Additional Information added by Author:

Patient had a history of a gunshot wound to the head (accidental) when she was 5 yo requiring emergent decompressive craniectomy. Three months later after stabilization, the neurosurgeon replaced the bone flap back. She was followed clinically and over the next year and half some of that bone resorbed, leaving the underlying dura uncovered by bone, with pulsations apparent through the scalp. The decision was made now to perform a cranioplasty to establish calvarial continuity.

Reason for the indicationrion for PMMA instead of bone grafts in this case: The discussion was had with the parents about variety of material and the choice was made to use exogenous material partially because of family preference but partly because of surgeon preference for something with little chance of resorption, and to only use the DBX for the smaller more irregular areas of defect, but a custom implant for the larger defect.

Titantium plates were used to fixate the PMMA implant, but resorbable where absorbable plates were used a scaffold to hold the thin layer of DBX in place.

Relief of symptoms; avoid complications related to trauma to the skull, prevent traumatic brain injury, skull defect

bleeding disorders

Mayfield head rest, supine, intubation with oral ray secured down the midline and secured to chin, 2 large bore IVs, arterial line, foley cath, sphinx pillow / positioning (hip abduction pillow modified as shown in the video), padding to avoid pressure, bone-wax and thrombin available, blood & FFP available

History & physical, CBC, basic metabolic panel, PT/PTT, INR, anesthesiology evaluation for ASA class, low dose radiation 3D CT 1mm cuts head-to-hyoid

Scalp anatomy: skin, subcutaneous tissue, galea, periosteum, skull bone. Incision down to bone through periosteum must be mindful of any thin bone or cranial defects where dura is exposed. Identify cranial sutures: coronal and sagittal at the fontanelles. The major cerebral sinuses must be avoided and the dura carefully dissected free of the cranial sutures where it tends to be more adherent.

a. Advantages: Relief of symptoms
b. Disadvantages: Blood loss

bleeding, infection, damage to dura mater leading to CSF leak, bone fragments

bleeding, infection, damage to dura mater leading to CSF leak, bone fragments

Kumar Patel and Michael Golinko