Dural adhesion to porous cranioplastic implant: A potential safety concern

BACKGROUND: Patient-specific implants are used for cranioplastic skull reconstruction when large bone flaps must be replaced or where there are complex or critical contours, especially near the face. These implants have a low complication rate, with poor fit and postoperative infection being the most common complications. We report here a potentially serious hazard that may arise from the use of porous implants. CASE DESCRIPTION: A 45-year-old woman sustained severe head trauma in a motor vehicle accident that required urgent surgical intervention. Because of progressive resorption of her native bone flap, she underwent replacement of her native flap with a hard tissue replacement/patient-matched implant cranioplasty. Eight years later, she sustained a traumatic laceration over her vertex that necessitated removal of her cranioplastic implant because of persistent local infection. Intraoperatively, the dural flap was ingrowing and firmly adherent to the inside surface of the porous cranioplasty. After several failed attempts to remove the whole implant piecemeal, we attempted to dissect the dural flap from the brain surface to remove it together with the cranioplastic implant but exposure of the extensive cortical adhesions between the brain surface and the dural flap was compromised by the hard overlying cranioplastic implant. Despite our meticulous attempts to cut off these cortical adhesions, a perisylvian blood vessel was avulsed, resulting in intraparenchymal hemorrhage. CONCLUSION: In this case, dural adhesion and ingrowth to the underside of the cranioplasty implant led to disastrous bleeding when the implant needed to be removed years after initial implantation.