|Year : 2019 | Volume
| Issue : 4 | Page : 122-126
Simultaneous or staged operation? Timing of cranioplasty and ventriculoperitoneal shunt after decompressive craniectomy
Hsin-Yao Lin1, Kai-Chun Lin2, Cheng-Chia Tsai3, Dehui Wan4
1 Department of Surgery, Division of Neurosurgery, Maykay Memorial Hospital, Taipei; Institute of Nano Engineering and Microsystems; National Tsing Hua University; Institute of Biomedical Engineering, National Tsing Hua University, Hsinchu, Taiwan
2 Department of Surgery, Division of Neurosurgery, Maykay Memorial Hospital, Taipei, Taiwan
3 Department of Surgery, Division of Neurosurgery, Maykay Memorial Hospital, Taipei; Department of Medicine, Mackay Medical College, Taiwan
4 Institute of Biomedical Engineering, National Tsing Hua University; Frontier Research Center on Fundamental and Applied Science of Matters, National Tsing Hua University, Hsinchu, Taiwan
|Date of Submission||22-Feb-2019|
|Date of Decision||04-Mar-2019|
|Date of Acceptance||26-Mar-2019|
|Date of Web Publication||27-Aug-2019|
Dr. Cheng-Chia Tsai
Department of Surgery, Division of Neurosurgery, Maykay Memorial Hospital, Taipei; Department of Medicine, Mackay Medical College, Hsinchu
Prof. Dehui Wan
No. 101, Section 2 Kuang-Fu Road, Hsinchu
Source of Support: None, Conflict of Interest: None
Aims: Cranioplasty and ventriculoperitoneal shunt (VPS) are common procedures for patients who undergo decompressive craniectomy. The ideal time for these two procedures remains controversial.
Settings and Design: This is a retrospective, single institute, chart review comparing the complications associated with simultaneous and staged cranioplasty and VPS.
Materials and Methods: From January 2012 to December 2017, 56 patients who underwent both cranioplasty and VPS surgery at our hospital were separated into simultaneous or staged operation groups. We compared the demographic data and complications, including infections, subdural or epidural hemorrhage, and revision surgery between the groups.
Statistical Analysis Used: Independent Student's t-test was used for analysis of continuous variables, and Fisher's exact test was used for categorical data. MedCalc (version: 18.11) was used to perform all analysis.
Results: Nineteen patients underwent simultaneous cranioplasty and VPS, whereas 37 underwent staged operation. Etiologies for craniectomy included traumatic brain injury, infarction, spontaneous subarachnoid hemorrhage, and spontaneous intracerebral hemorrhage. There were no significant differences in the baseline characteristics between the groups. The overall complication rate was 14.3%. Three (15.8%) patients experienced complications in the simultaneous group: One (5.3%) with skin infection and two (10.5%) with overdrainage. Five (13.5%) patients experienced complications in the staged group: three (10.8%) with skin infections, one with central nervous system (CNS) infections, and one with both skin and CNS infections. Overall complications, wound infections, CNS infections, overdrainage, and revision surgery showed no significant differences between the groups.
Conclusions: Simultaneous cranioplasty and VPS showed complication rates similar to those of staged operation.
Keywords: Cranioplasty, decompressive craniectomy, ventriculoperitoneal shunt
|How to cite this article:|
Lin HY, Lin KC, Tsai CC, Wan D. Simultaneous or staged operation? Timing of cranioplasty and ventriculoperitoneal shunt after decompressive craniectomy. Formos J Surg 2019;52:122-6
|How to cite this URL:|
Lin HY, Lin KC, Tsai CC, Wan D. Simultaneous or staged operation? Timing of cranioplasty and ventriculoperitoneal shunt after decompressive craniectomy. Formos J Surg [serial online] 2019 [cited 2019 Nov 19];52:122-6. Available from: http://www.e-fjs.org/text.asp?2019/52/4/122/265490
| Introduction|| |
Decompressive craniectomy (DC) is effective in reducing intracranial pressure (ICP) for patients suffering from refractory increased ICP under medical management caused by cerebral infarction, traumatic brain injury (TBI), intracerebral hemorrhage (ICH), and aneurysmal ICH.,,, A large cranial defect after DC can alter the cerebrospinal fluid (CSF) circulation dynamic and become a risk factor for hydrocephalus., Hydrocephalus is a common complication after TBI, ICH, and aneurysmal ICH. A review of complications after DC in TBI patients revealed a rate of 2%–29% for hydrocephalus. Consequently, patients who undergo DC may require cranioplasty and ventriculoperitoneal shunt (VPS) after the subacute stage.
The best methods for managing patients with both hydrocephalus and cranial defects remain controversial. Simultaneously performing VPS and cranioplasty can reduce medical costs and hospital stay; however, safety is a major concern. The infection rates for simultaneous operation are reported to be as high as 41%. In addition, both cranioplasty and VPS can affect CSF hydrodynamics. Simultaneous surgery can result in unpredictable changes in CSF circulation and higher complication rates.
To address this issue, we conducted a retrospective study to compare the complication rates between simultaneous and staged operation at our institute.
| Materials and Methods|| |
We conducted a retrospective study by reviewing medical records at the Taipei MacKay Memorial Hospital. From January 2012 to December 2017, 71 consecutive patients underwent both cranioplasty and VPS operations at our hospital. The demographic and clinical characteristics, including age, gender, underlying pathologies, time from craniectomy to cranioplasty and VPS, severity of hydrocephalus based on the bifrontal index, and the degree of skin flap bulging over the cranial defect, were recorded. The skin flap was defined as flaccid when the brain was below the assumed skull line over the cranial defect. The skin flap was defined as bulging when the brain was partially or completely above the assumed skull line. Patients younger than 18-year-old were excluded. Patients with malignant brain tumor as the reason for craniectomy were excluded. Patients followed up for <3 months were also excluded from the study. A total of 56 patients were included in the study.
Patients who underwent cranioplasty and VPS at the same time were placed in the simultaneous operation group and those that underwent the procedures on different days were placed in the staged operation group.
We collected data regarding complications as the outcomes for both procedures. The overall complications, superficial wound infections, central nervous system (CNS) infections, over-drainage, and revision surgery were all compared between the two groups.
The MacKay Memorial Hospital Institutional Review Board approved the study on April 11th in 2019 (19MMHIS050e). The demographic and clinic characteristics, as well as the complications and revision surgery as the treatment outcomes were compared between the groups. The independent Student's t-test was used for analysis of continuous variables, and Fisher's exact test was used for categorical data. P < 0.05 was considered statistical significance. MedCalc (version: 18.11, Belgium company, https://www.medcalc.org/index.php) was used to perform all analysis.
| Results|| |
Seventy-one patients underwent both cranioplasty and VPS at our hospital during the interval between January 2012 and December 2017. Of these, 15 patients were excluded in accordance with our exclusion criteria, specifically 11 patients who were followed up for <3 months, one patient diagnosed with malignant brain tumor, and two patients with insufficient pre- and post-operative imaging data. One patient who received bilateral DC was excluded because he underwent left side cranioplasty first followed by both right side cranioplasty and VPS at the next admission.
Of the remaining 56 cases, 19 patients underwent simultaneous cranioplasty and VPS (simultaneous group), and 37 patients underwent staged operations for cranioplasty and VPS (staged group). In the simultaneous group, the etiologies for craniectomy were TBI (15 cases), infarction (two cases), and spontaneous ICH (two cases), and the mean age at first admission was 57.5 (standard deviation = 18) years old.
In the staged group, there were 24 cases due to TBI, six cases due to infarction, two cases due to ICH, four cases due to subarachnoid hemorrhage, and one case due to spontaneous subdural hemorrhage, and the mean age at first admission was 52.6 (standard deviation = 15.6) years old.
Twenty-one patients were female, with seven in the simultaneous group and 14 in the staged group. The mean follow-up length was 26.1 months for the simultaneous group and 37.8 months for the staged group. The average interval between DC and the subsequent procedure was 140.1 days in the simultaneous group and 64.5 days in the staged group. Hydrocephalus severity, determined based on the bifrontal index, was 0.395 and 0.424 in the simultaneous and staged groups, respectively. The difference in the bifrontal index was not significant (P = 0.075) between the simultaneous and staged operation group but was very close. In the simultaneous group, 11 patients had tense convex cranial defects, and others had flaccid skin flaps, with and without partial convex cranial defects. In the staged group, 26 patients had tense convex cranial defects. [Table 1] shows more details on the baseline patient characteristics. There was no significant difference in the baseline characteristics between the two groups except in the time from DC to the first procedure. The mean time from DC to simultaneous cranioplasty and VPS was 140.1 days and the mean time from DC in the staged group to either DC or VPS was 61.24 days. The difference between the two groups was significant, with P = 0.003. In the staged group, 27 (73%) patients received a VPS first.
The overall complication rate was 14.3%. There were five superficial skin infections and two deep infections (one VPS infection and one subdural empyema). Overdrainage with subdural effusion was noted in two patients and resolved by adjustment of the VPS valve pressure. The overall complication rate was 15.8% in the simultaneous operation group and 13.5% in the staged operation group. No significant difference was observed between the groups.
Three (15.8%) patients experienced complications in the simultaneous group: one (5.3%) with skin infection and two (10.5%) with overdrainage. In addition, five (13.5%) patients experienced complications in the staged group: three (10.8%) with skin infections, one with CNS infections, and one with both skin and CNS infections. The two patients with CNS infections required revision surgery. One patient with subdural empyema after cranioplasty underwent debridement and removal of infected autogenous bone graft. The other patients with VPS infection underwent removal of VPS. Both patients received a full course of antibiotics treatment before they moved to subsequent operations. No significant differences in the complications were observed between the two groups.
Although we typically do not perform brain computed tomography (CT) scans at our institute after cranioplasty or VPS, there was no clinically significant ICH or IVH in our patients after surgery. [Table 2] lists detailed postoperative complications.
| Discussion|| |
DC is an important treatment option for patients with medical intractable increased ICP and is a common procedure for neurosurgeons. Consequently, cranioplasty is necessary after the patient becomes stable. Cranioplasty is indicated not only for cosmetic reasons but also for improved neurologic outcomes due to better cerebral blood flow and cortical perfusion., Hydrocephalus is one of the complications of DC, and some etiologies leading to DC are also risk factors for hydrocephalus, such as subarachnoid hemorrhage. VPS placement may be needed in approximately 17% of patients after DC. When hydrocephalus develops in patients after DC, cranioplasty, and VPS may both be needed. However, the optimal time for cranioplasty and VPS is still controversial. Compared to other elective cranial surgeries, cranioplasty has a higher postoperative infection rate.,
Performing cranioplasty and VPS at the same time are attractive because of the lower admission cost, but the safety is a major concern. We conducted this study to provide some information on the rate of postoperative complications in patients that undergo cranioplasty and VPS simultaneously and those that undergo the procedures at different times.
In our study, neither the patient demographic data nor the overall complication rates were significantly different between the two groups. Only the time from DC to the next procedure was significantly earlier in the staged group compared to the simultaneous group (P = 0.003) at 61.24 days versus 140.1 days, respectively. Most patients in the staged group underwent VPS first (73%) and cranioplasty later. The bifrontal index was also a little higher in the staged group than in the simultaneous group (0.424 vs. 0.395, respectively), although the difference was not significant (P = 0.075). One possible reason is that the neurosurgeons at our institute preferred to perform VPS first for patients with more severe hydrocephalus. The time from DC to the next procedure was significantly longer in the simultaneous group in our study and was similar to the interval in Yang's study. Postoperative infections were not significantly different in the two groups but were a little higher in the staged group. This result is different from those reported in some studies but was similar to the results obtained by Meyer et al.,,, A comparison of the complications encountered in these studies is presented in [Table 3]. Heo (2014), Patrick (2015), and Yang (2017) all reported significantly higher surgical site infection rates in the simultaneous group. The overall complications were significantly higher in Heo and Patrick's studies. In contrast to the earlier works, the latest study by Meyer showed no significant difference in infections after cranioplasty and VPS between the simultaneous and staged groups. Patrick and Yang's studies showed no significant differences in bleeding complications in both groups. Meyer's study also showed no difference in VPS obstruction, and our study showed no difference in overdrainage in both groups. At least, five studies analyzed the complications related to the timing of cranioplasty and VPS with similar sample sizes and patient demographic data. However, the results are contradictory, especially regarding infection at the surgical sites. More attention to sterile technique is warranted if the simultaneous operation is decided on.
|Table 3: Summary of postoperative complications in different studies (simultaneous vs. staged)|
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In our study, complications related to CSF circulation were only noted in the simultaneous group. Two patients presented subdural effusion on brain CT scan due to overdrainage, and this was resolved in both patients after adjusting the valve pressure of the programmable shunt. None of the patients presented with significant clinical neurologic deficits or required revision surgery. This was similar to the results obtained by Heo et al. In their study, no significant difference was found between the two groups with regard to subdural effusion, but a trend was noted, specifically, 25% in the simultaneous group and 10.5% in the staged group. One possible reason is that the change in CSF circulation due to simultaneous CP and VPS is more unpredictable than the change with staged operation. If we decide to perform the simultaneous operation, we should consider setting a higher pressure in the beginning and adjusting the pressure according to clinical and image findings to avoid complications from changes in CSF hydrodynamics.
Several limitations are worth noting because of the retrospective nature of this study. The heterogeneity of the etiology to perform DC may bias the complication rates. Selection bias exists in the decision-making process regarding simultaneous or staged operation by different neurosurgeons. In addition, this is only a small cohort at a single institute. However, this study provides some data supporting safety procedures when performing cranioplasty and VPS simultaneously.
| Conclusions|| |
The simultaneous performance of cranioplasty and VPS did not have higher complication rates in comparison to the staged performance of these two procedures in our series, either in terms of infections or complications related to changes in CSF circulation. Further randomized controlled trials are needed to determine the best solution for this issue.
We would like to thank www.enago.com for English editing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Agarwalla PK, Stapleton CJ, Ogilvy CS. Craniectomy in acute ischemic stroke. Neurosurgery 2014;74 Suppl 1:S151-62.
El Ahmadieh TY, Adel JG, El Tecle NE, Daou MR, Aoun SG, Nanney AD 3rd
, et al.
Surgical treatment of elevated intracranial pressure: Decompressive craniectomy and intracranial pressure monitoring. Neurosurg Clin N
Bohman LE, Schuster JM. Decompressive craniectomy for management of traumatic brain injury: An update. Curr Neurol Neurosci Rep 2013;13:392.
Jussen D, Marticorena S, Sandow N, Vajkoczy P, Horn P. Ultra-early decompressive hemicraniectomy in aneurysmal intracerebral hemorrhage: A retrospective observational study. Minerva Anestesiol 2015;81:398-404.
Dujovny M, Fernandez P, Alperin N, Betz W, Misra M, Mafee M, et al.
Post-cranioplasty cerebrospinal fluid hydrodynamic changes: Magnetic resonance imaging quantitative analysis. Neurol Res 1997;19:311-6.
Fodstad H, Ekstedt J, Fridén H. CSF hydrodynamic studies before and after cranioplasty. Acta Neurochir Suppl (Wien) 1979;28:514-8.
Stiver SI. Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus 2009;26:E7.
Zhou Q, Zhang SZ, Xu RX, Wang JQ, Tu YY. One-stage operation of ventriculo-peritoneal shunt and cranioplasty: Analysis of 54 cases. Di Yi Jun Yi Da Xue Xue Bao 2005;25:254-5.
Schuss P, Borger V, Güresir Á, Vatter H, Güresir E. Cranioplasty and ventriculoperitoneal shunt placement after decompressive craniectomy: Staged surgery is associated with fewer postoperative complications. World Neurosurg 2015;84:1051-4.
Fodstad H, Love JA, Ekstedt J, Fridén H, Liliequist B. Effect of cranioplasty on cerebrospinal fluid hydrodynamics in patients with the syndrome of the trephined. Acta Neurochir (Wien) 1984;70:21-30.
Panwar N, Agrawal M, Sinha VD. Postcranioplasty quantitative assessment of intracranial fluid dynamics and its impact on neurocognition cranioplasty effect: A Pilot study. World Neurosurg 2019;122:e96-107.
Halani SH, Chu JK, Malcolm JG, Rindler RS, Allen JW, Grossberg JA, et al.
Effects of cranioplasty on cerebral blood flow following decompressive craniectomy: A systematic review of the literature. Neurosurgery 2017;81:204-16.
Yang XJ, Hong GL, Su SB, Yang SY. Complications induced by decompressive craniectomies after traumatic brain injury. Chin J Traumatol 2003;6:99-103.
Yang XF, Wen L, Shen F, Li G, Lou R, Liu WG, et al.
Surgical complications secondary to decompressive craniectomy in patients with a head injury: A series of 108 consecutive cases. Acta Neurochir (Wien) 2008;150:1241-7.
de Oliveira JG, Beck J, Setzer M, Gerlach R, Vatter H, Seifert V, et al.
Risk of shunt-dependent hydrocephalus after occlusion of ruptured intracranial aneurysms by surgical clipping or endovascular coiling: A single-institution series and meta-analysis. Neurosurgery 2007;61:924-33.
Fattahian R, Bagheri SR, Sadeghi M. Development of posttraumatic hydrocephalus requiring ventriculoperitoneal shunt after decompressive craniectomy for traumatic brain injury: A systematic review and meta-analysis of retrospective studies. Med Arch 2018;72:214-9.
Chang V, Hartzfeld P, Langlois M, Mahmood A, Seyfried D. Outcomes of cranial repair after craniectomy. J Neurosurg 2010;112:1120-4.
Schuss P, Vatter H, Marquardt G, Imöhl L, Ulrich CT, Seifert V, et al.
Cranioplasty after decompressive craniectomy: The effect of timing on postoperative complications. J Neurotrauma 2012;29:1090-5.
Yang XF, Wang H, Wen L, Huang X, Li G, Gong JB, et al.
The safety of simultaneous cranioplasty and shunt implantation. Brain Inj 2017;31:1651-5.
Meyer RM 4th
, Morton RP, Abecassis IJ, Barber JK, Emerson SN, Nerva JD, et al.
Risk of complications with simultaneous cranioplasty and placement of ventriculoperitoneal shunt. World Neurosurg 2017;107:830-3.
Heo J, Park SQ, Cho SJ, Chang JC, Park HK. Evaluation of simultaneous cranioplasty and ventriculoperitoneal shunt procedures. J Neurosurg 2014;121:313-8.
[Table 1], [Table 2], [Table 3]