Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Cranioplasty

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] s/p prior [decompressive craniectomy/craniectomy] [weeks/months] ago with a [location] cranial defect planned for cranioplasty with [autologous bone flap / custom PEEK or titanium / PMMA] implant.

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

External sources — operative figures/atlases are copyrighted (linked, not copied). See media-sources.md for licensing.

Operative technique & approach

Imaging

Open-access figures

Bones of the skull — lateral view

Sobotta 1909 — public domain — via Wikimedia Commons. Relevant to calvarian defect anatomy and cranial bone landmarks.

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Cranioplasty — Figure 1 Figure 1. Source: Which One Is Better to Reduce the Infection Rate, Early or Late Cranioplasty? — J Korean Neurosurg Soc. 2016 Sep 8;59(5):492–7. doi: 10.3340/jkns.2016.59.5.492; CC BY-NC.

Cranioplasty — Figure 2 Figure 2. Source: Which One Is Better to Reduce the Infection Rate, Early or Late Cranioplasty? — J Korean Neurosurg Soc. 2016 Sep 8;59(5):492–7. doi: 10.3340/jkns.2016.59.5.492; CC BY-NC.

Cranioplasty — Figure 3 Figure 3. Source: Which One Is Better to Reduce the Infection Rate, Early or Late Cranioplasty? — J Korean Neurosurg Soc. 2016 Sep 8;59(5):492–7. doi: 10.3340/jkns.2016.59.5.492; CC BY-NC.

Cranioplasty — Figure 4 Figure 4. Source: Which One Is Better to Reduce the Infection Rate, Early or Late Cranioplasty? — J Korean Neurosurg Soc. 2016 Sep 8;59(5):492–7. doi: 10.3340/jkns.2016.59.5.492; CC BY-NC.

Cranioplasty — Fig. 3 Fig. 3. Postoperative complications within 2 weeks after cranioplasty. EDH, SDH, NA and NC stand for epidural hematoma, subdural hematoma, not applicable and not checked, respectively. Numbers… Source: Long-Term Incidence and Predicting Factors of Cranioplasty Infection after Decompressive Craniectomy — Journal of Korean Neurosurgical Society 2012; CC BY-NC.

Cranioplasty — Figure 8 Figure 8. Source: Long-Term Incidence and Predicting Factors of Cranioplasty Infection after Decompressive Craniectomy — J Korean Neurosurg Soc. 2012 Oct 22;52(4):396–403. doi: 10.3340/jkns.2012.52.4.396; CC BY-NC.

Cranioplasty — Figure 9 Figure 9. Source: Long-Term Incidence and Predicting Factors of Cranioplasty Infection after Decompressive Craniectomy — J Korean Neurosurg Soc. 2012 Oct 22;52(4):396–403. doi: 10.3340/jkns.2012.52.4.396; CC BY-NC.

Cranioplasty — Figure 10 Figure 10. Source: Long-Term Incidence and Predicting Factors of Cranioplasty Infection after Decompressive Craniectomy — J Korean Neurosurg Soc. 2012 Oct 22;52(4):396–403. doi: 10.3340/jkns.2012.52.4.396; CC BY-NC.

History of Present Illness

Past Medical History

Imaging Review

CT Head (non-contrast)

CT Bone Window / 3D CT Reconstruction

Custom Implant Planning CT

CT Angiography (when indicated)

Labs

Neurological Examination

Mental Status

Syndrome of the Trephined Assessment

Motor

Speech/Language (if dominant hemisphere affected)

Cranial Nerves

Surgical Planning

Case Logistics, OR Needs & Orders

Diagnosis & Indication

Implant Selection

Material Advantages Disadvantages Best Use
Autologous bone flap (frozen / abdominal) Biocompatible, cheapest, osteointegration potential Resorption (15-50%, esp. pediatric/fragmented), infection if previously contaminated, may not fit if brain contour changed First-line if flap is intact, non-infected, non-irradiated
PEEK (polyether ether ketone) Custom fit (CAD/CAM), lightweight, radiolucent, no thermal conductivity, excellent cosmesis Expensive, fabrication lead time (4-6 wk), no osteointegration, requires thin-cut CT Large/complex defects, cosmetically sensitive areas
Titanium mesh Strong, custom or intraop moldable, osteointegration possible Palpable/visible in thin scalp, thermal conductivity (cold sensitivity), artifact on imaging Large defects, structural strength needed
PMMA (polymethylmethacrylate) Intraop moldable, inexpensive, no lead time Exothermic curing (dural injury risk), no osteointegration, brittle, infection-prone Smaller defects, resource-limited settings, revision
Hydroxyapatite Bioactive, osteoconductive Brittle, limited to smaller defects, expensive Small defects, pediatric (growth potential)

Timing Considerations

Position

Key Surgical Steps

  1. Incision planning — reopen original scar; mark prior incision, inspect scalp thickness/vascularity; if prior incision is compromised, plan alternative flap with plastic surgery
  2. Scalp flap elevation — careful subgaleal/subperiosteal dissection off the dura (dura is often adherent, thin, and avascular — avoid durotomy and cortical injury); use Bovie on dura only with extreme caution
  3. Define bony edges circumferentially — clear 5-10 mm rim of bone edge to seat implant; remove any fibrous tissue from bony margins
  4. Hemostasis — scalp/dura; epidural bleeding common from dural edges and granulation tissue
  5. Dural tacking sutures — place central and peripheral tack-up sutures through drill holes or implant perforations to obliterate epidural dead space and reduce hematoma risk
  6. Autologous bone flap assessment (if using) — inspect flap for resorption, fragmentation; obtain cultures; soak in antibiotic-impregnated saline
  7. Implant placement — place autologous flap or custom/PMMA implant; confirm fit, contour, and symmetry (compare with contralateral side); for PMMA, mold on a wet towel/glove off the field to avoid exothermic injury to dura
  8. Fixation — titanium plates and screws at minimum 3 points around the perimeter (ideally 4-6 for large defects); countersink plates to avoid palpable hardware
  9. Temporal hollowing management — if temporalis muscle atrophy is significant, consider temporalis muscle advancement, fat grafting, or extended implant design to restore temporal contour
  10. Subgaleal drain placement — closed suction drain (e.g., Jackson-Pratt) in subgaleal space
  11. Closure in layers — pericranium/temporalis reapproximation, galea, skin (staples or suture)

Critical Anatomy & Structures at Risk

  1. Underlying dura/brain — adherent dura; durotomy and cortical injury during dissection is the primary intraoperative risk
  2. Cortical veins — bridging veins adherent to dura; injury causes venous infarct
  3. Superior sagittal sinus (parasagittal/vertex defects) — catastrophic hemorrhage if injured
  4. Temporalis muscle (temporal defects) — atrophy common; manage for cosmesis
  5. Superficial temporal artery — preserve when possible for future bypass option

Equipment & Instrumentation

Anesthesia Considerations

Potential Complications & Contingencies

  1. Infection (~5-15%; higher with autologous bone, diabetes, prior infection) — may require implant removal, IV antibiotics, delayed re-cranioplasty
  2. Epidural/subgaleal hematoma — prevented by central tack-up sutures, drain, meticulous hemostasis; may require emergent evacuation
  3. Bone flap resorption (autologous — 15-50%) — monitor with serial CT; may require revision with synthetic implant
  4. Durotomy / CSF leak — primary dural repair or patch graft intraoperatively; postop pseudomeningocele management
  5. Seizures — perioperative prophylaxis; continue home AEDs
  6. Poor cosmesis / contour asymmetry — careful implant selection and fitting; revision may be needed
  7. Implant exposure / wound dehiscence — compromised scalp vascularity, infection, or tension; may require flap coverage (plastic surgery consultation)
  8. Hydrocephalus (new or worsening) — monitor postoperatively; may require VP shunt

Operative Note Template

Preoperative Diagnosis: [Location] cranial defect s/p prior [decompressive craniectomy for malignant MCA stroke / TBI / hemorrhage] [± syndrome of the trephined]

Postoperative Diagnosis: Same

Procedure: Cranioplasty of [location] defect with [autologous bone flap / custom PEEK implant / custom titanium implant / PMMA bone cement]

Surgeon: Assistant: Anesthesia: General endotracheal anesthesia

EBL: Fluids: Specimens: [Bone flap cultures / tissue cultures / none] Drains: Subgaleal closed-suction drain Complications: None Implants: [Autologous bone flap (previously cryopreserved / stored in abdominal subcutaneous pocket) / Custom PEEK implant (manufacturer: , lot: __) / Custom titanium mesh implant (manufacturer: __, lot: __) / PMMA bone cement (_ cc)]; fixation: [__ titanium plates, __ screws]

Indications: The patient is a [age]yo [M/F] who is [weeks/months] status post [decompressive craniectomy for ___] with a [size] cm [location] cranial defect. [The patient reports syndrome of the trephined with headache, cognitive decline, and motor regression since craniectomy / The patient presents for elective cranioplasty for brain protection and cosmesis.] [Autologous bone was available and in acceptable condition / Synthetic implant was chosen given prior infection history / bone flap resorption / large defect size requiring custom fabrication.] The brain is no longer bulging on preoperative imaging. [CT head demonstrates resolved cerebral edema without hydrocephalus. CRP/ESR are within normal limits.] Risks including infection, hematoma, bone resorption, implant failure, seizure, cosmetic dissatisfaction, and need for reoperation were discussed. The patient provided informed consent.

Description of Procedure: After informed consent was verified and the surgical site was marked, the patient was brought to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced. An arterial line and Foley catheter were placed. [Stereotactic navigation was registered and accuracy confirmed to within ___ mm.]

The patient was positioned supine with the head rotated [___] degrees to the [contralateral] side. The head was secured in a [Mayfield skull clamp / horseshoe headrest]. All pressure points were padded. A time-out was performed confirming correct patient, procedure, site, implant availability, and antibiotic administration.

The [left/right] [frontotemporal/parietal/frontal] region was prepped and draped in standard sterile fashion. Preoperative cefazolin [2g IV] [and vancomycin 1g IV] were administered.

Incision and Exposure: The prior [question-mark / linear / curvilinear] incision was identified and reopened sharply. The scalp flap was elevated in the subgaleal plane. Careful dissection was performed to separate the scalp flap and underlying scar from the adherent, thin dura, avoiding durotomy and cortical injury. [The dura was noted to be ___ (thin/adherent/intact/thickened).] The bony edges of the defect were defined circumferentially with clearing of fibrous tissue from the margins. Hemostasis of the scalp edges and dural surface was achieved with bipolar cautery and hemostatic agents.

Dural Tacking: [Central and peripheral] dural tack-up sutures were placed through [drill holes at the bony margin / perforations in the implant] to obliterate epidural dead space.

Implant Placement: [The previously cryopreserved autologous bone flap was thawed, inspected, and found to be in acceptable condition without significant resorption or fragmentation. It was soaked in antibiotic-impregnated saline. Cultures of the flap were sent. / The custom [PEEK/titanium] implant was opened, inspected, and confirmed to match the preoperative virtual surgical plan.] The implant was placed into the defect and its fit, contour, and symmetry were confirmed by visual inspection and palpation, comparing with the contralateral side.

Fixation: The implant was secured circumferentially with [__] titanium plates and [__] screws at [___] fixation points around the perimeter. Stability was confirmed.

[Temporal Contour: The temporalis muscle was advanced / a temporal extension of the implant was confirmed to address temporal hollowing.]

Closure: A subgaleal closed-suction drain was placed. Meticulous hemostasis was confirmed. The wound was copiously irrigated with antibiotic saline. The galea was closed with [3-0 Vicryl] interrupted sutures. The skin was closed with [staples / nylon suture]. A sterile dressing was applied.

Postoperative: The patient was awakened from anesthesia, extubated, and found to be [at neurological baseline / following commands with intact motor function]. The patient was transferred to the [floor / step-down unit] in stable condition for monitoring.

Postoperative Plan

Implant-Specific Follow-Up

Autologous bone flap:

Synthetic implant (PEEK / titanium / PMMA):

Return to Activity

Follow-Up Schedule

Chief-Level Case Review

Use these as the senior-level mental model for Cranioplasty:

Common Pimp Questions

Use these to pressure-test preparation for Cranioplasty:

  1. What is the life-threatening mass-effect problem and what is the operative endpoint?
  2. What anticoagulant/antiplatelet reversal and blood-product plan is required before incision?
  3. What exposure gives rapid control while preserving options for expansion?
  4. What ICP, seizure, sodium, ventilation, and blood-pressure targets matter immediately postop?
  5. What injury pattern or associated lesion would change the incision, bone flap, or disposition?

Attending Preference Variables

Items that commonly vary by surgeon or institution: