How to manage patients with persistent brain bulge from craniectomy (surgical removal of a portion of the skull) site following decompressive craniectomy (surgical procedure to relieve pressure on the brain) even after 3 months of cranioplasty (surgical repair of the skull)?

Management of Persistent Brain Bulge After Cranioplasty

For patients with persistent brain bulge from craniectomy site following decompressive craniectomy even after 3 months of cranioplasty, a comprehensive management approach including both medical and surgical interventions is necessary to reduce morbidity and mortality. 1

Medical Management Options

• Osmotherapy using mannitol 20% or hypertonic saline solutions with target serum osmolality of 300-310 mOsmol/kg to reduce brain edema 2
• Maintain cerebral perfusion pressure (CPP) >60 mmHg using volume replacement and/or catecholamines 2
• Consider sedation, intubation, and controlled mechanical ventilation with target PaCO₂ of 35 mmHg for severe cases 2
• Regular monitoring of intracranial pressure (ICP) and CPP to guide management 2

Surgical Management Considerations

• Ensure adequate craniectomy size (at least 12 cm diameter) was achieved during initial surgery, as inadequate decompression may contribute to persistent bulging 2
• Consider dural expansion with a large dural augmentation graft for persistent brain bulge not responding to medical management 2
• For very large infarcts (>400 cm³), temporal lobectomy may be considered, and reoperation may be necessary if brainstem decompression is inadequate 2
• Evaluate for hydrocephalus development, which may require ventriculoperitoneal shunt placement 1, 3

Special Considerations for Ventriculoperitoneal Shunts

• Patients with severe brain bulging who develop hydrocephalus may require a ventriculoperitoneal shunt, but timing is critical 3
• Performing cranioplasty and VP shunt placement at different times has lower complication rates (21%) compared to simultaneous procedures (56%) 3
• For patients with severe depression at the skull defect after VP shunting, temporary occlusion of the shunt tube with an aneurysm clip before cranioplasty can safely eliminate the dead space between the skull plate and the dura 4

Monitoring and Follow-up

• Close neurological monitoring for signs of deterioration, particularly changes in level of consciousness 1
• CT imaging to assess the degree of brain swelling/bulging and to evaluate for decreased vasogenic edema 1
• Regular follow-up with neurosurgical evaluation to monitor for complications including infection, hematoma formation, or hydrocephalus 1, 3

Complications to Monitor

• Subdural hematoma and subdural fluid collection are common complications, especially in patients with severe brain bulging 3
• Infection risk is approximately 3% and is higher when cranioplasty is performed within 3 months of the primary surgery 5
• Fracture of the cranioplasty material occurs in approximately 2% of cases, with higher rates in pediatric patients 5

Prognosis Discussion

• Clinicians should discuss with family members that half of the surviving patients with massive hemispheric infarctions, even after decompressive craniectomy, are severely disabled and a third are fully dependent on care 6
• The outcome after cerebellar infarct can be good after suboccipital craniectomy 6
• In patients with skin flap of sinking or flat type, approximately 10% may show unquestionable objective improvement within a few days following cranioplasty 5

Brain bulging after cranioplasty represents a challenging neurosurgical complication that requires specialized neurointensive care and often additional neurosurgical intervention. The management approach must be tailored based on the severity of bulging, presence of hydrocephalus, and patient-specific factors.