Immediate titanium mesh cranioplasty for treatment of post-craniotomy infections
Post-craniotomy infections are relatively infrequent but known complications of cranial surgery. Their incidence is approximately 0.5% for first-time craniotomies and rises to 1.1% for repeat craniotomies in glioma patients . In addition to repeat surgery, the risk of post-craniotomy infection is increased by duration of surgical procedure and prior radiation therapy . When they occur, they can manifest as superficial scalp infections or deeper infections including osteomyelitis, epidural abscesses, subdural empyemas, meningitis and/or intradural abscesses.
Historically, the management of non-superficial post-craniotomy infections has involved debridement of the operative cavity and removal of the bone flap, with delayed cranioplasty performed several months later . If the bone flap is of a significant size, this strategy has several significant drawbacks including a cosmetic defect that can be disfiguring, increased susceptibility to brain injury requiring use of a protective helmet, and an additional surgery for a delayed cranioplasty. Treatment regimens to avoid a delay period have included suction-irrigation antibiotic systems and retention of the infected bone flap after debridement .
In cases where an infected bone flap has been removed and a subsequent cranioplasty is necessitated, there are a number of cranioplasty materials available. Polymethylmethacrylate is an acrylic resin which can be molded and when cured, offers strength and protection similar to that of native skull . Polymethylmethacrylate, however, is associated with infection rates similar to that of autogenous/autoclaved bone cranioplasty . Hydroxyapatite, a calcium based bone cement that offers benefits of increased osteoconduction and osteointegration, is also an option. It to, however, can become infected and has also been described to cause an intense foreign body inflammatory reaction and extrusion . Another alternative, dynamic titanium mesh, has the favorable qualities of high tensile strength and biologic inertness. Multiple studies have demonstrated lower rates of infection in titanium mesh cranioplasties . Titanium spinal implants have been used in the setting of spinal pyogenic and tuberculous osteomyelitis and discitis without becoming sources of ongoing infections
