Marrone Salvatore, Costanzo Roberta, Scalia Gianluca, Iacopino Domenico Gerardo, Nicoletti Giovanni Federico, Umana Giuseppe Emmanuele
Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone," Palermo.
Department of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi,".
Surg Neurol Int. 2022 Sep 30;13:454. doi: 10.25259/SNI_746_2022. eCollection 2022.
In rare cases, chronic subdural hematoma can be a complication following cranioplasty implantation. Therefore, it can develop spontaneously or after a trauma in the underlying site of a duroplasty and represent, if compression of the brain structures, a life-threatening condition. In case of a patient with cranioplasty in polyetheretherketone (PEEK), performing a burr hole on prosthesis can represent, although unusual, an effective and safe technique for evacuation of the chronic subdural hematoma, avoiding the need to remove the prosthesis itself. Nevertheless, a rare and insidious prosthesis infection can occur, even after years.
A 54-year-old male patient, following severe traumatic brain injury, underwent a right hemispheric decompressive craniectomy associated to acute subdural hematoma evacuation and, subsequently, a PEEK cranioplasty implant with polytetrafluoroethylene (PTFE or Gore-Tex) duroplasty. About 10 years later, he experienced worsening headache with sensory alterations; therefore, he underwent a brain computed tomography scan documenting a right hemispheric chronic subdural hematoma (cSDH), expanding in subsequent radiological examinations. Because of symptoms' worsening, he underwent cSDH evacuation through a burr hole centered on the parietal region of the PEEK prosthesis, associated with mini-reopening of duroplasty. Two years after the procedure, he went to the emergency department because of the appearance of a serum-purulent material drained from the surgical site. He underwent cranioplasty removal and then started a targeted therapy to treat a triple surgical site infection, often unpredictable and totally accidental.
Based on the literature evidence, performing a burr hole on a cranial prosthesis in bone-like material such as PEEK represents a surgical procedure never performed before and in our opinion could, in selected cases, guarantee the cSDH evacuation and the treatment of intracranial hypertension, avoiding the cranioplasty removal, although there is a risk of even late surgical site infection.
在罕见情况下，慢性硬膜下血肿可能是颅骨成形术植入后的一种并发症。因此，它可自发发生或在硬脑膜成形术的潜在部位遭受创伤后出现，若压迫脑结构，则代表一种危及生命的状况。对于聚醚醚酮（PEEK）颅骨成形术的患者，在假体上钻孔虽然不常见，但可能是一种有效且安全的慢性硬膜下血肿引流技术，无需移除假体本身。然而，即使数年之后，也可能发生罕见且隐匿的假体感染。
一名54岁男性患者，在遭受严重创伤性脑损伤后，接受了与急性硬膜下血肿清除相关的右半球减压性颅骨切除术，随后植入了带有聚四氟乙烯（PTFE或戈尔泰克斯）硬脑膜成形术的PEEK颅骨成形术。大约10年后，他出现头痛加重并伴有感觉改变；因此，他接受了脑部计算机断层扫描，结果显示右半球慢性硬膜下血肿（cSDH），在随后的影像学检查中血肿扩大。由于症状加重，他通过以PEEK假体顶叶区域为中心的钻孔进行了cSDH引流，并伴有硬脑膜成形术的小范围重新打开。手术后两年，他因手术部位出现血清脓性物质而前往急诊科。他接受了颅骨成形术移除，然后开始针对性治疗三重手术部位感染，这种感染通常不可预测且完全是意外情况。
基于文献证据，在诸如PEEK等骨样材料的颅骨假体上钻孔是一种前所未有的手术操作，我们认为在某些情况下，它可以保证cSDH引流和颅内高压的治疗，避免颅骨成形术移除，尽管存在甚至是晚期手术部位感染的风险。
