Impact of timing of cranioplasty on hydrocephalus after decompressive hemicraniectomy in malignant middle cerebral artery infarction

There is an increasing body of evidence in the recent literature, which demonstrates that cranioplasty may also accelerate and improve neurological recovery. Although the exact pathophysiological mechanisms for this improvement remain essentially unknown, there are a rapidly growing number of neurosurgeons adopting this concept.


Communicating hydrocephalus is an almost universal finding in patients after hemicraniectomy. Delayed time to cranioplasty is linked with the development of persistent hydrocephalus, necessitating permanent CSF diversion in some patients.
Waziri et al., propose that early cranioplasty, when possible, may restore normal intracranial pressuredynamics and prevent the need for permanent CSF diversion in patients after hemicraniectomy 1).

Factors

One modifiable factor that may alter the risk of cranioplasty is the timing of cranioplasty after craniectomy. 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.
When considering ideal timing for cranioplasty, predominant issues include residual brain edema, brain retraction into the cranial vault, risk of infection, and development of delayed post-traumatic hydrocephalus.


Waiting to perform cranioplasty is important to prevent the development of devitalized autograft or allograft infections.
It is generally accepted to wait 3 to 6 months before reconstructive surgery. If there is an infected area, this waiting period can be as long as one year.
Cranioplasty is performed after craniectomy when intracranial pressure is under control for functional and aesthetic restorations and for protection, but it may also lead to some neurological improvement after the bone flap placement 2) 3) 4).

Timing of cranioplasty after decompressive craniectomy for trauma

The optimal timing of cranioplasty after decompressive craniectomy for trauma is unknown.
After decompressive craniectomy for trauma, early (<12 weeks) cranioplasty does not alter the incidence of complication rates. In patients <18 years of age, early (<12 weeks) cranioplasty increases the risk of bone resorption. Delaying cranioplasty (≥12 weeks) results in longer operative times and may increase costs 5).

Timing of cranioplasty after decompressive craniectomy for malignant middle cerebral artery infarction

Patients with malignant middle cerebral artery infarction frequently develop hydrocephalus after decompressive hemicraniectomy. Hydrocephalus itself and known shunt related complications after ventriculoperitoneal shunt implantation may negatively impact patients outcome.
A later time point of cranioplasty might lead to a lower incidence of required shunting procedures in general 6).

1) Waziri A, Fusco D, Mayer SA, McKhann GM 2nd, Connolly ES Jr. Postoperative hydrocephalus in patients undergoing decompressive hemicraniectomy for ischemic or hemorrhagic stroke. Neurosurgery. 2007 Sep;61(3):489-93; discussion 493-4. PubMed PMID: 17881960.
2) Honeybul S, Janzen C, Kruger K, Ho KM. The impact of cranioplasty on neurological function. Br J Neurosurg. 2013;27:636–641. doi: 10.3109/02688697.2013.817532.
3) Jelcic N, De Pellegrin S, Cecchin D, Della Puppa A, Cagnin A. Cognitive improvement after cranioplasty: a possible volume transmission-related effect. Acta Neurochir (Wien) 2013;155:1597–1599. doi: 10.1007/s00701-012-1519-6.
4) Di Stefano C, Sturiale C, Trentini P, Bonora R, Rossi D, Cervigni G, et al. Unexpected neuropsychological improvement after cranioplasty: a case series study. Br J Neurosurg. 2012;26:827–831. doi: 10.3109/02688697.2012.692838.
5) Piedra MP, Nemecek AN, Ragel BT. Timing of cranioplasty after decompressive craniectomy for trauma. Surg Neurol Int. 2014 Feb 25;5:25. doi: 10.4103/2152-7806.127762. PubMed PMID: 24778913; PubMed Central PMCID: PMC3994696.
6) Finger T, Prinz V, Schreck E, Pinczolits A, Bayerl S, Liman T, Woitzik J, Vajkoczy P. Impact of timing of cranioplasty on hydrocephalus after decompressive hemicraniectomy in malignant middle cerebral artery infarction. Clin Neurol Neurosurg. 2016 Dec 9;153:27-34. doi: 10.1016/j.clineuro.2016.12.001. [Epub ahead of print] PubMed PMID: 28012353.

Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke

Early decompressive hemicraniectomy reduces mortality without increasing the risk of very severe disability among patients 60 years of age or younger with complete or subtotal space-occupying middle-cerebral-artery infarction. Its benefit in older patients is uncertain.

METHODS:

We randomly assigned 112 patients 61 years of age or older (median, 70 years; range, 61 to 82) with malignant middle-cerebral-artery infarction to either conservative treatment in the intensive care unit (the control group) or hemicraniectomy (the hemicraniectomy group); assignments were made within 48 hours after the onset of symptoms. The primary end point was survival without severe disability (defined by a score of 0 to 4 on the modified Rankin scale, which ranges from 0 [no symptoms] to 6 [death]) 6 months after randomization.

RESULTS:

Hemicraniectomy improved the primary outcome; the proportion of patients who survived without severe disability was 38% in the hemicraniectomy group, as compared with 18% in the control group (odds ratio, 2.91; 95% confidence interval, 1.06 to 7.49; P=0.04). This difference resulted from lower mortality in the surgery group (33% vs. 70%). No patients had a modified Rankin scale score of 0 to 2 (survival with no disability or slight disability); 7% of patients in the surgery group and 3% of patients in the control group had a score of 3 (moderate disability); 32% and 15%, respectively, had a score of 4 (moderately severe disability [requirement for assistance with most bodily needs]); and 28% and 13%, respectively, had a score of 5 (severe disability). Infections were more frequent in the hemicraniectomy group, and herniation was more frequent in the control group.

CONCLUSIONS:

Hemicraniectomy increased survival without severe disability among patients 61 years of age or older with a malignant middle-cerebral-artery infarction. The majority of survivors required assistance with most bodily needs. (Funded by the Deutsche Forschungsgemeinschaft; DESTINY II Current Controlled Trials number, ISRCTN21702227.) ((Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M,
Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger
J, Hacke W; DESTINY II Investigators. Hemicraniectomy in older patients with
extensive middle-cerebral-artery stroke. N Engl J Med. 2014 Mar
20;370(12):1091-100. doi: 10.1056/NEJMoa1311367. PubMed PMID: 24645942.))

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