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LETTER TO THE EDITOR
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Spontaneous calvarial regeneration following decompressive craniectomy obviating need for cranioplasty: A serendipitous occurrence


1 Department of Neurosurgery, National Neurosciences Centre, Kolkatta, West Bengal, India
2 Department of Neuroanesthesiology, National Neurosciences Centre, Kolkatta, West Bengal, India

Date of Submission11-May-2020
Date of Decision04-Jul-2020
Date of Acceptance02-Aug-2020
Date of Web Publication02-Jul-2021

Correspondence Address:
Prasad Krishnan,
National Neurosciences Centre, Peerless Hospital Campus, 2nd Floor, 360 Panchasayar, Kolkata 700094, West Bengal.
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpn.JPN_115_20

 




How to cite this URL:
Raju D, Aditya G, Ray A, Ghosh N, Krishnan P. Spontaneous calvarial regeneration following decompressive craniectomy obviating need for cranioplasty: A serendipitous occurrence. J Pediatr Neurosci [Epub ahead of print] [cited 2021 Nov 28]. Available from: https://www.pediatricneurosciences.com/preprintarticle.asp?id=320377




A 15-year-old boy presented following a road traffic accident in an unconscious state with no eye opening or verbal response. He was decerebrating on pain and the right pupil was larger than the left though both were reacting to light. Computed tomography (CT) scans revealed a large right frontal extradural hematoma with mass effect and midline shift. The basal cisterns were effaced [Figure 1]A. He underwent right frontal craniotomy with the removal of the extradural hematoma followed by stellate durotomy (to allow space for brain expansion). This was followed by a duraplasty using pericranium (which was harvested as a pedicled flap at the time of exposure). The bone flap was not replaced and stored in vitro. The boy had an uneventful postoperative recovery. CT scan done at the time of discharge showed no pseudomeningocele or residual clot [Figure 1]B and [Figure 1]C.
Figure 1: CT scan images showing (A) large right frontal extradural hematoma with significant mass effect and midline shift. (B) Postoperative image at the time of discharge showing that decompressive craniotomy has been done and there is no residual clot. (C) 3D reconstruction of the skull showing extent of bone defect

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Three months later he was readmitted for cranioplasty but a CT scan revealed that patchy new bone formation had already started at the operative site [Figure 2]A–[C]. Suspecting that this process might continue, cranioplasty was deferred and he was reviewed with repeat imaging after a further six months [Figure 2]D–[F]. The bone had significantly reformed and even the contour was similar to what might have been achieved by cranioplasty with autologous bone. A repeat imaging done after 1 year showed still further remodeling and new bone formation.
Figure 2: CT scans 3 months later (A, B, and C) showing patchy areas of bone formation and CT scans 6 months after the initial surgery (D, E, and F) showing significant reconstruction of the almost whole of the craniotomy––axial, coronal, and 3D reconstructions shown

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Osteogenesis in cranial defects and following cranial osteonecrosis has been documented in experiments in animals[1],[2] where both dura and pericranium have been found to be responsible for laying down new bone more so if they were in contact with each other. Only two case reports of a similar occurrence after decompressive craniectomy for trauma[3],[4] could be found in literature––curiously both in young patients. One of these was in an 18-year-old patient who had undergone bilateral decompressive craniectomies[3] while the other was in a 6-year-old child who had undergone a bifrontal decompressive craniotomy.[4] In the first case[3] (as opposed to ours) duraplasty had incorporated artificial dural substitutes and in both[3],[4] the calcifications too were also not dense enough to preclude cranioplasty as in ours.

Specs of calcification are often found on imaging prior to and also intraoperatively during cranioplasty. The propensity in young children for ossifying calvarial defects has also been described.[3]

The rarity of our finding of near-complete regeneration of bone may be due to the following reasons––(1) nowadays artificial dural substitutes being increasingly instead of locally harvested pericranium for a lax duraplasty and these may not act as a substrate for new bone formation; (2) often circumferential durotomy (removal of dura in a circular fashion near the margins of the cranial defect) is done rather than stellate durotomy (which is what we had done) and in the former the dura which has potential for new bone formation is lost and finally (3) there is a trend towards early cranioplasties (within 3 months of decompressive craniotomy that is believed to enhance cognitive recovery[5]) which may be performed before the new bone formation can be appreciated to its fullest extent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gosain AK, Santoro TD, Song LS, Capel CC, Sudhakar PV, Matloub HS. Osteogenesis in calvarial defects: contribution of the dura, the pericranium, and the surrounding bone in adult versus infant animals. Plast Reconstr Surg 2003;112:515-27.  Back to cited text no. 1
    
2.
Ozerdem OR, Anlatici R, Bahar T, Kayaselçuk F, Barutçu O, Tuncer I, et al. Roles of periosteum, dura, and adjacent bone on healing of cranial osteonecrosis. J Craniofac Surg 2003;14:371-9; discussion 380-2.  Back to cited text no. 2
    
3.
Vega RA, Hutchins L. Heterotopic ossification of the calvarium following bilateral craniectomies in traumatic brain injury. Ochsner J 2017;17:118-20.  Back to cited text no. 3
    
4.
Guida L, Mazzoleni F, Bozzetti A, Sganzerla E, Giussani C. Extensive dural ossification after decompressive posttraumatic craniectomy: a case report and review of the literature. World Neurosurg 2018;120:59-62.  Back to cited text no. 4
    
5.
Bjornson A, Tajsic T, Kolias AG, Wells A, Naushahi MJ, Anwar F, et al. A case series of early and late cranioplasty-comparison of surgical outcomes. Acta Neurochir (Wien) 2019;161:467-72.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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