement in patients requiring both. The authors assessed the results of performing cranioplasty and VP shunt placement at the same time in patients with cranial defects and hydrocephalus. Methods A retrospective review was performed of 51 patients who had undergone cranioplasty and VP shunt operations after decompressive craniectomy for refractory intracranial hypertension between 2003 and 2012 at the authors' institution. Patient characteristics, data on whether the operations were performed simultaneously, brain bulging, hydrocephalus, cranial defect size, and complications were analyzed. Results The overall complication rate was 43% (22 of 51 patients). In 32 cases, cranioplasty and VP shunt placement were performed at the same time. Complications included subdural hematoma, subdural fluid collection, and infection. The group undergoing cranioplasty and VP shunt placement at the same time had higher complication rates than the group undergoing the procedures at different times (56% vs 21%, respectively). The severity of complications was also greater in the former group. Patients with severe brain bulging had higher complication rates than did those without brain bulging (51% vs 0%, respectively). Cranial defect size, severity of hydrocephalus, indication for decompressive craniectomy, age, sex, and interval between decompressive craniectomy and subsequent operation did not affect complication rates. Conclusions Patients undergoing cranioplasty and VP shunt placement at the same time had higher complication rates, especially those with severe brain bulging.

Timing of cranioplasty after decompressive craniectomy for ischemic or hemorrhagic stroke

2013 ◽  
Vol 118 (1) ◽  
pp. 109-114 ◽  
Author(s):  
Mark P. Piedra ◽  
Brian T. Ragel ◽  
Aclan Dogan ◽  
Nicholas D. Coppa ◽  
Johnny B. Delashaw
Keyword(s):  
Decompressive Craniectomy ◽  
Hemorrhagic Stroke ◽  
Multivariate Logistic Regression Analysis ◽  
Case Series ◽  
Csf Shunt ◽  
Optimal Timing ◽  
Complication Rates ◽  
Postoperative Hematoma ◽  
The Difference ◽  
Early Cranioplasty

Object The optimal timing of cranioplasty after decompressive craniectomy for stroke is not known. Case series suggest that early cranioplasty is associated with higher rates of infection while delaying cranioplasty may be associated with higher rates of bone resorption. The authors examined whether the timing of cranioplasty after decompressive craniectomy for stroke affects postoperative complication rates. Methods A retrospective cohort study was undertaken to evaluate complication rates in patients undergoing cranioplasty at early (within 10 weeks of craniectomy) or late (≥ 10 weeks) stages. Multivariate logistic regression analysis was used to determine characteristics that would predict complications in patients undergoing cranioplasty after decompressive craniectomy for stroke. Results While the overall complication rate was higher in the early cranioplasty cohort (22% vs 16% in the late cranioplasty cohort), the difference was not statistically significant (p = 0.5541). Patients in the early cranioplasty cohort had lower rates of postoperative hematoma but higher rates of infection. Presence of a CSF shunt was the only significant predictor of complications (OR 8.96, 95% CI 1.84–43.6). Conclusions Complications rates for early cranioplasty (within 10 weeks of craniectomy) are similar to those encountered when cranioplasty is delayed, although the cohort size in this study was too small to state equivalence. Patients with a ventriculoperitoneal shunt are at higher risk for complications after cranioplasty.

scholarly journals Multidisciplinary Approach for Improved Outcomes in Secondary Cranial Reconstruction: Introducing the Pericranial-Onlay Cranioplasty Technique

2014 ◽  
Vol 10 (2) ◽  
pp. 179-190 ◽  
Author(s):  
Chad R. Gordon ◽  
Mark Fisher ◽  
Jason Liauw ◽  
Ioan Lina ◽  
Varun Puvanesarajah ◽  
...  
Keyword(s):  
Multidisciplinary Approach ◽  
Case Series ◽  
Standard Technique ◽  
Senior Author ◽  
Bone Flap ◽  
Complication Rates ◽  
Perioperative Morbidity ◽  
Scalp Flap ◽  
Aesthetic Appearance ◽  
Onlay Technique

AbstractBACKGROUND:Although materials for secondary cranial reconstruction have evolved with time, the overall approach in terms of bone flap/implant reconstruction after necessary delay has remained constant.OBJECTIVE:To present our cases series of 50 consecutive secondary cranial reconstruction patients and to describe a multidisciplinary cranioplasty approach developed to reduce morbidity, to minimize infection, and to improve aesthetic appearance.METHODS:Standard technique teaches us to place the bone flap and/or alloplastic implant directly over the dura or dural protectant after scalp flap re-elevation. However, this procedure is fraught with high complication rates, including infection. While raising the previously incised scalp flap overlying the full-thickness calvarial defect, the dissection is performed within the loose areolar tissue plane beneath the galea aponeurosis, thus leaving vascularized pericranium intact over the dura.RESULTS:A total of 50 consecutive patients were treated by the senior author encompassing 46 cranioplasties using the pericranial-onlay approach, along with 4 isolated temporal soft tissue reconstructions with liquid poly-methyl-methacrylate. Of the 46 cranioplasties (> 5 cm2), only 1 autologous bone flap developed deep infection necessitating bone flap removal (1 of 46, 2.17%; 95% confidence interval, 0.003-11.3). None of the alloplastic custom implants placed have developed any infection requiring removal.CONCLUSION:This multidisciplinary approach illustrated in our case series, including our “pericranial-onlay” technique described here for the first time, has the potential to improve patient outcomes, to decrease perioperative morbidity, and to minimize costs associated with postoperative infections after secondary cranial reconstruction.

Overt Cerebrospinal Fluid Drainage Is Not a Sine Qua Non for Paradoxical Herniation After Decompressive Craniectomy

Neurosurgery ◽  
2010 ◽  
Vol 67 (1) ◽  
pp. E214-E215 ◽  
Author(s):  
Ralph Rahme ◽  
Michel W. Bojanowski
Keyword(s):  
Cerebrospinal Fluid ◽  
Decompressive Craniectomy ◽  
Intracranial Hypotension ◽  
Skin Flap ◽  
Endovascular Embolization ◽  
Trendelenburg Position ◽  
Transtentorial Herniation ◽  
Csf Drainage ◽  
Life Saving ◽  
Brain Sagging

Abstract OBJECTIVE AND IMPORTANCE Paradoxical transtentorial herniation is a rare but well-documented complication of cerebrospinal fluid (CSF) drainage in patients with large decompressive craniectomies. However, brain sagging in the absence of CSF hypovolemia has not been previously reported. CLINICAL PRESENTATION A 30-year-old woman suffered massive intracerebral hemorrhage from a small residual left frontal arteriovenous malformation 1 year following endovascular embolization and stereotactic radiosurgery. The patient initially presented in coma with left mydriasis and decorticate posturing and underwent emergent decompressive craniectomy, evacuation of the hematoma, and insertion of an intracranial pressure (ICP) monitor. Postoperatively, despite a depressed skin flap and low ICP readings, she continued to deteriorate neurologically, and CT revealed increasing midline shift, transtentorial herniation, and brainstem compression. INTERVENTION OR TECHNIQUE Although there was no history of CSF drainage, the diagnosis of brain sag was suspected, because herniation seemed to occur in the setting of intracranial hypotension. The patient was placed in a 15° Trendelenburg position and improved dramatically within hours. A few days later, she was fully awake and had purposeful movements with her left side, although she had persistent aphasia and right hemiplegia. CONCLUSION Although rare, paradoxical herniation in the setting of a large craniectomy defect may occur in the absence of CSF drainage. This entity should be suspected whenever transtentorial herniation occurs in conjunction with direct or indirect signs of intracranial hypotension. Placing the patient in the Trendelenburg position should be attempted, because this simple maneuver may turn out to be life-saving.

Reversal of DIRECT-ACTING Oral Anticoagulants in Urgent Surgery of the Proximal Aorta: case Series and Review of the literature

2019 ◽  
Vol 24 (38) ◽  
pp. 4534-4539 ◽  
Author(s):  
Eric Zimmermann ◽  
Fawzi Ameer ◽  
Berhane Worku ◽  
Dimitrios Avgerinos
Keyword(s):  
Oral Anticoagulants ◽  
Aortic Surgery ◽  
Management Strategies ◽  
Case Series ◽  
Published Data ◽  
Review Of Literature ◽  
Clotting Factors ◽  
Urgent Surgery ◽  
Direct Acting ◽  
Direct Acting Oral Anticoagulants

Introduction: Proximal aorta interventions impose significant bleeding risk. Patients on concomitant anticoagulation regimens compound the risk of bleeding in any surgery, but especially cardiothoracic interventions. The employment of direct-acting oral anticoagulants (DOAC), namely those that target clotting factors II or X, has expanded at a precipitous rate over the last decade. The emergence of their reversal agents has followed slowly, leaving clinicians with management dilemmas in urgent surgery. We discuss current reversal strategies based on the available published data and our experience with proximal aortic surgery in patients taking DOACs. Literature Search: We performed a review of literature and present three cases from our experience to offer insight into management strategies that have been historically successful. A review of literature was conducted via PubMed with the following search string: (NOAC or DOAC or TSOAC) and (aorta or aortic or (Stanford and type and a)). Case Presentation: We present three case presentations that illustrate the importance of DOAC identification and offer management strategies in mitigating associated bleeding risks in urgent or emergent surgeries. Conclusion: Treatment teams should be aware of the technical limitations of identifying and reversing DOACs. In view of the tendency toward publishing positive outcomes, more scientific rigor is required in the area of emergency DOAC reversal strategies.

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