Malignant Cerebral Edema After Cranioplasty: A Case Report and Literature Insights

Melanie Mandell; Fabio Grassia; Muhammad Riaz

doi:10.12659/AJCR.946230

08 January 2025 : Case report USA

Malignant Cerebral Edema After Cranioplasty: A Case Report and Literature Insights

Unusual clinical course, Unusual or unexpected effect of treatment, Clinical situation which can not be reproduced for ethical reasons

Melanie Mandell^{EF 1*}, Fabio Grassia^{AB 2}, Muhammad Riaz^{AG 2}

DOI: 10.12659/AJCR.946230

Am J Case Rep 2025; 26:e946230

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Introduction Case Report Discussion Conclusions References:

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Table 1. Prior cases of malignant cerebral edema from a literature review [8–16,18,20–22].

Reference	Indication for craniectomy	Patient demographics	Time between operations	Pre-operative condition	Cranioplasty material
[]⁸	TBI	37 (M)	2 months	SSFS	Titanium-enhanced autologous bone
[]⁸	TBI	48 (M)	9 weeks	SSFS	Autologous
[]⁸	TBI	49 (M)	2 months	SSFS	Autologous
[]⁸	Revision of prior cranioplasty	48 (M)	2 years	SSFS	Titanium
[]⁹	Ischemic stroke	25 (F)	11 months	SSFS	Titanium
[]⁹	Ischemic stroke	74 (F)	2 months	SSFS	Autologous
[]⁹	Hemorrhagic stroke	41 (F)	12 months	SSFS	Titanium
[]¹⁰	Ischemic stroke	44 (F)	6 months	SSFS	N/S
[]¹¹	TBI	51 (M)	6 months	SSFS	Titanium
[]¹²	Hemorrhagic stroke	50 (F)	3 months	SSFS	Autologous
[]¹³	TBI	22 (M)	9 months	SSFS	Autologous
[]¹³	TBI	14 (M)	10 months	SSFS	Autologous
[]¹³	TBI	28 (M)	17 months	SSFS	Methyl methacrylate cement
[]¹³	TBI	24 (M)	3 months	N/S	Autologous
[]¹⁴	TBI	45 (M)	3 months	Recurrent subdural hygroma	Titanium
[]¹⁵	Ischemic stroke	58 (F)	6 months	SSFS	Autologous
[]¹⁶	Ischemic stroke	52 (M)	6 months	SSFS	Titanium
[]¹⁸	Ischemic stroke	63 (M)	9 months	SSFS	Autologous
[]²⁰	Ischemic stroke	50 (F)	4 months	SSFS	Autologous
[]²¹	TBI	17 (M)	2 months	N/S	Autologous
[]²²	Ischemic stroke	42 (M)	1 year	Persistent postischemic area in distribution of prior stroke	Titanium
N/S – not specified; SSFS – sunken skin flap syndrome; M – Male; F – Female.
Reference	Post-Op drain	MCE symptom evolution	CT findings	Intervention	Outcome
[]⁸	Closed suction drain	Never emerged from anesthesia	Bilateral large cerebral edema	Ipsilateral DC	Fatal
[]⁸	Negative pressure drain	Immediate seizure, coma	Diffuse cerebral edema	N/S	Fatal
[]⁸	Negative pressure drain	Immediate seizure, coma	Diffuse cerebral edema	N/S	Fatal
[]⁸	Negative pressure drain	Began to seize 1 hr post-op	Diffuse cerebral edema	Surgical decompression	Fatal
[]⁹	Closed suction drain	Never emerged from anesthesia	Diffuse cerebral edema	Plate removed	Fatal
[]⁹	Closed suction drain	Emerged, seizure in PACU	Generalized cerebral edema, small cortical hemorrhages	Bone flap removed, EVD placed	Fatal
[]⁹	Closed suction drain	Emerged, seizure in PACU	Diffuse cerebral edema	N/S	Fatal
[]¹⁰	Hemovac, subgaleal drain	Gradual onset, seizure 12 hours post-op	New R MCA hypodensity, diffuse edema	Hyperosmotic therapy initiated prior to seizure, continued aggressive medical management s/p status epilepticus	Survived
[]¹¹	Closed suction drain	Never emerged from anesthesia	Ipsilateral diffuse cerebral swelling with diffuse hemorrhage	Ipsilateral DC	Fatal
[]¹²	Epidural, subdural suction drainage	Seizure in recovery room	Diffuse cerebral edema	Drains clamped	Survived
[]¹³	Closed suction drain	Never emerged from anesthesia	Diffuse cerebral edema	Contralateral DC	Fatal
[]¹³	Closed suction drain	Never emerged from anesthesia	Diffuse hemorrhagic cerebral edema	Ipsilateral DC	Fatal
[]¹³	Closed suction drain	Had sufficient spontaneous respirations but never woke up from anesthesia	Diffuse cerebral edema, CTA demonstrated slowed flow	Bilateral DC	Fatal
[]¹³	Closed suction drain	Epidural hematoma 4 hours post-op, returned to the OR for clot evacuation, flap replaced, did not emerge	Diffuse cerebral edema	Bilateral DC and EVD placed	Fatal
[]¹⁴	Epidural negative pressure drain	Never emerged from anesthesia	Diffuse cerebral edema	Removal of ipsilateral mesh, contralateral DC	Fatal
[]¹⁵	Closed suction drain	Status epilepticus within 1 hour	Interhemispheric acute subdural hematoma, unilateral intraventricular hemorrhage, ATH	IV midazolam, phenytoin and removal of subgaleal drain	Survived
[]¹⁶	N/S	Never emerged from anesthesia	Diffuse severe cerebral edema	Contralateral DC, lax duraplasty	Fatal
[]¹⁸	N/S	Never emerged from anesthesia	Diffuse gyral swelling with sulcal effacement	Family declined further intervention	Fatal
[]²⁰	N/S	Never emerged from anesthesia	Diffuse cerebral edema	Mannitol, hyperventilation	Fatal
[]²¹	N/S	Never emerged from anesthesia	Massive cerebral edema	Expansion of craniotomy, bifrontal lobectomy	Fatal
[]²²	Closed suction drain	Generalized seizures at the time of extubation	Epidural, subdural hematoma in the postischemic area, brain stem swelling	Family declined further surgical intervention, medical management failed	Fatal
N/S – not specified; SSFS – sunken skin flap syndrome; M – Male; F – Female.

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Malignant Cerebral Edema After Cranioplasty: A Case Report and Literature Insights

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