Bone Flap Necrosis After Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction
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ORIGINAL ARTICLE
Bone Flap Necrosis After Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction Christian Ewald • Pedro Duenisch • Jan Walter • Theresa Go¨tz Otto W. Witte • Rolf Kalff • Albrecht Gu¨nther
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Published online: 22 August 2013 Ó Springer Science+Business Media New York 2013
Abstract Background Autologous bone flap reinsertion follows as a second surgical intervention after decompressive craniectomy in patients with malignant middle cerebral artery (MCA) infarction. In addition to surgery-related short-term complications, aseptic resorption of the reimplanted bone flap is a possible long-term problem which has not yet been sufficiently elucidated in these patients. Methods A total of 109 patients who had undergone decompressive hemicraniectomy for malignant MCA infarction in our institution between September 1994 and December 2011 were included in the study. Clinical and radiological findings were retrieved retrospectively. Aseptic bone necrosis was classified into two categories based on computer tomographic features. Results A total of 76 patients received their own cryoconserved bone flap (mean age 54.34 ± 10.73 years; 49 males). The overall short-term complication rate was 9.2 %. Bone flap necrosis occurred in 26 patients (22.8 %)
C. Ewald (&) P. Duenisch J. Walter R. Kalff Neurosurgical Department, Jena University Hospital, Friedrich Schiller University Jena, Erlanger Allee 101, 07747 Jena, Germany e-mail: [email protected] T. Go¨tz Biomagnetic Center, Hans-Berger-Department of Neurology and Center for Sepsis Control and Care (CSCC), Jena University Hospital, Friedrich Schiller University Jena, Erlanger Allee 101, 07747 Jena, Germany O. W. Witte A. Gu¨nther Hans-Berger-Department of Neurology and Center for Sepsis Control & Care (CSCC), Jena University Hospital, Friedrich Schiller University Jena, Erlanger Allee 101, 07747 Jena, Germany
with 7 flaps showing signs of surgically relevant type II necrosis after a median time of 14 months (interquartile range [IQR] 4–22). Conclusions There is a noticeable complication rate in patients undergoing bone flap reinsertion after hemicraniectomy due to malignant MCA infarction. Aseptic bone necrosis represents a significant complication during longterm follow-up. The pathophysiological mechanisms remain unclear and more efforts should be undertaken to understand and possibly prevent this complication in these patients. Keywords Decompressive craniectomy Cranioplasty Aseptic bone flap necrosis Bone resorption Middle cerebral artery infarction
Introduction To date, decompressive hemicraniectomy is an accepted treatment option in patients with life-threatening, spaceoccupying middle cerebral artery (MCA) infarction [1–3]. About 80 % of the patients survive the initial event. After clinical and radiological consolidation, cranioplasty with reinsertion of the removed bone flap is necessary for mechanical, cosmetic, and therapeutic reasons [4–11]. In addition to a recently published study involving surgical
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