J Neurol Surg A Cent Eur Neurosurg 2018; 79(03): 200-205
DOI: 10.1055/s-0037-1604362
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Outcomes of Cranioplasty with Preformed Titanium versus Freehand Molded Polymethylmethacrylate Implants

Julius Höhne
1   Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
,
Korbinian Werzmirzowsky
1   Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
,
Christian Ott
1   Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
,
Christoph Hohenberger
1   Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
,
Bahaa Ghareb Hassanin
1   Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
2   Department of Neurosurgery, Sohag University Faculty of Medicine, Sohag, Egypt
,
Alexander Brawanski
1   Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
,
Karl-Michael Schebesch
1   Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
› Author Affiliations
Further Information

Publication History

31 December 2016

24 May 2017

Publication Date:
11 August 2017 (online)

Abstract

Objective Cranioplasty reshapes the neurocranium and viscerocranium after craniectomy. Different materials have been used for cranioplasty. However, no consistent data are yet available comparing these different materials regarding indications, complications, and outcome. We report our experience with preformed titanium implants and freehand molded polymethylmethacrylate (PMMA) implants for cranioplasty.

Methods This retrospective single-center analysis included 120 consecutive cranioplasty patients who had been operated between 2006 and 2013. A total of 60 patients (27 women, 33 men; mean age: 54 years) had received a preformed titanium implant and 60 patients (22 women, 38 men; mean age: 46 years) a freehand molded PMMA implant. We evaluated all demographic and procedure-related data, indications, and outcome. The longest follow-up was 5.5 years.

Results The most frequent indications for cranioplasty were trauma (n = 48 [40%]), malignant infarction (n = 27 [23%]), tumor (n = 22 [18%]), spontaneous intracerebral or aneurysmal subarachnoid hemorrhage (n = 16 [13%]), revision surgery (n = 5 [4%]), and empyema (n = 2 [2%]). PMMA implants were more often associated with wound-healing disorders (p < 0.023; odds ratio [OR]: 10.53) and epidural hematoma (p < 0.03; OR: 8.46), resulting in a significantly higher re-operation rate (p < 0.005). Precise fitting was radiologically confirmed in 98% of titanium implants but in only 71% of PMMA implants (p < 0.001). Magnetic resonance imaging of patients with titanium implants (n = 4) did not show any relevant artifacts.

Conclusion Cranioplasty with preformed titanium implants seems to be superior to freehand molded PMMA implants regarding surgical morbidity, revision rate, and aesthetic results.

 
  • References

  • 1 Vahedi K, Hofmeijer J, Juettler E. , et al; DECIMAL, DESTINY, and HAMLET investigators. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 6 (03) 215-222
  • 2 Vahedi K, Vicaut E, Mateo J. , et al; DECIMAL Investigators. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 2007; 38 (09) 2506-2517
  • 3 Rahme R, Zuccarello M, Kleindorfer D, Adeoye OM, Ringer AJ. Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living?. J Neurosurg 2012; 117 (04) 749-754
  • 4 Jüttler E, Unterberg A, Woitzik J. , et al; DESTINY II Investigators. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 2014; 370 (12) 1091-1100
  • 5 Timofeev I, Kirkpatrick PJ, Corteen E. , et al. Decompressive craniectomy in traumatic brain injury: outcome following protocol-driven therapy. Acta Neurochir Suppl (Wien) 2006; 96: 11-16
  • 6 Cooper DJ, Rosenfeld JV, Murray L. , et al; DECRA Trial Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 2011; 364 (16) 1493-1502
  • 7 Jiang JY, Xu W, Li WP. , et al. Efficacy of standard trauma craniectomy for refractory intracranial hypertension with severe traumatic brain injury: a multicenter, prospective, randomized controlled study. J Neurotrauma 2005; 22 (06) 623-628
  • 8 Hutchinson PJ, Corteen E, Czosnyka M. , et al. Decompressive craniectomy in traumatic brain injury: the randomized multicenter RESCUEicp study ( www.RESCUEicp.com ). Acta Neurochir Suppl (Wien) 2006; 96: 17-20
  • 9 Gouello G, Hamel O, Asehnoune K, Bord E, Robert R, Buffenoir K. Study of the long-term results of decompressive craniectomy after severe traumatic brain injury based on a series of 60 consecutive cases. Sci World J 2014; 2014: 207585
  • 10 Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB. ; HAMLET investigators. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 2009; 8 (04) 326-333
  • 11 Jüttler E, Schwab S, Schmiedek P. , et al; DESTINY Study Group. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 2007; 38 (09) 2518-2525
  • 12 Adeoye O, Hornung R, Khatri P, Ringer A, Kleindorfer D. The rate of hemicraniectomy for acute ischemic stroke is increasing in the United States. J Stroke Cerebrovasc Dis 2011; 20 (03) 251-254
  • 13 Honeybul S, Janzen C, Kruger K, Ho KM. Decompressive craniectomy for severe traumatic brain injury: is life worth living?. J Neurosurg 2013; 119 (06) 1566-1575
  • 14 Zanaty M, Chalouhi N, Starke RM. , et al. Complications following cranioplasty: incidence and predictors in 348 cases. J Neurosurg 2015; 123 (01) 182-188
  • 15 Piitulainen JM, Kauko T, Aitasalo KM, Vuorinen V, Vallittu PK, Posti JP. Outcomes of cranioplasty with synthetic materials and autologous bone grafts. World Neurosurg 2015; 83 (05) 708-714
  • 16 Sobani ZA, Shamim MS, Zafar SN. , et al. Cranioplasty after decompressive craniectomy: an institutional audit and analysis of factors related to complications. Surg Neurol Int 2011; 2: 123
  • 17 Gooch MR, Gin GE, Kenning TJ, German JW. Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases. Neurosurg Focus 2009; 26 (06) E9
  • 18 Reddy S, Khalifian S, Flores JM. , et al. Clinical outcomes in cranioplasty: risk factors and choice of reconstructive material. Plast Reconstr Surg 2014; 133 (04) 864-873
  • 19 Chang V, Hartzfeld P, Langlois M, Mahmood A, Seyfried D. Outcomes of cranial repair after craniectomy. J Neurosurg 2010; 112 (05) 1120-1124
  • 20 Luo J, Liu B, Xie Z. , et al. Comparison of manually shaped and computer-shaped titanium mesh for repairing large frontotemporoparietal skull defects after traumatic brain injury. Neurosurg Focus 2012; 33 (01) E13
  • 21 Wachter D, Reineke K, Behm T, Rohde V. Cranioplasty after decompressive hemicraniectomy: underestimated surgery-associated complications?. Clin Neurol Neurosurg 2013; 115 (08) 1293-1297
  • 22 Höhne J, Brawanski A, Gassner HG, Schebesch KM. Feasibility of the custom-made titanium cranioplasty CRANIOTOP(®). Surg Neurol Int 2013; 4: 88
  • 23 Schebesch KM, Höhne J, Gassner HG, Brawanski A. Preformed titanium cranioplasty after resection of skull base meningiomas—a technical note. J Craniomaxillofac Surg 2013; 41 (08) 803-807
  • 24 Park JS, Lee KS, Shim JJ, Yoon SM, Choi WR, Don JW. Large defect may cause infectious complications in cranioplasty. J Korean Neurosurg Soc 2007; 42 (02) 89-91
  • 25 Schwarz F, Dünisch P, Walter J, Sakr Y, Kalff R, Ewald C. Cranioplasty after decompressive craniectomy: is there a rationale for an initial artificial bone-substitute implant? A single-center experience after 631 procedures. J Neurosurg 2016; 124 (03) 710-715
  • 26 Honeybul S, Morrison DA, Ho KM, Lind CR, Geelhoed E. A randomized controlled trial comparing autologous cranioplasty with custom-made titanium cranioplasty. J Neurosurg 2017; 126 (01) 81-90
  • 27 Marchac D, Greensmith A. Long-term experience with methylmethacrylate cranioplasty in craniofacial surgery. J Plast Reconstr Aesthet Surg 2008; 61 (07) 744-752 ; discussion 753
  • 28 Cabraja M, Klein M, Lehmann TN. Long-term results following titanium cranioplasty of large skull defects. Neurosurg Focus 2009; 26 (06) E10
  • 29 Schuss P, Vatter H, Marquardt G. , et al. Cranioplasty after decompressive craniectomy: the effect of timing on postoperative complications. J Neurotrauma 2012; 29 (06) 1090-1095
  • 30 Hill CS, Luoma AM, Wilson SR, Kitchen N. Titanium cranioplasty and the prediction of complications. Br J Neurosurg 2012; 26 (06) 832-837
  • 31 Lindner D, Schlothofer-Schumann K, Kern BC, Marx O, Müns A, Meixensberger J. Cranioplasty using custom-made hydroxyapatite versus titanium: a randomized clinical trial. J Neurosurg 2017; 126 (01) 175-183
  • 32 Wiggins A, Austerberry R, Morrison D, Ho KM, Honeybul S. Cranioplasty with custom-made titanium plates—14 years experience. Neurosurgery 2013; 72 (02) 248-256 ; discussion 256
  • 33 Al-Tamimi YZ, Sinha P, Trivedi M. , et al. Comparison of acrylic and titanium cranioplasty. Br J Neurosurg 2012; 26 (04) 510-513
  • 34 Kim H, Sung SO, Kim SJ, Kim SR, Park IS, Jo KW. Analysis of the factors affecting graft infection after cranioplasty. Acta Neurochir (Wien) 2013; 155 (11) 2171-2176
  • 35 Im SH, Jang DK, Han YM, Kim JT, Chung DS, Park YS. Long-term incidence and predicting factors of cranioplasty infection after decompressive craniectomy. J Korean Neurosurg Soc 2012; 52 (04) 396-403
  • 36 Thavarajah D, De Lacy P, Hussien A, Sugar A. The minimum time for cranioplasty insertion from craniectomy is six months to reduce risk of infection—a case series of 82 patients. Br J Neurosurg 2012; 26 (01) 78-80
  • 37 Coulter IC, Pesic-Smith JD, Cato-Addison WB. , et al. Routine but risky: a multi-centre analysis of the outcomes of cranioplasty in the Northeast of England. Acta Neurochir (Wien) 2014; 156 (07) 1361-1368
  • 38 Lee L, Ker J, Quah BL, Chou N, Choy D, Yeo TT. A retrospective analysis and review of an institution's experience with the complications of cranioplasty. Br J Neurosurg 2013; 27 (05) 629-635
  • 39 Jaberi J, Gambrell K, Tiwana P, Madden C, Finn R. Long-term clinical outcome analysis of poly-methyl-methacrylate cranioplasty for large skull defects. J Oral Maxillofac Surg 2013; 71 (02) e81-e88
  • 40 Joffe J, Harris M, Kahugu F, Nicoll S, Linney A, Richards R. A prospective study of computer-aided design and manufacture of titanium plate for cranioplasty and its clinical outcome. Br J Neurosurg 1999; 13 (06) 576-580
  • 41 Giese H, Sauvigny T, Sakowitz OW. , et al. German Cranial Reconstruction Registry (GCRR): protocol for a prospective, multicentre, open registry. BMJ Open 2015; 5 (09) e009273
  • 42 Chandler CL, Uttley D, Archer DJ, MacVicar D. Imaging after titanium cranioplasty. Br J Neurosurg 1994; 8 (04) 409-414