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Table of Contents    
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1629-1634

Epidural Fluid Collections After Cranioplasty

Department of Neurosurgery, National Neurosciences Centre, Kolkata, West Bengal, India

Date of Submission18-Jan-2022
Date of Decision27-May-2022
Date of Acceptance16-Jun-2022
Date of Web Publication30-Aug-2022

Correspondence Address:
Prasad Krishnan
Department of Neurosurgery, National Neurosciences Centre, Peerless Hospital Campus. 2nd Floor, 360 Panchasayar, Garia, Kolkata - 700 094, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.355177

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 » Abstract 

Background: Common complications following cranioplasty (CP) include infections, seizures, bone flap resorption, and intra-cranial hemorrhages. Epidural fluid collections (EFCs), often seen in the immediate post-operative scan as hypo-dense accumulations below the bone flap, have been very infrequently discussed in the literature as in the majority of the cases, they are small, get resorbed spontaneously, and usually do not cause neurological deficits.
Objective: To document our experience with EFCs that needed re-operation and analyze their clinical and radiological findings.
Materials and Methods: We describe a series of six cases of symptomatic EFCs following CP that necessitated re-operation in a series of 89 cases over 7 years.
Conclusions: EFCs following CP have a different pathogenetic mechanism compared to post-operative epidural hemorrhages. Meticulous surgical techniques can reduce their incidence. Symptomatic EFCs can be evacuated by either re-opening the flap or placing burr holes in the replaced bone. EFCs may become symptomatic even a few days after CP.

Keywords: Complications, cranioplasty, decompressive craniotomy, epidural fluid collection, infection, re-operation
Key Message: Epidural fluid collections (as opposed to epidural hemorrhages) are hypo-dense collections below the cranioplasty flap. These are usually asymptomatic, regressing spontaneously but rarely may be large, cause mass effects on the brain, and need evacuation.

How to cite this article:
Raju D, Bhosle R, Krishnan P. Epidural Fluid Collections After Cranioplasty. Neurol India 2022;70:1629-34

How to cite this URL:
Raju D, Bhosle R, Krishnan P. Epidural Fluid Collections After Cranioplasty. Neurol India [serial online] 2022 [cited 2022 Oct 2];70:1629-34. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1629/355177

Decompressive craniectomy (DC) is a commonly performed operation to relive raised intra-cranial pressure, and patients who survive undergo interval cranioplasty[1] with the aim of providing protection to the brain as well as improving cosmesis and brain functions. Complications following cranioplasty (CP) commonly reported in large series include infections, seizures, intra-cranial hemorrhages (epidural, sub-dural and intra-parenchymal) and bone flap resorptions and are reported to occur in up to 40% of cases.[2]

The entity of post-operative epidural fluid collections (EFCs) has been infrequently addressed in the literature.[3],[4],[5],[6] A systematic review and meta-analysis of complications of CP Shepetovskey[2] reported that epidural extra-axial collections as a separate complication were reported in only three series. Kim et al.[4] have defined EFCs as the radiological presence of “low density fluid in the epidural space on brain CT scan” after CP in an attempt to differentiate it from a post-operative epidural hematoma.

 » Case Series Top

We analyzed the records and images of 89 consecutive cases of CP performed by the corresponding author at our institution between January 2015 and December 2021 – a period of 7 years – with the primary objective of finding out how many of these patients had developed EFCs and also to audit how many of these required a second procedure to treat the same. Of the 89 patients, the stored autologous bone was used in 68 cases, polymethyl methacrylate (PMMA) bone cement was used in 16 cases, and titanium mesh was used in five cases to perform the CP. In all our cases, a sub-galeal drain was kept prior to closure, and in those patients who were on anti-platelets or anti-coagulants, these medications were stopped at least 5 days before the surgery and the procedure was carried out after ensuring that hematological parameters such as prothrombin time, activated partial thromboplastin time, and platelet count were normal on the day before operation. In all patients, post-operative computed tomography (CT) scans were performed on the first post-operative day (POD) and later as required. We defined EFCs as the presence of hypo-dense fluid collections below the replaced flap in more than 2 sections 5 mm apart. By these criteria, 48 patients (53.9%) had EFC. Forty-two of them were asymptomatic and did not need any surgical intervention. In six patients (12.5% of those with EFCs and 6.7% of all CP), there was a significant collection below the flap [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6] that caused symptoms and needed re-operation. One of these patients had a ventriculoperitoneal (VP) shunt in situ, and in one case, a lumbar puncture was performed to slacken a bulging flap to aid in placement of the bone. Two patients had significantly concave scalp defects pre-operatively even without any cerebrospinal fluid (CSF) drainage. Three patients were noted to have contralateral hemiparesis on the day after CP (i.e., POD 1), and of them, two underwent re-operation the same day. In one patient, we waited for spontaneous improvement, but as the deficit remained static over the next 2 days, he was re-operated on POD3. In three other cases, progressive neurological deterioration was noted from POD 2, and although two of them underwent re-surgery on POD3, in one case, surgery was performed on POD4.
Figure 1: Axial CT scan images showing (a) acute left-sided SDH with mass effects and mid-line shift; (b) post-decompressive craniotomy showing no residual mass effect or shift; (c, d) post-CP images showing EFC with mass effects and shift to the right with “air bubbles” (green arrows); (e) after catheter drainage showing resolution of the collection

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Figure 2: Axial CT scan images showing (a) acute right-sided SDH with mass effects and mid-line shift; (b) pre-CP image showing concavity at the operative site; (c) post-CP image showing EFC with mass effects and shift to the left and (d) 3D re-constructed CT images after re-craniotomy and evacuation showing holes in the PMMA bone flap for multiple dural hitches to prevent recollection

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Figure 3: Axial CT scan images (a, b) showing bifrontal hemorrhagic contusions with perilesional edema and effaced cisterns and ventricles; (c) post-operative 3D re-constructed CT scan showing bilateral decompressive craniotomy; (d) post-operative axial CT image showing re-constituted ventricles; pre-CP axial CT (e) and clinical (f) images showing the sunken craniotomy site and post-CP axial (g) and coronal (h) CT images showing bilateral EFCs with small hemorrhagic collection on the left side and sub-galeal collection as well; post-evacuation images axial (i) and coronal (j) showing resolution of the EFCs

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Figure 4: Axial CT scan images showing (a, b) bifrontal contusions (right more than left) with mass effects and cisternal effacement; (c, d) left parietal contusion and EDH; post-decompressive craniotomy images (e, f) showing no mid-line shift and bilateral decompressive craniotomy; (g) axial image on POD 1 after right-sided CP showing small EFC which has enlarged on POD 3 (h) and is causing mid-line shift with “air bubbles” (green arrows); (i) axial images after removal of the bone flap and (j) axial image after bilateral CP after a further 3 months with no further EFC

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Figure 5: Axial CT scan images showing (a, b) acute left-sided SDH and temporal contusions with mass effects and mid-line shift; (c) post-DC showing no residual mid-line shift; (d) pre-CP axial image showing a “full” and convex flap with open sulci; (e, f) post-CP axial images showing EFCs with mass effects and effacement of cortical sulci with no significant mid-line shift with “air bubbles” (green arrows)

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Figure 6: Axial CT scan images (a) on POD1 after DC for acute left-sided SDH with contusions; (b) delayed scan showing a satisfactory decrease of ICP; (c) CT scan image performed after late onset fresh deterioration showing a post-traumatic hydrocephalus; (d) axial CT image performed after VP shunt prior to CP showing a sunken flap; (e) post-CP axial image showing EFC

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Three of these patients were treated by re-craniotomy and evacuation with bone flap replacement, two underwent burr hole and evacuation by placement of a ventricular drain in the epidural space, and in one case, the bone flap was removed and re-cranioplasty was performed at a later date. The details of these patients are given in [Table 1].
Table 1: List of cases in the present series with epidural fluid collections

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 » Discussion Top

The true incidence of EFCs following CP is unclear as definitions of EFCs vary and many series report only symptomatic collections [Table 2]. Lee et al.[3] have described an overall rate of 37.3% (22 out of 59 cases), and although they have included all cases where any hypo-density is found in post-operative CT scans, regardless of the amount, it is still less than our series which considers a case as having an EFC only if it seen in more than 2 sections 5 mm apart. Kim et al.[4] found EFCs in 49 out of 117 patients (41.8%) undergoing CP, whereas Jeong et al.[5] found it in 79.2% of their cases (65 out of 82 cases undergoing CP).
Table 2: Series of epidural fluid collections after cranioplasty described in the literature

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Several reasons have been speculated for the formation of EFCs following CP. These include leak of CSF because of violation of the neo-dura covering the brain during either elevation of the skin or placement of hitch sutures,[3],[5] stiffness of the neo-dura because of calcification[3] (probably because it may prevent its expansion with the resultant formation of a dead space between the dura and replaced bone), foreign body reaction to the hydroxyapatite material used to create an artificial bone,[7] and (counter-intuitively) using an autologous bone rather than bone cement[4] for cranioplasty, large bone flaps[5] (presumably because excessive dissection might lead to pooling of the tissue fluid from the dissected site), the absence of sub-galeal drain,[6] and intra-cranial hypotension because of the presence of VP shunt[4] where the sunken brain might not expand to abut the replaced bone.

Post-operative CT scans in three of our six patients who needed re-operation showed the presence of an “air bubble” below the replaced flap. Lee et al.[3] and Kim et al.[4] have shown the presence of “air bubble” in the post-operative scans in their series to correlate significantly with the presence of EFCs.

In our series, none of the patients who were re-operated showed any evidence of CSF leak, nor did any of them have significant dural calcifications. The autologous bone had been used for CP in four cases, and PMMA bone cement had been used in two cases. There were three patients with concave flaps prior to CP, of which one was following a VP shunt. One patient with a full flap underwent lumbar puncture (LP) after induction of anesthesia to slacken it and aid better seating of the bone. By definition, these collections are supposed to be non-infectious and non-hemorrhagic,[2] and in all our patients too, during re-operation for removal of EFCs, a watery fluid tinged with blood was expressed. No obvious bleeding point in the scalp or neo-dura was demonstrable in cases that underwent re-craniotomy.

A male preponderance has been reported in the formation of EFCs after cranioplasty by Lee et al.[3] All our patients in this series were males too. It is possible that this finding may be because of the fact that the most common cause of de-compressive craniotomies in our institution is resultant to trauma which has a definite male preponderance.

In our series, the time interval between DC and CP in patients that needed re-operations because of EFCs was 5.7 months on average. Kim et al.[4] speculate that early cranioplasty (when the brain is relatively more swollen) may have a lesser incidence of this complication. One of our patients had a VP shunt, and another underwent an LP at the time of cranioplasty. It has been reported[5] that EFC incidence is higher in patients with shunts than in those without shunts (81.8% against 42.1%).

Chang et al.[6] report a lower incidence (2.4%) of EFCs in patients with drains compared to those without drains (8.6%). All our patients as well as those in the two other series[3],[4] had sub-galeal drains placed at the time of CP closure, and hence, although this may decrease the incidence, it is not completely protective. Nguyen et al.[8] have argued for fenestrating the bone flap to prevent extra-axial collections. Although we have not made multiple holes in any of the flaps we replaced, we have never seen this complication in the few cases where we have used titanium mesh for CP, suggesting that this technique may have some protective value.

However, the natural history of an EFC is usually of regression and disappearance,[3],[5] and the same happened in 42 of our 48 patients (87.5%) too. Lee et al.[3] have remarked that although small EFCs are common, it is rare for an EFC to have enough volume to produce a detectable change of neurological status. In the lack of any existing guidelines, we had arbitrarily chosen the presence of extra-axial hypo-density in CT scans in more than 2 cuts 5 mm apart as a criterion for labeling the case as having an EFC, thereby hoping to draw a line between a mere radiological finding and something that might be considered a “complication”.

A noteworthy finding in our series is that not all patients had neurological deterioration on the day following CP itself. This was found in three patients only, and although two of them underwent re-surgery on the same day (POD1), in one case, re-operation was performed as the deficit remained static and did not improve over the next 48 hours. With this limited series, we cannot say if a further trial of “watchful expectancy” might be beneficial to patients who have static protean deficits which may be expected to resolve with time. In three other cases, although collection was noted on CT scan performed on POD 1, neurological deterioration started from POD 2 and was progressive. This would imply that fluid accumulation below the replaced flap may be an ongoing process in some patients and that discharge must be deferred for a few days if significant EFCs are found even in the absence of immediate post-operative deficits.

 » Conclusions Top

There are only a few series reporting EFCs following CP. Most EFCs are small, get re-absorbed spontaneously, and cause no deficits, and in such cases, it can be debated whether to consider them as complications or mere radiological findings. However, apart from the fact that they are hypo-dense on imaging and found to be serohemorrhagic on evacuation, they appear to have a distinctly different pathogenetic mechanism from post-operative epidural hemorrhages as their origin is not attributable to bleeding from the scalp or neo-dura, and in several instances, mere catheter drainage via a burr hole on the flap may suffice. As they have been described as a potential cause of post-operative surgical site infection,[9] every attempt must be made to prevent EFCs. Placement of a sub-galeal drain with holes near the temporobasal gap of the replaced flap, avoidance of unnecessary dissection of the temporalis muscle, care to prevent CSF leak by breeching neo-dura, and placement of hitches through the replaced bone during CP (particularly when the flap is concave or in shunted patients) may decrease the incidence of EFCs. Finally, it must be borne in mind that EFCs may become symptomatic and cause neurological deficits at some interval after CP and cases with significant collections on imaging must be observed carefully even if they are asymptomatic in the immediate aftermath of a CP.

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Conflicts of interest

There are no conflicts of interest.

 » References Top

Krishnan P, Bhattacharyya AK, Sil K, De R. Bone flap preservation after decompressive craniectomy- Experience with 55 cases. Neurol India 2006;54:291-2.  Back to cited text no. 1
[PUBMED]  [Full text]  
Shepetovsky D, Mezzini G, Magrassi L. Complications of cranioplasty in relationship to traumatic brain injury: A systematic review and meta-analysis. Neurosurg Rev 2021;44:3125-42.  Back to cited text no. 2
Lee JW, Kim JH, Kang HI, Moon BG, Lee SJ, Kim JS. Epidural fluid collection after cranioplasty: fate and predictive factors. J Korean Neurosurg Soc 2011;50:231-4.  Back to cited text no. 3
Kim SP, Kang DS, Cheong JH, Kim JH, Song KY, Kong MH. Clinical analysis of epidural fluid collection as a complication after cranioplasty. J Korean Neurosurg Soc 2014;56:410-8.  Back to cited text no. 4
Jeong SH, Wang US, Kim SW, Ha SW, Kim JK. Symptomatic epidural fluid collection following cranioplasty after decompressive craniectomy for traumatic brain injury. Korean J Neurotrauma 2016;12:6-10.  Back to cited text no. 5
Chang V, Hartzfeld P, Langlois M, Mahmood A, Seyfried D. Outcomes of cranial repair after craniectomy. J Neurosurg 2010;112:1120-4.  Back to cited text no. 6
Imaizumi S, Owada K, Onuma T, Kamii H, Nakajima T. Epidural fluid collection after cranioplasty using hydroxyapatite ceremics following bone cement Jpn J Neurosurg (Tokyo) 2000;9:44-7.  Back to cited text no. 7
Nguyen HS, Doan N, Wolfla C, Pollock G. Fenestration of bone flap during interval autologous cranioplasty. Surg Neurol Int 2015;6:190. doi: 10.4103/2152-7806.172535.  Back to cited text no. 8
Kim MJ, Lee HB, Ha SK, Lim DJ, Kim SD. Predictive factors of surgical site infection following cranioplasty: A study including 3d printed implants. Front Neurol 2021;12:745575. doi: 10.3389/fneur. 2021.745575.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]


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