Malignant cerebral edema after cranioplasty, a rare complication: case series and literature review

Cranioplasty is standard neurosurgery performed after decompressive craniectomy. Fatal malignant cerebral oedema complications associated with this procedure are rare and clinically distinct, although unpredictable. It is thought that the pressure difference from removing atmospheric pressure had a long-term effect on the brain. This combined with the negative pressure applied by intraoperative pressure drainage may impact the perfusion brain. Here, the authors report four cases of cerebral oedema after cranioplasty and review similar cases in the literature. CASE PRESENTATION: The authors report on four cases of patients who underwent cranioplasty following decompressive craniotomy and subsequently died after surgery. Three of the patients had undergone craniotomy following trauma, while one patient had skull resorption. All four patients developed cerebral oedema immediately after surgery and exhibited significant craniofacial depression (also known as sunk flap syndrome). A negative pressure drainage system was utilized in all cases. One patient remained intubated, while the remaining three developed postoperative epilepsy and subsequently fell into a coma. Dilated and fixed pupils were observed in all patients, and computed tomography scans revealed diffuse cerebral oedema. Despite intensive resuscitation efforts and attempts at decompression, all four patients ultimately succumbed to their conditions. CONCLUSION: Fatal post-cranioplasty malignant cerebral oedema is a rare but very dangerous complication. Despite being rare, neurosurgeons should be aware that this fatal complication can occur after cranioplasty.