Abstract

Purpose For post-craniotomy surgical site infection (SSI) involving the bone, typical management involves removal of the bone flap and delayed cranioplasty. The disadvantages of delayed cranioplasty include cosmetic deformity, vulnerability of unprotected brain, skin contraction, syndrome of the trephined and the risks of further surgery. Second procedures also add to cost due to surgical time, hospital stay, and opportunity costs for patients from being away from work. Methods We retrospectively reviewed patients who underwent post-craniotomy bone flap removal due to SSI, with immediate titanium mesh cranioplasty. The primary outcome was re-operation due to persistent infection or wound healing complications. The secondary outcome was re-operation due to unacceptable cosmetic result. Results Nineteen patients were included between 2018 to 2024. Two patients required additional debridement and removal of the titanium mesh due to persistent infection. Another patient had the plate replaced with PEEK due to poor skin quality, wound breakdown and an unacceptable cosmetic result. Two further patients with bifrontal craniotomies had the mesh replaced for cosmetic reasons. Fourteen patients had long term resolution with no further procedure. Conclusion Immediate TM insertion at the time of bone flap removal is an acceptable option in the management of post-craniotomy SSI. It seems the overall complication rate is comparable to delayed titanium cranioplasty, with the benefit of avoiding the risks and costs of a second operation. Cosmetic results are worse with larger defects, but these patients can still benefit from early TM placement by making operative conditions easier when the custom made, delayed cranioplasty is inserted.