RESUMEN
OBJECTIVE: Craniectomy, used to relieve refractory intracranial pressure in traumatic brain injury (TBI), may cause cognitive deficits which could be improved by skull breach repair. This paper studied whether late cranioplasty improves a specific pattern of cognitive functions. DESIGN: A case series of five TBI patients with craniectomy undergoing late cranioplasty (median interval time: 14 months, range: 12-36). METHODS: Longitudinal neuropsychological and brain MRI assessments 1 week before cranioplasty and 3 months later. RESULTS: After cranioplasty, mean score of the verbal fluency test improved compared to pre-cranioplasty (p = 0.02). Similarly, significant improvements after cranioplasty were observed in other tests scores exploring executive functions, such as working memory (p = 0.03) and speed of attention (p = 0.04), independently from the size and site of cranioplasty. CONCLUSIONS: The cognitive improvement induced by cranioplasty, even when performed after a long interval from craniectomy, may be due to the restoration of physiological cerebrospinal fluid circulation which, in turn, allows an efficient brain volume transmission signal circulation. The restoration of this essential way of signal communication seems to affect large-scale neuronal networks responsible for the executive functions.
Asunto(s)
Lesiones Encefálicas/cirugía , Craniectomía Descompresiva , Función Ejecutiva , Procedimientos de Cirugía Plástica , Adulto , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/fisiopatología , Cognición , Humanos , Presión Intracraneal , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Recuperación de la Función , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Large cranial defects still represent a challenge in neurosurgery. Currently different biomaterials are available for cranial reconstruction including titanium, acrylic mesh and different types of calcium phosphate-based bone grafts. The goal of surgery is a perfect fit of the implant without infection and absorption, and a good aesthetic result. This paper describes a surgical method for cranioplasty, using a customised porous hydroxyapatite (HA) prosthesis. MATERIALS AND METHODS: Sixty patients treated surgically with a customised porous-HA prosthesis for large cranial defects, were followed retrospectively. A two-year follow-up was carried out with periodic visits and CT scans. Safety (the incidence of adverse events and fractures of the implant) and clinical performance (biological and cosmetic results) were evaluated. RESULTS: Fifty one patients were followed-up, no rejection occurred and only one case of infection was recorded. Five patients had minor surgery-related complications, and no spontaneous implant fractures or mobilisation were reported. Three patients exhibited implant fractures as a result of trauma and all healed spontaneously. All patients showed a satisfactory clinical outcome with good cosmetic appearance in the early postoperative period and after a long-term follow-up. CONCLUSIONS: Cranioplasty performed with a customised porous-HA prosthesis gave a positive outcome, showing it to be an appropriate technique for use in large and complex cranial reconstruction.
Asunto(s)
Materiales Biocompatibles/química , Cerámica/química , Craneotomía/métodos , Durapatita/química , Procedimientos de Cirugía Plástica/instrumentación , Diseño de Prótesis , Adolescente , Adulto , Anciano , Diseño Asistido por Computadora , Seguridad de Equipos , Estética , Estudios de Seguimiento , Hueso Frontal/cirugía , Humanos , Hidroxiapatitas/química , Imagenología Tridimensional/métodos , Persona de Mediana Edad , Oseointegración/fisiología , Hueso Parietal/cirugía , Satisfacción del Paciente , Complicaciones Posoperatorias , Infecciones Relacionadas con Prótesis/etiología , Procedimientos de Cirugía Plástica/métodos , Estudios Retrospectivos , Hueso Temporal/cirugía , Tomografía Computarizada por Rayos X/métodos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Removal of a large cranial tumour and reconstruction of the consequent bone defect in the same surgical setting is an ordinary procedure. A custom-made hydroxyapatite ceramic reconstruction of a cranial bone defect is a modern option that currently needs a preoperative stage of studying the bone defect and designing the implant. Consequently, if a reconstructive hydroxyapatite-based procedure after a cranial tumour resection is the aim, a two-stage surgery is necessary. The authors investigated the possibility of performing this procedure in a one-step surgery by the use of a neuronavigation system. METHODS: Preoperatively, an epoxy-resin model is built by stereolithography on three-dimensional (3D) cranial computed tomographic (CT) scan data of the patient affected by the cranial tumour. Afterwards, the implant is designed on the base of the planned bone flap that the surgeon simulates on the model for the tumour resection. The CT scan of the patient is fused in the neuronavigational system with a 3D cranial CT scan performed on the model without the planned bone flap. Intra-operatively, the surgeon is guided by the neuronavigational system to remove the cranial tumour through the craniotomy preoperatively planned on the model and, for this reason, perfectly matching the prosthesis for shape and size. RESULTS: In an illustrative case, a 26-year-old woman presented to the authors' attention for a large growing fronto-temporal osteoma. Because of the site of the tumour and the consequent challenging reconstruction of the bone defect, it was decided to attempt the cranioplasty with a custom-made hydroxyapatite ceramic implant. The removal of the osteoma and reconstruction with a hydroxyapatite ceramic implant was done in a one-step surgery. Seriate postoperative cranial CT scans showed a satisfying 3D result. CONCLUSIONS: Surgical removal of a cranial bone tumour and optimal reconstruction with a custom-made hydroxyapatite ceramic implant is an appealing procedure that can be carried out in a one-step surgery by means of an intraoperative image-guidance system.