The document summarizes complications that can occur after cranioplasty surgery. It discusses the history of cranioplasty and various materials used for the procedure such as autografts, allografts, and alloplasts. It then summarizes findings from several meta-analyses on overall complication rates, infection rates, extra-axial fluid collections, hydrocephalus, seizures, intracranial hemorrhage, and bone resorption. Risk factors for complications identified in one study included older age, diabetes, hypertension, and hemorrhagic stroke. The document concludes by thanking the reader.

1. cka
SURESH BISHOKARMA, MS
MCH RESIDENT, NEUROSURGERY
NINAS
COMPLICATIONS
OF
CRANIOPLASTY

2. INTRODUCTION

3. Restore cerebral protection and craniofacial cosmesis.
Goals of cranioplasty

4. The practice of cranial reconstruction dates at least as far back as 3000BC,
where archeological evidence suggests the repair of head trephanation with
the use of precious metals, shells and gourds by an ancient perusian.
HISTORY
8/22/2018

5. Autografts
Marked strength and
Elasticity,
Biocompatibility,
General availability, and
Resistance to infection.
Material used for cranioplasty
* Allograft
* 1910: Cadaveric
skull
* 1915: Morestin:
cadaveric cartilage:
World War I
* Issue:
o infection,
o strength and
o lack of
calcification
* Alloplast
* METALS:
* 1890: aluminum and gold
* vitallium (1941)
* tantalum (1942)
* stainless steel mesh (1944)
* Titanium (1965)
* ACRYLICS: Methyl methacrylate
(MMA) was repurposed for use in
human calvarial repair (1940) Zander
* CERAMICS: hydroxyapatite and
coralline carbon- ated calcium
phosphate cement (CCPC)
* PLASTICS: Celluloid (1800)
Frankel: porouspolyethylene and poly-
etheretherketone (PEEK).

6. Rijal S et al. 2018. Outcome of cranioplasty after decompressive craniectomy: Algorithm based study

7. Technique of Cranioplasty

8. POST CRANIOPLASTY CT FREQUENCY
No change 37(92.5%)
Epidural collection 2(5%)
Contusion 1(2.5%)
Total 40
Post operative complications
Study duration: 5 years

9. CRANIOPLASTY SITE WOUND INFECTION FREQUENCY
No 44(93.6%)
Yes 3(6.4%)
Total 47(100%)

10. LITERATURE REVIEW

11. Total studies included: 25
Infections (n = 18 studies),
Complications requiring reoperation (n = 11),
Intracranial hemorrhage (n = 6),
Extra-axial fluid collections (n = 5),
Hydrocephalus (n = 6),
Seizures (n = 4), and
Bone resorption (n = 3; Fig. 2).
The pooled rate of overall complications was 19.5% (n = 609/3126) across
all studies, ranging from 3.9% to 45.3%.
Overall complications
Malcolm et al. Meta-analysis; J Clin Neuro. 2016
Malcolm et al. Complications following cranioplasty and relationship to timing: A
systematic review and meta-analysis. Meta-analysis; J Clin Neuro. 2016

12. OVERALL COMPLICATION
Malcolm et al. Meta-analysis; J Clin Neuro. 2016
Overall complication rate:609/3126= 19.5%

13. Bone resorption: 50% (Pediatric), 0%–7% (adult).
High rate of surgical site infection: an average of 7.9% across 18 studies
(recent large-scale systematic review)
Autologous cranioplasty
Malcolm et al. Meta-analysis; J Clin Neuro. 2016

14. INFECTION
Overall infection rate:165/2021= 8.15%
Malcolm et al. Meta-analysis; J Clin Neuro. 2016

15. Five studies reported non-infectious, non-hemorrhagic extra- axial fluid
collections, including epidural and subdural fluid collections, hygroma, dural
tears, and CSF fistulas.
The pooled rate of extra-axial fluid collections was 13.9% (n = 71/510),
ranging from 2.11% to 45.3% [51,71].
There was no difference in odds of fluid collection in the early cranioplasty
group (n = 19/147 procedures, 12.9%) compared with the late cranioplasty
group (n = 52/363, 14.3%; OR 0.64, CI 0.20–2.05, p = 0.46)
EXTRA-AXIAL FLUID COLLECTION
Malcolm et al. Meta-analysis; J Clin Neuro. 2016

16. EXTRA-AXIAL FLUID COLLECTION
Overall fluid collection rate:71/510= 13.9%
Malcolm et al. Meta-analysis; J Clin Neuro. 2016

17. HYDROCEPHALUS
Overall fluid collection rate:47/840= 5.6%
Malcolm et al. Meta-analysis; J Clin Neuro. 2016

18. SEIZURE
Seizure rate:31/643= 4.8%
Malcolm et al. Meta-analysis; J Clin Neuro. 2016

19. POST OPERATIVE ICH
ICH rate: 53/0= 4.9%
Malcolm et al. Meta-analysis; J Clin Neuro. 2016

20. BONE RESORPTION
Malcolm et al. Meta-analysis; J Clin Neuro. 2016

21. POST CRANIOPLASTY CT FREQUENCY
No change 37(92.5%)
Epidural collection 2(5%)
Contusion 1(2.5%)
Total 40
Post operative complications
Study duration: 5 years

22. Age, sex, race, hypertension, DM, smoking status, reason for craniotomy,
urgency status, and cranioplasty location and the development of any
complication postcranioplasty.
The overall complication rate was 31.32% (109 of 348).
Univariate predictors included in multivariate analysis were age, DM,
hypertension, and hemorrhagic stroke.
Univariate analysis applied for graft material type showed no difference
between synthetic and autologous bone graft (OR 1.34; p = 0.20).
In multivariate analysis, hypertension (OR 1.92, CI 1.22– 3.02), increasing
age (OR 1.02, CI 1.00–1.04), and hemorrhagic stroke (OR 3.84, CI 1.93–
7.63) predicted complications.
Predictors of complications
Zanty et al. Complications following cranioplasty: incidence and predictors in 348 cases. 2015; JNS.

23. Leão RS et al. Complications with PMMA compared with other materials used in cranioplasty: a systematic review and meta-analysis
Braz. Oral Res. 2018

24. Thank you

NATIONAL INSTITUTE OF NEUROLOGICAL AND ALLIED SCIENCES, BANSBARI, KATHMANDU