Clinically manifested frontal lobe compression after anterior craniectomy and deep inferior epigastric perforator flap reconstruction

The advantages of immediate cranioplasty after craniectomy are well documented.(1,2) The principal benefits of craniciplasty are protection and aesthetic improvements. Reconstruction of the cranial defect improves the patient's appearance by restoring the normal convex curvature of the skull. Various materials have been used, including hydroxyapatite cement, methylmethacrylate, autologous bone, and assorted metals.(1-4) Although immediate craniciplasty is preferred in most situations, circumstances may arise in which delayed craniciplasty is indicated. 1,2 Such circumstances include infection, inadequate skin cover, and lack of a suitable cranioplasty material. This case report describes a patient for whom an anterior craniectomy was performed followed by soft-tissue reconstruction with a deep inferior epigastric perforator flap. An immediate cranioplasty was not performed because of the high risk of infection resulting from ongoing osteomyelitis and osteoradionecrosis. The postoperative course was complicated by severe neurological changes consistent with frontal lobe syndrome, secondary to compression of the frontal lobe by the flap. The purpose of this report is to describe the mechanisms, pathophysiological features, and prevention of this complication.