Background: Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach. Methods: The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP. Results: The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations. Conclusions: This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.

Objectives: Africa and other Asian low middle-income countries account for the greatest burden of the global road-traffic injury (RTI)-related head injury (HI). This study set out to describe the incidence, causation, and severity of RTI-related HI and associated injuries in a Nigerian academic neurosurgical practice. Methods: This is a retrospective cross-sectional analysis of RTI-related HI from a prospective HI registry in an academic neurosurgery practice in Nigeria. Results: All-terrain RTI accounted for 80.6% (833/1,034) of HI over a 7-year study period. All age groups were involved, mean 33.06 years (SD 18.30), mode 21–30, 231/833 (27.7%). The male:female ratio was 631:202, ≈3:1. The road trauma occurred exclusively from motorcycle-and motor-vehicle crash (MCC/MVC), MCC caused 56.8% (473/833) of these; the victims were vulnerable road users (VRU) in 74%, and >90% belong in the low socioeconomic class. Using the Glasgow Coma Scale grading, the HI was moderate/severe in 52%; loss of consciousness occurred in 93%, the Abbreviated Injury Severity-head > 3 in 74%, and computed tomography (CT) Rotterdam score > 3 in 52%. Significant extracranial injuries occurred in many organ systems, 421/833 (50.5%) having Injury Severity Score (ISS) > 25. Surgical lesions included extensive brain contusions in 157 (18.8%); acute extradural hematoma in 34 (4.1%); acute subdural hematoma in 32 (3.8%); and traumatic intracerebral hemorrhage in 27 (3.2%), but only 97 (11.6%) received operative care for various logistic reasons. The in-hospital outcome was good in 71.3% and poor in 28.7%; the statistically significant (p < 0.001) determinants of this outcome profile were the severity of the HI, the CT Rotterdam score, and the ISS. Conclusion: In this study from Nigeria, RTI-related HI emanates from significant trauma to vulnerable road users and are caused exclusively by motorcycles and motor vehicles.

Background: Although head injury (HI) is a major public health problem in Nigeria and other low and middle income countries of the world, there is a paucity of data from these societies. This is largely due to under-reporting. We carried out a prospective study of the clinicoepidemiological profiles and outcomes following the first hospitalization of a cohort of head-injured patients in Ikeja, Nigeria, a metropolitan African city. Methods: In an 8-month period from May until December 2005, data from all HI cases seen in our neurosurgical unit were prospectively recorded for subsequent analysis. These include demographics, mechanism of injury, pre-neurosurgical care received, severity of injury using the Glasgow Coma Scale, presence of hemodynamic instability, pupillary anomalies and associated systemic injuries, cranial computed tomography (CT) findings and the number of surgical interventions, as well as outcomes after the first hospital admission using the Glasgow Outcome Scale. Determinants of outcome were explored using the χ2 test and the level of significance was put at p = 0.05. Results: There were 143 cases of HI, which is about one fifth of our total workload, including 122 males and 21 females aged 0.5–85 years (mean age 29.15). The majority (88%) were either school children or low income earners. Road accidents accounted for 75% of the cases; three quarter of the cases had some initial care in other health facilities before the arrival in our unit, at an average of 33 h. Mild, moderate and severe HI accounted for 60, 18 and 22%, respectively. About a quarter of the patients sustained other systemic injuries. Cranial CT scanning was obtainable in 40 patients (28%); 9 of these revealed surgical mass lesions, of whom 5 had life-saving operations. Many well-known determinants of a poor outcome of HI were prevalent in this study group and found to have a significantly adverse effect on patient outcome. Conclusions: HI is a major public health problem in Nigeria, taking up at least one fifth of the neurosurgical workload. The prehospital emergency medical service is poorly organized. Determinants of a poor outcome of HI are highly prevalent, including poor accessibility to cranial CT scanning, absence or inadequacy of logistics for neurocritical care and an inadequate number of neurosurgeons.

The neurosurgical procedure of hinge decompressive craniectomy (hDC), or hinge craniotomy (HC), as described from units in the advanced countries makes use of metallic implants, usually titanium plates and screws, which may not be economically viable in resource-limited practice settings. We describe our surgical techniques for performing this same procedure of hDC in a developing country using the patient's own temporalis muscle instead of any other potentially costly implants. The technique as described appears to be successful in achieving intracranial decompression in cases of traumatic brain swelling in which it has been used. Clinical and radiological illustrations of the feasibility, and practical utility, of the procedures in four clinical scenarios of traumatic brain injury are presented. Like all other techniques of HC, this new surgical technique of hDC temporalis saves the survivors the added imperative of future cranioplasty of the usual postcraniectomy skull defect. Unlike the others, the procedure eliminates the added cost of the metallic implants needed to perform the former techniques. The procedure of hDC temporalis appears to be a viable option for performing the surgical procedure of HC and has added cost-cutting economic benefits for resource-limited practice settings.