Complications following cranioplasty: incidence and ...€¦ · perioperative cefazolin. We also evaluated whether post-cranioplasty hydrocephalus and reoperation for hemato-ma evacuation

J Neurosurg Volume 123 • July 2015

cliNical articleJ Neurosurg 123:182–188, 2015

Cranioplasty is more than a cosmetic repair of cra-nial defects; it is part of the rehabilitation process following a patient’s neurological injury. Recent

studies have shown that cranioplasty may improve the patient’s psychological status, social performance, and neurocognitive functioning.1,14,19,21 The factors that con-tribute to periprocedural complications, including pa-tients’ demographic information, comorbidities, surgical procedure, and under lying disease, need to be thoroughly evaluated. Previous studies that were intended to answer

these questions were limited by their design or by their sample size. Our aim was to evaluate risk factors that predispose patients to an increased risk of cranioplasty complications. Recent evidence in the literature empha-sizes patient-specific factors over surgery-specific factors as major predictors of cranioplasty complications.47,51 It is also becoming evident that surgical treatment for cranio-plasty complications is associated with additional surgical procedures.17,46 In this study, we evaluated the association between patient-specific factors and complications fol-

abbreviatioNs AED = antiepileptic drug; DHC = decompressive hemicraniectomy; DM = diabetes mellitus; SAH = subarachnoid hemorrhage; TBI = traumatic brain injury. submitted February 24, 2014. accepted September 10, 2014.iNclude wheN citiNg Published online March 13, 2015; DOI: 10.3171/2014.9.JNS14405.disclosure Dr. Tjoumakaris is a consultant at Stryker.

Complications following cranioplasty: incidence and predictors in 348 casesmario Zanaty, md,1 Nohra chalouhi, md,1 robert m. starke, md,2 shannon w. clark, md,1 cory d. bovenzi, bs,1 mark saigh, ba,1 eric schwartz, bs,1 emily s. i. Kunkel,1 alexandra s. efthimiadis-budike, bs,1 pascal Jabbour, md,1 richard dalyai, md,1 robert h. rosenwasser, md,1 and stavropoula i. tjoumakaris, md1

1Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; and 2Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia

obJect The factors that contribute to periprocedural complications following cranioplasty, including patient-specific and surgery-specific factors, need to be thoroughly assessed. The aim of this study was to evaluate risk factors that pre-dispose patients to an increased risk of cranioplasty complications and death.methods The authors conducted a retrospective review of all patients at their institution who underwent cranioplasty following craniectomy for stroke, subarachnoid hemorrhage, epidural hematoma, subdural hematoma, and trauma between January 2000 and December 2011. The following predictors were tested: age, sex, race, diabetic status, hy-pertensive status, tobacco use, reason for craniectomy, urgency status of the craniectomy, graft material, and location of cranioplasty. The cranioplasty complications included reoperation for hematoma, hydrocephalus postcranioplasty, postcranioplasty seizures, and cranioplasty graft infection. A multivariate logistic regression analysis was performed. Confidence intervals were calculated as the 95% CI.results Three hundred forty-eight patients were included in the study. The overall complication rate was 31.32% (109 of 348). The mortality rate was 3.16%. Predictors of overall complications in multivariate analysis were 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). Predictors of mortality in multivariate analysis were diabetes mellitus (OR 7.56, CI 1.56–36.58), seizures (OR 7.25, CI 1.238–42.79), bi-frontal cranioplasty (OR 5.40, CI 1.20–24.27), and repeated surgery for hematoma evacuation (OR 13.00, CI 1.51–112.02). Multivariate analysis was also applied to identify the variables that affect the development of seizures, the need for reop-eration for hematoma evacuation, the development of hydrocephalus, and the development of infections.coNclusioNs The authors’ goal was to provide the neurosurgeon with predictors of morbidity and mortality that could be incorporated in the clinical decision-making algorithm. Control of a patient’s risk factors and early recognition of complications may help practitioners avoid the exhaustive list of complications.http://thejns.org/doi/abs/10.3171/2014.9.JNS14405Key words cranioplasty complication; infection; seizure; mortality rate; cranioplasty morbidity; reoperation; hematoma

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cranioplasty complications

lowing cranioplasty surgery. We also evaluated whether some complications increase the risk of developing oth-ers. Finally, we studied factors that are associated with patient death following cranioplasty.

methodsstudy design

The Thomas Jefferson University Hospital Institutional Review Board approved the study protocol. We queried a prospectively maintained database of patients who had undergone cranioplasty at our institution between January 2000 and December 2011. The study included all patients who underwent a craniectomy for traumatic brain injury (TBI), subdural hematoma, hemorrhagic or ischemic stroke, epidural hematoma, and subarachnoid hemorrhage (SAH). The aim of the study was to identify the predic-tors of infections, seizures, hydrocephalus, and hematoma in the postoperative setting (in vascular patients specifi-cally). We selected our patients to be comparable, as much as possible, in their baseline risks and pathological entity. Therefore, we excluded patients with craniotomy for sei-zure, infectious disease, and tumors.

variables studiedPatient demographic data including age and sex were

collected, in addition to the following medical comor-bidities: smoking history, hypertension, diabetes mellitus (DM), therapeutic indication for craniectomy (reason for craniectomy), urgency of the therapeutic craniectomy, and the cranioplasty graft material. Complications related to the cranioplasty were identified as postoperative hema-toma requiring reoperation, infection of the cranioplasty graft, postcranioplasty hydrocephalus, postcranioplasty seizure, and death.

The variables were defined as follows. 1) Diabetes mellitus: any patient who has been diagnosed with DM Type 1 or Type 2. Patients were not stratified according to hemoglobin A1C level. 2) Hypertension: any patient who has been diagnosed with Stage 1 or more hyper-tension. Patients were not stratified to controlled versus uncontrolled hypertension. 3) Smoking: any patient who had smoked in the past, regardless of the number of pack-years. A patient who stopped smoking after the craniec-tomy was still counted as a smoker. 4) Graft material: categorized as autologous or synthetic. 5) Urgency of cra-niotomy: categorized into urgent versus elective. 6) Loca-tion: convexity cranioplasty, bifrontal cranioplasty, sub-occipital cranioplasty. 7) Postcranioplasty seizure: any patient who experienced a seizure after the cranioplasty operation. 8) Reoperation for hematoma: any intracra-nial hematoma that occurred after the cranioplasty and required an operation for evacuation. 9) Postcranioplasty hydrocephalus: a hydrocephalus that developed after the cranioplasty, documented by a CT scan. 10) Postcranio-plasty infection: any case of graft infection that needed to be removed or any case in which infection was suspected and antibiotic therapy was administered for more than 2 weeks, regardless of culture results. 11) Race: Caucasian, African American, Asian, and Hispanic. 12) Reason for craniectomy: SAH, TBI, nontraumatic epidural hema-

toma, nontraumatic subdural hematoma, ischemic stroke, and hemorrhagic stroke.

statistical analysisData are presented as the mean and range for con-

tinuous variables, and as frequency for categorical vari-ables. Analysis was performed using the unpaired t-test, chi-square, or Fisher exact tests as appropriate. Univari-ate analysis was used to test covariates predictive of cra-nioplasty complication. Interaction and confounding was assessed through stratification and relevant expansion co-variates. Factors that were predictive in univariate analysis (p < 0.15)2 were entered into a multivariate logistic regres-sion analysis. Probability values of ≤ 0.05 were considered statistically significant. Statistical analysis was performed with Stata version 10.0 software (StataCorp LP). Confi-dence intervals were calculated as the 95% CI.

resultsbaseline characteristics

We enrolled 348 patients in our study. Patient demo-graphic data and surgical indications are included in Table 1. The mean age (± SD) was 46.5 ± 12.7 years. The pro-portion of male patients in the study was 50.86%. The ma-jority of the patients were Caucasians (72.99%), followed by African Americans (16.09%), Hispanics (6.90%), and Asians (4.02%). Diabetic patients constituted 14.94% (52 of 348) of the study population. The proportion of patients with hypertension was 54.31% (189 of 348), and the pro-portion of smokers was 47.13% (164 of 348). The major-ity of patients received autologous bone graft (67.24%). The most common indication for craniectomy was SAH (52.01%) followed by stroke (27.01%) and TBI (18.96%).

table 1. characteristics of 348 patients who underwent cranioplasty

Variable No.Sex Male 177 Female 171Mean age (yrs) ± SD 46.5 ± 12.7Race Caucasian 254 African American 56 Hispanic 24 Asian 14Smoking status 164 smokersDiabetic status 52 patients w/ DMBlood pressure 189 patients w/ hypertension Craniectomy indication SAH 181 TBI 66 Stroke 94 EDH/SDH 7

EDH = epidural hematoma; SDH = subdural hematoma.

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predictors of overall complicationsWe studied the association between each of the follow-

ing variables—age, sex, race, hypertension, DM, smoking status, reason for craniotomy, urgency status, and cranio-plasty location—and the development of any complication postcranioplasty. The list of complications was as follows: reoperation for hematoma evacuation, postcranioplasty hydrocephalus, postcranioplasty seizures, and postcranio-plasty infection.

The overall complication rate was 31.32% (109 of 348). The mortality rate was 3.16%. Table 2 lists the proportion of each complication encountered. Univariate predictors included in multivariate analysis were age, DM, hyperten-sion, 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 hemor-rhagic stroke (OR 3.84, CI 1.93–7.63) predicted complica-tions (Table 3).

predictors of postcranioplasty hydrocephalusMultivariate logistic regression analysis identified in-

creasing age (OR 1.05, CI 1.011–1.08), therapeutic indi-cation for SAH (OR 2.04, CI 1.16–3.58), and therapeutic indication for TBI (OR 2.12, CI 1.23–3.65) as significant predictors of postcranioplasty hydrocephalus develop-ment, whereas male sex was found to have a protective effect (OR 0.39, CI 0.19–0.80) (Table 4). Smoking was as-sociated with postoperative hydrocephalus (OR 1.91, p = 0.001) in univariate analysis, but the association was no longer significant in multivariate analysis (OR 1.89, CI 0.94–3.80). The other variables (race, hypertension, DM, urgency status, graft material, cranioplasty location) did not affect the risk of hydrocephalus development in uni-variate analysis, and therefore were excluded from multi-variate analysis.

predictors of reoperation for hematoma evacuationMultivariate logistic analysis (Table 5) identified male

sex (OR 2.87, CI 1.13–7.25), African American race (OR 3.82, CI 1.50–9.72), and hypertension (OR 3.72, CI 2.93–5.30) as predictors of subsequent reoperation for hemato-ma evacuation. Right-sided hemicraniectomy was associ-ated with a higher risk in univariate analysis, but the risk was no longer significant when multivariate analysis was applied (OR 4.32, CI 0.98–19.00). Urgency status, smok-

ing, diabetic status, age, graft material, and reason for cra-niectomy were not associated with reoperation for hema-toma evacuation in univariate analysis, and were therefore excluded from the multivariate analysis.

predictors of infectionAll patients who underwent cranioplasty have received

perioperative cefazolin. We also evaluated whether post-cranioplasty hydrocephalus and reoperation for hemato-ma evacuation could affect the risk of infection, as long as these complications preceded the infection of the graft. Univariate analysis revealed that increasing age (OR 3.37, p = 0.05), DM (OR 1.84, p < 0.05), hemorrhagic stroke (OR 5.27, p < 0.05), postcranioplasty hydrocephalus (OR 1.91, p < 0.05), and reoperation for hematoma evacuation (OR 2.67, p = 0.051) were predictive of infection. Bilateral convexity cranioplasty showed a higher rate of infection when compared with suboccipital, bifrontal, and unilat-eral convexity cranioplasty (OR 12.01, p < 0.05) in uni-variate analysis. Sex, race, hypertension, smoking, graft material, and urgency status did not increase the risk of infection. In multivariate analysis (Table 6), bilateral convexity cranioplasty (OR 14.41, CI 1.52–36.66), post-cranioplasty hydrocephalus (OR 1.90, CI 0.99–3.65; p = 0.05), and hemorrhagic stroke (OR 4.33, CI 1.66–11.34) remained associated with a higher risk of infection, whereas reoperation for hematoma evacuation showed a higher trend (OR 1.90, p = 0.054) but was not statistically significant (not shown).

predictors of seizureWe excluded from the analysis any patient who had

experienced a seizure before the cranioplasty or any pa-tients who were receiving antiepileptic drugs (AEDs). The large majority of patients who were temporarily receiv-ing AEDs were no longer taking these drugs by the time of cranioplasty. Patients who were receiving long-term AEDs were excluded from the analysis, because they had experienced a seizure before cranioplasty or had a base-

table 2. postcranioplasty complications and their proportions

Authors & YearNo. of

Patients

Most Common Indication

Complications

Overall SeizuresSurgical Site Hematoma Hydrocephalus

Overall Infection

Superficial Infection

Deep Infection Death

Present study 348 SAH (52%) 31.32% 14.37% 6.90% 13.51% 26.43% 14.94% 11.49% 3.16%Broughton et al., 2014 87 TBI (46%) 30.0% 5.7% 10.3% 2.3%Lee et al., 2013 236 TBI (60.17%) 25.92% 14.81% 1.65%Wachter et al., 2013 136 TBI (38.2%) 30.1% 6.6%Gooch et al., 2009 62 TBI (66%) 33.8% 11.3%

table 3. predictor of complications on multivariate analysis

Predictors OR p Value 95% CIHypertension 1.92 0.005 1.22–3.02Increasing age 1.02 0.029 1.00–1.04Hemorrhagic stroke 3.84 <0.001 1.93–7.63




line disease (epilepsy) for which they were being treated with the drugs. Therefore, none of the patients analyzed in the seizure cohort was receiving AEDs at time of the cranioplasty surgery.

We also evaluated whether postcranioplasty infec-tion, reoperation for hematoma, and postcranioplasty hy-drocephalus affected the risk of seizures, provided they occurred before the seizure’s onset. Univariate analysis revealed the following variables to be associated with a higher risk of postcranioplasty seizure: male sex (OR 2.37, p < 0.05), older age of > 60 years (OR 1.02, p < 0.05), bifrontal and convexity cranioplasty location when com-pared with suboccipital (OR 9.43, p < 0.05), decompres-sive hemicraniectomy (DHC) for trauma (OR 3.22, p < 0.05), cranioplasty site infection (OR 4.54, p < 0.05), and reoperation for hematoma evacuation (OR 3.40, p < 0.05). Smoking, hypertension, DM, race, and urgency status did reach statistical significance. There was no difference in seizure rate between patients who had a synthetic graft and those who had an autologous bone graft. In multivari-ate analysis (Table 7), male sex (OR 2.35, CI 1.14–4.85), increasing age (OR 1.04, CI 1.01–1.07), and cranioplasty graft infection (OR 4.12, CI 2.07–8.20) were associated with a higher risk of postcranioplasty seizure develop-ment. Trauma (OR 2.18, CI 0.93–5.09; p = 0.07) and cranioplasty location (OR 2.86, CI 0.93–8.81; p = 0.06) showed a trend of increased risk but did not achieve statis-tical significance.

predictors of mortalityWe tested the following predictors: age, sex, race, dia-

betic status, hypertensive status, smoking, reason for cra-niectomy, urgency status of craniectomy, location of cra-nioplasty, graft material type, reoperation for hematoma evacuation, hydrocephalus postcranioplasty, graft infec-tion, and seizure postcranioplasty. In multivariate analysis (Table 8), only DM (OR 7.56, CI 1.56–36.58), seizures (OR 7.25, CI 1.238–42.79), bifrontal cranioplasty (OR 5.40, CI 1.20–24.27), and repeated surgery for hematoma evacua-tion (OR 13.00, CI 1.51–112.02) predicted death.

discussionoverview of cranioplasty complications

Cranioplasty is associated with a relatively high overall complication rate, estimated between 15% and 36.5%.8,10,

13,17,27,30,35,39,41,47,49 Furthermore, 25%–76% of patients with postcranioplasty complications may need additional pro-cedures to correct these complications.17,46 Therefore it is of paramount importance to understand, prevent, and treat the complications as they arise. The overall complication rate in our study was relatively high because the list of complications that we included was more exhaustive than in previous series. Another reason is that the definition of infected cranioplasty was not limited to cases that re-quired reoperation. The complications in our study were as follows: postcranioplasty hydrocephalus, reoperation for hematoma evacuation, superficial and deep infection, new-onset seizure, and death. We did not include subga-leal fluid collection, bone desorption, and wound dehis-cence that was not due to infection. The most common cause of craniectomy was SAH, followed by stroke, and then by TBI (the last being the most common cause of DHC in the literature).3,7,17,39,42,51 The aim of this study was to determine the most important predictors of complica-tions and death.

Patient-specific and surgery-specific factors are his-torically reported to be the most important determinant of complications following cranioplasty. Recently, most stud-ies have reported limited contributions of surgery-specific factors or implant material on the overall complication rate following cranioplasty. In addition, the data on time interval have been contradictory. Predictors of mortality have not been previously thoroughly examined. In our study, in addition to demographic data, we included in the analysis smoking status, hypertension, DM, the reason for cranioplasty, the urgency of the procedure, and graft type.

demographic information and associated comorbiditiesWe found that increased age and hypertension were as-

table 4. multivariate analysis of hydrocephalus predictors

Predictors OR p Value 95% CI

Male sex 0.39 0.010 0.19–0.80Increasing age 1.05 0.004 1.011–1.08Smoking 1.89 0.073 0.94–3.80SAH 2.04 0.013 1.16–3.58TBI 2.12 0.007 1.23–3.65

table 5. multivariate predictors of reoperation for hematoma


Male sex 2.87 0.026 1.13–7.25African American race 3.82 0.005 1.50–9.72Convexity hemicraniectomy 4.32 0.060 0.98–19.00Hypertension 3.72 <0.001 2.93–5.30

table 6. multivariate predictors of infection


Bilat convexity cranioplasty 14.41 0.020 1.52–36.66Hemorrhagic stroke 4.33 0.003 1.66–11.34Hydrocephalus* 1.90 0.050 0.99–3.65Older age (>65 yrs) 0.27 0.050 0.07–1.00

* Hydrocephalus that appeared after cranioplasty.

table 7. multivariate analysis of seizure development


Male sex 2.35 0.020 1.14–4.85Increasing age 1.04 0.005 1.01–1.07Infection 4.12 0.000 2.07–8.20Trauma 2.18 0.072 0.93–5.09Bifrontal & convexity cranioplasty 2.86 0.067 0.93–8.81



m. Zanaty et al.

sociated with higher risk of complications. Smoking was associated with an increased risk of hydrocephalus devel-opment in univariate analysis, and showed a strong trend in multivariate analysis. A recent study by Wachter et al. identified smoking and older age (> 60 years) as factors as-sociated with cranioplasty complications.46 These authors did not find sex to be a significant variable. We found that diabetic patients had a higher risk of death. Male patients had a higher rate of seizure, whereas females had a higher risk of hydrocephalus. Older age was also associated with seizure and hydrocephalus. Neurosurgeons should there-fore recognize these factors (age, sex, DM, and smoking) as possible predictors of postoperative complications and take all necessary preventive measures.

location of cranioplastyPatients with convexity cranioplasty had a higher risk

of infections and postoperative hematoma requiring reop-eration for evacuation when compared with bifrontal and suboccipital cranioplasties. We also found bifrontal cra-nioplasty to be associated with a higher risk of both sei-zure and death. Bifrontal defect was identified by Gooch et al.17 to be the only location significantly associated with cranioplasty complications. The authors postulated sev-eral reasons for this finding, such as a longer incision, a longer operative time, less soft-tissue coverage, and a pos-sible violation of the frontal sinus. Indeed, frontal sinus breach has been reported to increase the risk of infection after cranioplasty.6,28

timing, infection, and hydrocephalusThe timing of surgery is one of the most controversial

topics in cranioplasty.4,11 Some studies have shown that pa-tients who had early cranioplasties had better functional outcomes,3,5,46 whereas several others have shown that early cranioplasty (3–6 months) is associated with higher complication rates and worse outcomes,3,4,8–10,26,35,42 includ-ing hydrocephalus, increased intracranial pressure, and infection. Other studies have shown that late cranioplasty is associated with a higher risk of complications.17,38,42,48 Finally, recent studies, including a meta-analysis, have shown no difference in complication rates between early and late cranioplasties.5,24,39,51 We did not account for the timing of cranioplasty in our study because our patients underwent early operation unless there was a convinc-ing need to delay it, such as the presence of wound de-hiscence, hydrocephalus, or evidence of persistent brain swelling. We balanced the wait for maximal neurological improvement with early intervention to prevent hemody-namic changes in the CSF and cerebral blood flow that

may occur if the flap was left out for a prolonged period of time.5 Still, the large majority of our patients have under-gone early cranioplasty (within 3 months). We found no significant association of age, sex, DM, and mechanism of injury (SAH, trauma, ischemic stroke) with postcranio-plasty infection, which is consistent with the published lit-erature.22,29 Reoperation for hematoma showed no signifi-cant effect in our study, even though the need for multiple procedures has been shown to increase the risk of cranio-plasty site infection.29,43,47 On the other hand, Cheng et al.’s work9 showed that the number of procedures does not af-fect the risk of graft infection following cranioplasty.

We found hemorrhagic stroke to be predictive of in-fection. One reason would be shared risk factors between stroke and infection, such as DM and smoking.15,45 Even though it has been proven that DM50 and smoking40 in-crease the risk of surgical infection, the association did not achieve statistical significance in our study. We believe that the lack of a significant effect of smoking and DM might be related to the fact that stratification did not ac-count for present and past smokers, as well as controlled and uncontrolled DM. In many of our patients their DM was controlled, and many had quit smoking after experi-encing a stroke or an SAH. Quitting smoking and control-ling DM have been well known to decrease the patient’s risk of developing postsurgery infection.16,32 Cranioplasty has been reported to contribute to the development of per-sistent hydrocephalus requiring permanent CSF flow di-version.48 We found that female sex, increasing age, and craniectomy for SAH increased the risk of postcranioplas-ty hydrocephalus.

postcranioplasty hemorrhagePostcranioplasty hemorrhage includes epidural, sub-

dural, and intraparenchymal hematomas that required reoperation.6,17,36 Postcranioplasty hemorrhage has been previously explained by many mechanisms, the most im-portant of which is persistent bleeding by a scalp artery,36 along with a negative transluminal pressure caused by a subgaleal drain.37 Gooch and colleagues17 found that bi-frontal cranial defect was associated with a need for re-operation, including infection and hematoma evacuation. The authors, however, only studied the complications that occurred within 30 days of surgery. In our study, convex-ity location showed a trend of higher risk of reoperation for hematoma evacuation when compared with suboccipi-tal and bifrontal locations. Other significant risk factors in multivariate analysis were male sex and African American race. Although this finding may be due to the presence of hypertension, this factor was controlled for in multivariate analysis, which suggests that male sex and African Ameri-can race are independent predictors of hemorrhage. The problem with subjecting a patient to another surgery is the increased risk of further complications8 and the increased length of hospital stay. Indeed, in our study, patients un-dergoing another operation for hematoma evacuation had a significantly higher mortality rate.

postcranioplasty seizuresSeizures that follow cranioplasty surgery might be the

table 8. multivariate analysis of predictors of mortality


DM 7.56 0.012 1.56–36.58Bifrontal cranioplasty 5.40 0.028 1.20–24.27Postcranioplasty seizures 7.25 0.029 1.238–42.79Reop for hematoma evacuation 13.00 0.020 1.51–112.02




result of the underlying cause, the DHC surgery, or the cranioplasty operation itself. Surgery might produces free radicals, disturb the ionic balance, and manipulate the ce-rebral parenchyma, all of which have been postulated as mechanisms for postoperative seizure formation.25,48 In the literature, TBI, hemorrhagic stroke, and neurological defi-cits before cranioplasty increased the risk of seizures.25 In our study, we found that male sex, cranioplasty infection, and older age were significantly associated with seizures. Furthermore, seizure itself was significantly associated with death. On univariate analysis, reoperation for hema-toma evacuation was a predictor of seizure (OR 3.40, p < 0.05), but the association was no longer significant on multivariate analysis. Male sex and older age have been described as independent factors for first adult seizure in the general population.18,20,23,31,44

other predictorsGraft material (synthetic vs autologous) failed to show

any significant association with seizure, infection, death, or any other complication. The Glasgow Coma Scale, pre-operative Barthel Index, and the Coma Remission Scale may predict the risk of cranioplasty complications.5,46 Even though the risk of infection with autologous graft can get relatively high (up to 33%),12,33,34,52 many studies, including ours, suggest no difference in the infection rate between synthetic and autologous grafts.9,47

limitations and strengths of the studyThe limitations of this study are the retrospective de-

sign; a possible selection bias; and the lack of stratifica-tion of diabetic, smoker, and hypertensive patients. The study also did not include any surgery-specific risk factor. We did not study the association between the timing of cranioplasty and outcomes, although this might affect the results. The strength of the study is the long-term follow-up and the large size of the cohort, allowing for a robust statistical analysis. Both the long follow-up and the large number of patients allowed the evaluation of rare compli-cations.

conclusionsCranioplasty complications include infections, hydro-

cephalus, multiple operations, seizures, and even death. The independent predictors of mortality in the present series were DM, postcranioplasty seizure, reoperation for hematoma evacuation, and therapeutic indication for hemorrhagic stroke. Male sex could predispose a patient to seizures and additional operations. African American race also seemed to play a role in the development of hematoma requiring operation. Other important findings were the as-sociation of bilateral convexity cranioplasty with infec-tions. Finally, old age was a predictor of postcranioplasty seizure. Our goal was to provide the neurosurgeon with predictors of morbidity and mortality that could be incor-porated in the clinical decision-making algorithm. Control of the patient’s risk factors and early recognition of com-plications may help avoid the exhaustive list of complica-tions. Prospective multicenter trials are needed to settle the controversial question of risk factors.

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author contributionsConception and design: Tjoumakaris, Chalouhi, Starke, Clark, Jabbour, Rosenwasser. Acquisition of data: Zanaty, Clark, Boven-zi, Saigh, Schwartz, Kunkel, Efthimiadis-Budike, Dalyai. Analy-sis and interpretation of data: Zanaty, Chalouhi, Starke, Bovenzi, Saigh, Schwartz, Kunkel, Efthimiadis-Budike. Drafting the article: Tjoumakaris, Zanaty. Critically revising the article: Tjou-makaris, Chalouhi. Reviewed submitted version of manuscript: Zanaty, Chalouhi, Starke, Clark, Bovenzi, Saigh, Schwartz, Kun-kel, Efthimiadis-Budike, Jabbour, Dalyai, Rosenwasser. Statisti-cal analysis: Starke. Study supervision: Tjoumakaris, Jabbour.

correspondenceStavropoula I. Tjoumakaris, Department of Neurological Surgery, Division of Neurovascular Surgery and Endovascular Neurosur-gery, Thomas Jefferson University Hospital, 901 Walnut St., 3rd Fl., Philadelphia, PA 19107. email: [email protected].



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Complications following cranioplasty: incidence and ...€¦ · perioperative cefazolin. We also evaluated whether post-cranioplasty hydrocephalus and reoperation for hemato-ma evacuation