Early combined cranioplasty and programmable shunt in patients with skull bone defects and CSF-circulation disorders

OBJECTIVE: This study assesses the clinical outcome after early combined cranioplasty (own frozen bone) and shunt implantation (Codman-Medos programmable VP shunt) in patients with skull bone defects and cerebrospinal fluid (CSF) circulation disorders. METHOD: Medical records were reviewed retrospectively for the last 100 patients with CSF disorders after trauma or subarachnoid hemorrhage (SAH), who previously underwent decompressive craniotomy owing to therapy-resistant brain swelling. Patients treated with early (5 to 7 weeks after injury) combined cranioplasty and shunt implantation were analysed and a follow-up for the survivors was obtained. RESULTS: In 60 patients with a daily CSF external drainage over 150 ml and dilated ventricles in CT scan, a programmable VP shunt was implanted simultaneously with the cranioplasty within 5.1 weeks after decompression. The neurological condition 6 months later was good (independent patients) in 39 cases (65%); 12 patients (20%) survived with a severe disability; three patients (5%) remained in a persistent vegetative state and only six patients (10%) died. There were few complications: bone or shunt infection (three cases), post-operative intracranial bleeding (one case), transitory neurological impairment after bone reimplantation (two cases), bone resorption (two cases) and shunt dysfunction (three cases). CONCLUSION: The early reimplantation of the patient's own skull bone combined to the employment of a programmable shunt system allowed us a dynamic adjustment of the intracranial pressure (ICP) changes. The combined treatment reduced the number of required surgical procedures, complications and unsatisfactory patient outcomes.