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The Absence of Fever or Leukocytosis Does Not Exclude Infection Following Cranioplasty

  • Fady Girgis (a1), Brian P. Walcott (a2), Churl-Su Kwon (a2), Sameer A. Sheth (a2), Wael Asaad (a3), Brian V. Nahed (a2), Emad N. Eskandar (a2) and Jean-Valery Coumans (a2)...


Background: Cranioplasty encompasses various cranial reconstruction techniques that are used following craniectomy due to stroke or trauma. Despite classical infectious signs, symptoms, and radiologic findings, however, the diagnosis of infection following cranioplasty can be elusive, with the potential to result in definitive treatment delay. We sought to determine if fever or leukocytosis at presentation were indicative of infection, as well as to identify any factors that may limit its applicability. Methods: Following institutional review board approval, a retrospective cohort of 239 patients who underwent cranioplasty following craniectomy for stroke or trauma was established from 2001-2011 at a single center (Massachusetts General Hospital). Analysis was then focused on those who developed a surgical site infection, as defined by either frank intra-operative purulence or positive intra-operative cultures, and subsequently underwent operative management. Results: In 27 total cases of surgical site infection, only two had a fever and four had leukocytosis at presentation. This yielded a false-negative rate for fever of 92.6% and for leukocytosis of 85.2%. In regard to infectious etiology, 22 (81.5%) cases generated positive intra-operative cultures, with Propionibacterium acnes being the most common organism isolated. Median interval to infection was 99 days from initial cranioplasty to time of infectious presentation, and average follow-up was 3.4 years. Conclusions: The utilization of fever and elevated white blood cell count in the diagnosis of post-cranioplasty infection is associated with a high false-negative rate, making the absence of these features insufficient to exclude the diagnosis of infection.

L’absence de fièvre ou d’hyperleucocytose n’exclut pas la présence d’infection après une cranioplastie. Contexte: Plusieurs techniques de cranioplastie peuvent être utilisées pour la reconstruction crânienne après une craniectomie effectuée suite à un accident vasculaire cérébral ou à un traumatisme. Cependant, malgré les signes classiques d’infection, les symptômes et les signes radiologiques, le diagnostic d’infection après une cranioplastie peut échapper à la détection, ce qui peut en retarder le traitement. Nous avons cherché à déterminer si la fièvre ou l’hyperleucocytose au moment de la consultation étaient des indicateurs de l’infection et à identifier tout facteur qui pourrait limiter son applicabilité. Méthode: Le protocole a été approuvé par le comité d’éthique de la recherche de l’institution. L’étude a porté sur une cohorte rétrospective de 239 patients traités entre 2001 et 2011, qui avaient subi une cranioplastie après une craniectomie effectuée pour traiter un AVC ou un traumatisme dans un même centre, le Massachusetts General Hospital. L’analyse a ciblé les patients qui avaient présenté une infection de la zone opératoire, définie comme étant la présence de pus ou de cultures positives au niveau de la zone opératoire, et qui ont subi un traitement chirurgical. Résultats: Parmi les 27 cas d’infection au niveau de la zone opératoire, seulement 2 patients présentaient de la fièvre et 4 avaient une hyperleucocytose au moment de la consultation. Le taux de faux-négatif pour la fièvre était donc de 92,6% et pour l’hyperleucocytose de 85,2%. Quant à l’étiologie de l’infection, les cultures de la zone opératoire étaient positives chez 22 patients (81,5%) et le Propionibacterium acnes était l’agent infectieux le plus souvent impliqué. L’intervalle médian entre la cranioplastie initiale et la consultation pour l’infection était de 99 jours et le suivi moyen de 3,4 ans. Conclusions: L’utilisation de la fièvre et d’un décompte élevé de leucocytes pour diagnostiquer l’infection après une cranioplastie est associée à un taux élevé de faux-négatifs, ce qui rend l’absence de ces éléments insuffisante pour exclure le diagnostic d’infection.

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Corresponding author

Correspondence to: Fady Girgis, Department of Neurosurgery, University of Calgary, Foothills Medical Centre, 12th Floor, 1403, 29 St NW, Calgary, AB T2N 2T9. Email:


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