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BACKGROUND Cranioplasty (CPL) is a surgical procedure that has still a high rate of complications, although it is commonly considered an easy and routine operation. In the literature, cranioplasty complications may rise up to 41% of cases, and the most frequently reported are infections, autologous bone flap resorption, and hematomas. Although possible, poor cosmetic results are rarely mentioned. METHODS We retrospectively analyzed the cases of 313 patients who underwent 377 surgical procedures for cranioplasty and reoperations for complications between 2008 and 2014. In other 2 patients we performed a new surgical procedure for the prosthesis fracture. Pediatric patients (aging from 5 to 17 years) have been included in this series in order to compare the complication rate between adult and pediatric populations. The clinical-radiological follow-up of these 313 patients lasted between 1 and 6 years. RESULTS Overall complications for cranioplasty were seen in 38 (12.14%) out of the 313 patients. However, complications requiring surgical therapy were seen in 28 patients who underwent 64 new surgical procedures. Adult male patients represented the majority of the group with cranioplasty complications. In the pediatric group we have not observed any complication requiring more than a clinical observation. Infections and autologous bone resorption were the most frequent complications reported in this series; however, we observed a poor cosmetic result as a concomitant but separate complication in more than 26% of our 313 patients. CONCLUSIONS In this paper we present an overview of all the possible complications of cranioplasty reported in the literature, comparing them with those observed in our series. We also discuss critically the most evident causes of complications, suggesting, when possible, solutions to avoid or limit them.

Object In the last decade the indications for the endoscopic endonasal approach have been progressively expanded to include lesions that have not been traditionally considered amenable to resection through the transsphenoidal route. In this study, the authors analyze their experience with hypothalamic gliomas treated via the endoscopic endonasal approach. Methods Consecutive cases of hypothalamic gliomas treated since 2007 via an endoscopic endonasal approach were reviewed. Preoperative and postoperative neuroimaging as well as endocrinological, neurological, and visual symptoms were analyzed to assess the surgical outcome. Signs and symptoms of hypothalamic dysfunction including body mass index (BMI), memory, sleep-wake rhythm, and polyphagia were prospectively collected pre- and postoperatively to assess hypothalamic function. Quality of life was evaluated using the Katz scale. Results In the initial phase the endoscopic endonasal approach was adopted in 3 cases with a palliative intent, to obtain a biopsy sample or for debulking of the mass followed by radio- or chemotherapy. In 2 later cases it was successfully adopted to achieve gross-total tumor resection. Complications consisted of 2 postoperative CSF leaks, which required an endoscopic endonasal reintervention. Visual deficit improved in 3 cases and normalized in the other 2. Four patients developed diabetes insipidus, and 3 an anterior panhypopituitarism. All patients had a moderate increase in BMI. No patients presented with any other signs of hypothalamic damage, and their quality of life at follow-up is normal. Conclusions Despite the limitations of a short follow-up and small sample, the authors’ early experience with the endoscopic endonasal approach has revealed it to be a direct, straightforward, and safe approach to third ventricle astrocytomas. It allowed the authors to perform tumor resection with the same microsurgical technique: dissecting the tumor with 2 hands, performing a central debulking, and controlling the bleeding with bipolar coagulation. The main limitations were represented by some anatomical conditions, such as the position of the chiasm and the anterior communicating artery complex and, finally, by the challenge of watertight plastic repair. To definitively evaluate the role of this approach in hypothalamic gliomas, a comparison with transcranial series would be necessary, but due to the rarity of these cases such a study is still lacking. The authors observed that more aggressive surgery is associated with a worse endocrinological outcome; thus they consider it to be an open question (in particular in prepubertal patients) whether radical removal is an advisable goal for hypothalamic gliomas.