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Cranioplasty using alloplastic polyetheretherketone (PEEK) implants and chimeric microvascular soft tissue coverage in patients with Syndrome of the Trephined
Chrisovalantis Lakhiani, MD, Tara M. Chadab, MS, Jessica S. Wang, MD, David Janhofer, BS, David H. Song, MD, MBA, Karen K. Evans, MD.
Georgetown University Hospital, Washington, DC, USA.

Background
The Syndrome of the Trephined (SoT) is described as a phenomenon of sudden neurologic deterioration that can occur following decompressive craniectomy. While early cranioplastic repair has been shown to improve outcomes in patients with SoT, high failure rates for hostile calvarial defects have led many practitioners to delay reconstruction for six months to one year. We present our experience performing early cranioplasty using alloplastic polyetheretherketone (PEEK) implants and chimeric microvascular soft tissue coverage in patients with SoT.
Methods
Between 2012 and 2018 five patients with SoT following decompressive craniectomy presented to our tertiary medical center. Cranioplasty was performed using customized PEEK implant with microsurgical reconstruction to restore soft tissue deficit or protect against endemic infection. Patient demographic data, onset to SoT after craniectomy, time to resolution of symptoms, and complication data were recorded.
Results
Patients were all male, nonsmokers. Mean time to cranioplasty after craniectomy was 5.7 months. Mean calvarial defect size was 112.5cm. Flaps included 3 anterolateral thigh, and 2 latissimus dorsi. Three patients had failed prior reconstruction with banked calvarium due to infection. Following cranioplasty, improvement in neurologic functioning was seen at a mean of 2 days (range: 1 4). All patients demonstrated significant improvements in cognition and motor skill within the early postoperative period. At six-month follow-up, all patients had regained ability to speak, ambulate, and self-feed. Mean follow-up time was 1.2 years. CT scans at one year follow-up showed ventricular re-expansion, along with no evidence of infection recurrence. No complications were noted.
Conclusion
The most effective treatment strategy for improving neurologic sequelae in SoT is early cranioplasty, which re-establishes intracranial domain and normalizes cerebral hydrodynamics. In the setting of a hostile wound bed, autologous reconstruction is the gold standard to prevent infection. However, in the case of extensive, high-risk, and/or composite cranial defects, early cranioplasty with autologous bone may not be feasible. Here we demonstrate the efficacy of cranial vault reconstruction using an alloplastic implant in combination with total vascularized soft tissue coverage.


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