Cranioplasty following ventriculoperitoneal shunting: lessons learned
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ORIGINAL ARTICLE - NEUROSURGERY GENERAL
Cranioplasty following ventriculoperitoneal shunting: lessons learned Dorian Hirschmann 1 & Beate Kranawetter 1 & Constanze Kirchschlager 1 & Matthias Tomschik 1 & Jonathan Wais 1 & Fabian Winter 1 & Matthias Millesi 1 & Johannes Herta 1 & Karl Roessler 1 & Christian Dorfer 1 Received: 6 July 2020 / Accepted: 24 September 2020 # The Author(s) 2020
Abstract Objective Cranioplasty (CP) is considered as a straightforward and technically unchallenging operation; however, complication rates are high reaching up to 56%. Presence of a ventriculoperitoneal shunt (VPS) and timing of CP are reported risk factors for complications. Pressure gradients and scarring at the site of the cranial defect seem to be critical in this context. The authors present their experiences and lessons learned. Methods A consecutive series of all patients who underwent CP at the authors’ institution between 2002 and 2017 were included in this retrospective analysis. Complications were defined as all events that required reoperation. Logistic regression analysis and chi-squared test were conducted to evaluate the complication rates according to suspected risk factors. Results A total of 302 patients underwent cranioplasty between 2002 and 2017. The overall complication rate was 17.5%. Complications included epi-/subdural fluid collection (7.3%) including hemorrhage (4.6%) and hygroma (2.6%), bone graft resorption (5.3%), bone graft infection (2.0%), and hydrocephalus (5.7%). Overall, 57 patients (18.9%) had undergone shunt implantation prior to CP. The incidence of epi-/subdural fluid collection was 19.3% in patients with VPS and 4.5% in patients without VPS, OR 5.1 (95% CI 2.1–12.4). Incidence of hygroma was higher in patients who underwent early CP. Patients with temporary shunt ligation for CP did not suffer from complications. Conclusion CP in patients with a VPS remains a high-risk procedure. Any effort to understand the pressure dynamics and to reduce factors that may trigger the formation of a large epidural space must be undertaken. Keywords Cranioplasty . Complications . Shunt . Epidural hemorrhage . Fluid collection
Introduction Decompressive hemicraniectomy (DHC) is a well-established procedure for treatment of patients with elevated intracranial pressure. Underlying pathologies and indications for DHC are diverse; hence, cranioplasty procedures represent a frequently required neurosurgical procedure in a heterogeneous group of patients [1–3]. The procedure itself is often regarded as straightforward and technically unchallenging and is commonly performed by junior residents. However, the rate of associated complications is much higher than encountered in This article is part of the Topical Collection on Neurosurgery general * Christian Dorfer [email protected] 1
Department of Neurosurgery, Medical University Vienna, Spitalgasse 23, 1090 Vienna, Austria
many other neurosurgical procedures and must not be neglected or underestimated [4–7]. These complications include epidural a
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