Abstract
Cranioplasty is often undertaken as a joint neurosurgical and maxillofacial procedure. The principal aims remain to improve cosmesis and to protect the underlying brain. We report two cases of cranioplasty with subsequent improvement in neurological function and discuss the possible therapeutic role of cranioplasty.
Introduction
Cranioplasty is a procedure with a well-documented history. Defects of the cranial vault can occur secondary to bone loss from trauma, infections, or tumours.
The reasons for restoration of skull vault continuity are predominantly cited as improved cosmesis and brain protection. More contentious is the role of cranioplasty in the treatment of neurological symptoms attributed to syndrome of the trephined post craniectomy.
In 1945, Gardener noted a group of symptoms in patients with large cranial defects. He called this ‘the syndrome of the trephined’ and reported that the headaches, dizziness, irritability, seizures, discomfort, and psychiatric symptoms seen in these patients improved after cranioplasty. Similarly in 1977, Yamaura and Makino described improved neurological symptoms after cranioplasty to correct depression in the skin flap after cerebral decompression. They coined this ‘the sinking skin flap syndrome’ and the term is synonymous with syndrome of the trephined.
Although well documented in the neurosurgical literature, syndrome of the trephined is less well reviewed in oral and maxillofacial surgical texts. With increasing multidisciplinary care of patients and the involvement of maxillofacial surgeons in cranial vault reconstruction, the potential therapeutic role of cranioplasty is discussed. We present two cases where cranioplasty primarily for cosmesis and brain protection led to an improvement in neurological symptoms.
Case reports
A 48-year-old woman presented with a large right parietal cranial defect following previous parasagittal meningioma removal and removal of an infected bone flap ( Figs. 1 and 2 ).
She suffered from regular focal sensory seizures affecting the left upper limb, poorly controlled with lamotrigine and carbamazepine. Additionally she had generalized left-sided weakness requiring support to walk.
She underwent reconstruction with a polyether ether ketone (PEEK)-based cranial implant. Surgery and post-operative recovery were uneventful. After an initial transient increase in seizure activity, at 2 weeks she reported significantly fewer seizures and improved muscle strength. At 6 weeks, she had been seizure-free for 2 weeks and muscle strength had subjectively and objectively improved to allow her to be ambulatory with a stick. At 10 months post-operatively, the improvement remained and no surgical complications were noted ( Fig. 3 ).
A 79-year-old man presented with a frontal craniectomy after previous resection of a frontal meningioma ( Figs. 4 and 5 ). A previous reconstruction with a split calvarial bone graft became infected and was removed. He suffered from generalized tonic clonic seizures, treated with phenytoin. He remained confused with a Glasgow coma scale (GCS) score of 13–14 (E4, V3/4, M6) and no focal neurology.
Reconstruction of the cranial vault was performed with a prefabricated PEEK implant ( Fig. 6 ). At 8 weeks, the patient had improved to GCS 15 with no change in his epilepsy. On review at 4 months, GCS remained at 15 and there were no signs of infection or skin disturbance related to the PEEK implant.
