Timing of cranioplasty after decompressive craniectomy for ischemic or hemorrhagic stroke

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.

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

Mastology ◽

10.29289/259453942020v30s1100 ◽

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.

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Can early cranioplasty reduce the incidence of hydrocephalus after decompressive craniectomy? A meta-analysis

Surgical Neurology International ◽

10.25259/sni_120_2020 ◽

2020 ◽

Vol 11 ◽

pp. 94 ◽

Cited By ~ 2

Author(s):

Davide Nasi ◽

Mauro Dobran

Keyword(s):

Decompressive Craniectomy ◽

Lower Incidence ◽

English Language ◽

Meta Analysis ◽

Case Series ◽

Cerebrospinal Fluid Dynamics ◽

Inclusion Criteria ◽

Postoperative Hydrocephalus ◽

Meta Analyses ◽

Early Cranioplasty

Background: Do alterations of cerebrospinal fluid dynamics secondary to decompressive craniectomy (DC) lead to hydrocephalus, and can this effect be mitigated by early cranioplasty (CP)? In this meta-analysis, we evaluated whether the timing of CP decreased the incidence of postoperative hydrocephalus. Methods: We performed a systematic search of PubMed/MEDLINE, Scopus, and the Cochrane databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for English language articles (1990–2020). We included case series, case–control, and cohort studies, and clinical trials assessing the incidence of hydrocephalus in adult patients undergoing early CP (within 3 months) versus late CP (after 3 months) after DC. Results: Eleven studies matched the inclusion criteria. The rate of postoperative hydrocephalus was not significantly different between the early (=96/1063; 9.03%) and late CP (=65/966; 6.72%) group (P = 0.09). Only in the three studies specifically reporting on the rate of hydrocephalus after DC performed to address traumatic brain injury (TBI) alone was there a significantly lower incidence of hydrocephalus with early CP (P = 0.01). Conclusion: Early CP (within 90 days) after DC performed in TBI patients alone was associated with a lower incidence of hydrocephalus. However, this finding was not corroborated in the remaining eight studies involving CP for pathology exclusive of TBI.

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Complication Rates in Early Versus Late Cranioplasty—A Fourteen-Year Single-Center Case Series

Operative Neurosurgery ◽

10.1093/ons/opaa408 ◽

2021 ◽

Author(s):

Muhibullah S Tora ◽

James G Malcolm ◽

Zayan Mahmooth ◽

Amit Pujari ◽

Rima S Rindler ◽

...

Keyword(s):

Odds Ratio ◽

Chart Review ◽

Preoperative Planning ◽

Case Series ◽

Retrospective Chart Review ◽

Optimal Timing ◽

Complication Rates ◽

Neurosurgical Procedure ◽

Potential Benefits ◽

The Impact

Abstract BACKGROUND Cranioplasty (CP) following decompressive craniectomy (DC) is a common neurosurgical procedure for cranial cosmesis and protection. There is uncertainty regarding the complication rates and potential benefits related to the timing of CP. OBJECTIVE To investigate the impact of the timing of CP on complication rates for different etiologies of DC. METHODS A retrospective chart review was performed of all CP cases between 2004 and 2018 for traumatic and nontraumatic indications of DC. Demographics, clinical characteristics, and complications were collected. Early and late CP were defined as replacement of the bone flap at ≤90 and >90 d following DC, respectively. RESULTS A total of 278 patients were included, receiving 81 early and 197 late CPs. When analyzing all patients, early CP was associated with a statistically significant higher odds of any complication (odds ratio [OR]: 3.25, P < .001), reoperation (OR: 2.57, P = .019), hydrocephalus (OR: 6.03, P = .003), and symptomatic extra-axial collections (OR: 9.22, P = .003). Subgroup analysis demonstrated statistically significant higher odds of these complications only for the CP trauma subgroup, but not the nontrauma subgroup. The odds of complications postCP demonstrated a statistically significant decrease of 4.4% for each week after DC (Unit Odds Ratio [U-OR]: 0.956, P = .0363). CONCLUSION In our retrospective series, early CP was associated with higher odds of postoperative complications compared to late CP in the trauma subgroup. Greater care should be taken in preoperative planning and increased vigilance postoperatively for complications with this potentially more vulnerable subpopulation. Future prospective controlled trials are needed to elucidate optimal timing for CP.

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Outcomes of cranioplasty following decompressive craniectomy in the pediatric population

Journal of Neurosurgery Pediatrics ◽

10.3171/2013.4.peds12605 ◽

2013 ◽

Vol 12 (2) ◽

pp. 120-125 ◽

Cited By ~ 51

Author(s):

Brandon G. Rocque ◽

Kaushik Amancherla ◽

Sean M. Lew ◽

Sandi Lam

Keyword(s):

Bone Resorption ◽

Decompressive Craniectomy ◽

Complication Rate ◽

Case Reports ◽

Pediatric Population ◽

Defect Size ◽

Complication Rates ◽

Appreciable Effect ◽

Pooled Data ◽

Early Cranioplasty

Cranioplasty is routinely performed following decompressive craniectomy in both adult and pediatric populations. In adults, this procedure is associated with higher rates of complications than is elective cranial surgery. This study is a review of the literature describing risk factors for complications after cranioplasty surgery in pediatric patients. A systematic search of PubMed, Cochrane, and SCOPUS databases was undertaken. Articles were selected based on their titles and abstracts. Only studies that focused on a pediatric population were included; case reports were excluded. Studies in which the authors assessed bone flap storage method, timing of cranioplasty, material used (synthetic vs autogenous), skull defect size, and/or complication rates (bone resorption and surgical site infection) were selected for further analysis. Eleven studies that included a total of 441 cranioplasties performed in the pediatric population are included in this review. The findings are as follows: 1) Based on analysis of pooled data, using cryopreserved bone flaps during cranioplasty may lead to a higher rate of bone resorption and lower rate of infection than using bone flaps stored at room temperature. 2) In 3 of 4 articles describing the effect of time between craniectomy and cranioplasty on complication rate, the authors found no significant effect, while in 1 the authors found that the incidence of bone resorption was significantly lower in children who had undergone early cranioplasty. Pooling of data was not possible for this analysis. 3) There are insufficient data to assess the effect of cranioplasty material on complication rate when considering only cranioplasties performed to repair decompressive craniectomy defects. However, when considering cranioplasties performed for any indication, those in which freshly harvested autograft is used may have a lower rate of resorption than those in which stored autograft is used. 4) There is no appreciable effect of craniectomy defect size or patient age on complication rate. There is a paucity of articles describing outcomes and complications following cranioplasty in children and adolescents. However, based on the studies examined in this systematic review, there are reasons to suspect that method of flap preservation, timing of surgery, and material used may be significant. Larger prospective and retrospective studies are needed to shed more light on this important issue.

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Sinking Skin Flap Syndrome following Posttraumatic Hydrocephalus

Case Reports in Neurological Medicine ◽

10.1155/2021/6682310 ◽

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.

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Optimal timing of autologous cranioplasty after decompressive craniectomy in children

Journal of Neurosurgery Pediatrics ◽

10.3171/2012.6.peds1268 ◽

2012 ◽

Vol 10 (4) ◽

pp. 268-272 ◽

Cited By ~ 63

Author(s):

Mark P. Piedra ◽

Eric M. Thompson ◽

Nathan R. Selden ◽

Brian T. Ragel ◽

Daniel J. Guillaume

Keyword(s):

Intracranial Pressure ◽

Bone Resorption ◽

Decompressive Craniectomy ◽

Pediatric Patients ◽

Optimal Timing ◽

Raised Intracranial Pressure ◽

Elevated Intracranial Pressure ◽

Children's Hospital ◽

Children’S Hospital ◽

Early Cranioplasty

Object The object of this study was to determine if early cranioplasty after decompressive craniectomy for elevated intracranial pressure in children reduces complications. Methods Sixty-one consecutive cases involving pediatric patients who underwent autologous cranioplasty after decompressive craniectomy for raised intracranial pressure at a single academic children's hospital over 15 years were studied retrospectively. Results Sixty-one patients were divided into early (< 6 weeks; 28 patients) and late (≥ 6 weeks; 33 patients) cranioplasty cohorts. The cohorts were similar except for slightly lower age in the early (8.03 years) than the late (10.8 years) cranioplasty cohort (p < 0.05). Bone resorption after cranioplasty was significantly more common in the late (42%) than the early (14%) cranioplasty cohort (p < 0.05; OR 5.4). No other complication differed in incidence between the cohorts. Conclusions After decompressive craniectomy for raised intracranial pressure in children, early (< 6 weeks) cranioplasty reduces the occurrence of reoperation for bone resorption, without altering the incidence of other complications.

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25-gauge vitrectomy with gas tamponade for rhegmatogenous retinal detachment: experienced vs. inexperienced surgeons

10.21203/rs.3.rs-53301/v3 ◽

2020 ◽

Author(s):

Martin Pencak ◽

Miroslav Veith ◽

Zbynek Stranak ◽

Jakub Dite ◽

Jana Vranova ◽

...

Keyword(s):

Retinal Detachment ◽

Success Rate ◽

Rhegmatogenous Retinal Detachment ◽

Case Series ◽

Functional Results ◽

Complication Rates ◽

Gas Tamponade ◽

Single Operation ◽

Case Series Study ◽

The Difference

Abstract Introduction: To compare the results and complication rates of a 25-gauge pars plana vitrectomy (PPV) with gas tamponade for rhegmatogenous retinal detachment (RRD) between experienced and inexperienced surgeons.Materials and Methods: This is a retrospective comparative consecutive case series study of patients with uncomplicated RRD treated with 25g PPV with gas tamponade. Patients were divided into 2 groups: In experienced surgeon group (ESG) the procedure was performed by an experienced vitreoretinal surgeon and in inexperienced surgeon group (ISG) the procedure was performed by 2 inexperienced surgeons. Anatomical and functional results and complication rates were compared between the two groups.Results: 216 eyes were included in the study. In the ESG (106 eyes), the single operation success rate was 94.3%, and the final success rate was 100%. In the ISG (110 eyes), the single operation success rate was 93.6%, and the final success rate was 100.0%. The difference in single surgery success rate between groups was not statistically significant (P = 0.828). The mean postoperative BCVA improvement was 0.348 decimal in ESG and 0.405 decimal in ISG (P = 0.234). The difference in complication rates between groups was not significant.Conclusions: A 25g PPV with gas tamponade for treatment of RRD yields excellent anatomical results and improvement in BCVA. With good technique and use of modern vitrectomy machines and instruments, even inexperienced surgeons can achieve high single operation success rate, suggesting a short learning curve. The complication rate is comparable between experienced and inexperienced surgeons.

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Diagnosis of cerebral hemorrhage before the era of computed tomography

Orvosi Hetilap ◽

10.1556/oh.2013.29739 ◽

2013 ◽

Vol 154 (44) ◽

pp. 1743-1746

Author(s):

Gergely Hofgárt ◽

Rita Szepesi ◽

Bertalan Vámosi ◽

László Csiba

Keyword(s):

Computed Tomography ◽

Cerebrospinal Fluid ◽

Positive Predictive Value ◽

Predictive Value ◽

Hemorrhagic Stroke ◽

Cranial Computed Tomography ◽

Cerebral Stroke ◽

Daily Routine ◽

Stroke Patients ◽

The Difference

Introduction: During the past decades there has been a great progress in neuroimaging methods. Cranial computed tomography is part of the daily routine now and its use allows a fast diagnosis of parenchymal hemorrhage. However, before the availability of computed tomography the differentiation between ischemic and hemorrhagic stroke was based on patient history, physical examination, percutan angiography and cerebrospinal fluid sampling, and the clinical utility could be evaluated by autopsy of deceased patients. Aim: The authors explored the diagnostic performance of cerebrospinal fluid examination for the diagnosis of ischemic and hemorrhagic stroke. Method: Data of 200 deceased stroke patients were retrospectively evaluated. All patients had liquor sampling at admission and all of them had brain autopsy. Results: Bloody or yellowish cerebrospinal fluid at admission had a positive predictive value of 87.5% for hemorrhagic stroke confirmed by autopsy, while clear cerebrospinal fluid had positive predictive value of 90.7% for ischemic stroke. Patients who had clear liquor, but autopsy revealed hemorrhagic stroke had higher protein level in the cerebrospinal fluid, but the difference was not statistically significant (p = 0.09). Conclusions: The results confirm the importance of pathological evaluation of the brain in cases deceased from cerebral stroke. With this article the authors wanted to salute for those who contributed to the development of the Hungarian neuropathology. In this year we remember the 110th anniversary of the birth, and the 60th anniversary of the death of professor Kálmán Sántha. Professor László Molnár would be 90 years old in 2013. Orv. Hetil., 154 (44), 1743–1746.

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Epidemiology of pediatric hydrocephalus in Haiti: analysis of a surgical case series

Journal of Neurosurgery Pediatrics ◽

10.3171/2018.12.peds18568 ◽

2019 ◽

Vol 23 (5) ◽

pp. 568-576

Author(s):

Michael Ragheb ◽

Ashish H. Shah ◽

Sarah Jernigan ◽

Tulay Koru-Sengul ◽

John Ragheb

Keyword(s):

Public Health ◽

Logistic Regression ◽

Head Circumference ◽

Rainy Season ◽

Statistical Tests ◽

Multivariate Logistic Regression Analysis ◽

Case Series ◽

Multivariate Logistic Regression ◽

Surgical Case ◽

Operative Notes

OBJECTIVEHydrocephalus is recognized as a common disabling pediatric disease afflicting infants and children disproportionately in the developing world, where access to neurosurgical care is limited and risk of perinatal infection is high. This surgical case series describes the Project Medishare Hydrocephalus Specialty Surgery (PMHSS) program experience treating hydrocephalus in Haiti between 2008 and 2015.METHODSThe authors conducted a retrospective review of all cases involving children treated for hydrocephalus within the PMHSS program in Port-au-Prince, Haiti, from 2008 through 2015. All relevant epidemiological information of children treated were prospectively collected including relevant demographics, birth history, hydrocephalus etiology, head circumference, and operative notes. All appropriate associations and statistical tests were performed using univariate and multivariate logistic regression analyses.RESULTSAmong the 401 children treated within PMHSS, postinfectious hydrocephalus (PIH) accounted for 39.4% (n = 158) of cases based on clinical, radiographic, and endoscopic findings. The majority of children with hydrocephalus in Haiti were male (54.8%, n = 197), born in the rainy season (59.7%, n = 233), and born in a coastal/inland location (43.3%, n = 61). The most common surgical intervention was endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) (45.7%, n = 175). Multivariate logistic regression analysis yielded coastal birth location (OR 3.76, 95% CI 1.16–12.18) as a statistically significant predictor of PIH. Increasing head circumference (adjusted OR 1.06, 95% CI 0.99–1.13) demonstrated a slight trend toward significance with the incidence of PIH.CONCLUSIONSThis information will provide the foundation for future clinical and public health studies to better understand hydrocephalus in Haiti. The 39.4% prevalence of PIH falls within observed rates in Africa as does the apparently higher prevalence for those born during the rainy season. Although PIH was the most frequent etiology seen in almost all birth locations, the potential relationship with geography noted in this series will be the focus of further research in an effort to understand the link between climate and PIH in Haiti. The ultimate goal will be to develop an appropriate public health strategy to reduce the burden of PIH on the children of Haiti.

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Macular buckling versus vitrectomy on macular hole associated macular detachment in eyes with high myopia: a randomised trial

British Journal of Ophthalmology ◽

10.1136/bjophthalmol-2020-317800 ◽

2021 ◽

pp. bjophthalmol-2020-317800

Author(s):

Xiujuan Zhao ◽

Yonghao Li ◽

Wei Ma ◽

Ping Lian ◽

Xiling Yu ◽

...

Keyword(s):

Success Rate ◽

Macular Hole ◽

High Myopia ◽

Randomised Trial ◽

Case Series ◽

Primary Treatment ◽

Closure Rate ◽

Macular Detachment ◽

The Difference ◽

Myopic Maculopathy

AimTo compare the efficacy of macular buckling (MB) and pars plana vitrectomy (PPV) for full-thickness macular holes (FTMH) and associated macular detachment (MD) in highly myopic eyes.MethodsProspective interventional case series of eyes undergoing PPV or MB for FTMH and MD.Main outcome measuresBest-corrected visual acuity (BCVA) at postoperative month 24. Other measured outcomes include the initial surgical success rate, macular hole closure rate and the progression of myopic maculopathy.ResultsA total of 53 eyes from 53 participants were included in this study (26 participants receiving MB and 27 participants receiving PPV), and finally 49 eyes from 49 participants (25 participants in the MB group and 24 participants in the PPV group) were analysed. At postoperative month 24, the BCVA had improved significantly in those that underwent either MB (p<0.001) or PPV (p=0.04). The difference between the groups was not significant (p=0.653). The surgical failure rate after the primary treatment was significantly higher in the PPV group than the MB group (25.00% vs 4.00%, respectively; p=0.04). The macular closure rate was higher in the MB group compared with the PPV group, but the difference was not statistically significant (64.00% vs 58.33%, respectively; p=0.45). Myopic maculopathy development may be more severe following PPV than following MB surgery.ConclusionPatients with high myopia obtained anatomical and functional improvements from either MB or PPV. However, MB achieved a significantly higher success rate in retinal reattachment compared with PPV.Trial registration numberNCT03433547.

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