ACE-inhibitors: a preventive measure for bone flap resorption after autologous cranioplasty?

Schütz, Alessa Li-Na; Murek, Michael; Stieglitz, Lennart; Bernasconi, Corrado Angelo; Vulcu, Sonja; Beck, Jürgen; Raabe, Andreas; Schucht, Philippe (2018). ACE-inhibitors: a preventive measure for bone flap resorption after autologous cranioplasty? (In Press). Journal of neurosurgery, pp. 1-8. American Association of Neurological Surgeons 10.3171/2018.6.JNS172605

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OBJECTIVEDecompressive craniectomy (DC) is an established treatment for refractory intracranial hypertension. It is usually followed by autologous cranioplasty (AC), the reinsertion of a patient's explanted bone flap. A frequent long-term complication of AC is bone flap resorption (BFR), which results in disfigurement as well as loss of the protective covering of the brain. This study investigates risk factors for BFR after AC, including medical conditions and antihypertensive drug therapies, with a focus on angiotensin-converting enzyme inhibitors (ACEIs), which have been associated with a beneficial effect on bone healing and bone preservation in orthopedic, osteoporosis, and endocrinology research.METHODSIn this single-center, retrospective study 183 consecutive cases were evaluated for bone flap resorption after AC. Information on patient demographics, medical conditions, antihypertensive therapy, and BFR-defined as an indication for revision surgery established by a neurosurgeon based on clinical or radiographic assessments-was collected. A Kaplan-Meier analysis of time from AC to diagnosis of BFR was performed, and factors associated with BFR were investigated using the log-rank test and Cox regression.RESULTSA total of 158 patients were considered eligible for inclusion in the data analysis. The median follow-up time for this group was 2.2 years (95% CI 1.9-2.5 years). BFR occurred in 47 patients (29.7%), with a median time to event of 3.7 years (95% CI 3.3-4.1 years). An ACEI prescription was recorded in 57 cases (36.1%). Univariate Kaplan-Meier analysis and the log-rank test revealed that ACEI therapy (2-year event free probability [EFP] 83.8% ± 6.1% standard error vs 63.9% ± 5.6%, p = 0.02) and ventriculoperitoneal (VP) shunt treatment (2-year EFP 86.9% ± 7.1% vs 66% ± 5.0%, p = 0.024) were associated with a lower probability of BFR. Multiple Cox regression analysis showed ACEI therapy (HR 0.29, p = 0.012), VP shunt treatment (HR 0.278, p = 0.009), and male sex (HR 0.500, p = 0.040) to be associated with a lower risk for BFR, whereas bone fragmentation (HR 1.92, p = 0.031) was associated with a higher risk for BFR.CONCLUSIONSHypertensive patients treated with ACEIs demonstrate a lower rate of BFR than patients treated with other hypertensive medications and nonhypertensive patients. Our results are in line with previous reports on the positive influence of ACEIs on bone healing and preservation. Further analysis of the association between ACEI treatment and BFR development is needed and will be evaluated in a multicenter prospective trial.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurosurgery
04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurology

UniBE Contributor:

Schütz, Alessa Li-Na; Murek, Michael; Bernasconi, Corrado Angelo; Vulcu, Sonja; Beck, Jürgen; Raabe, Andreas and Schucht, Philippe

Subjects:

600 Technology > 610 Medicine & health

ISSN:

0022-3085

Publisher:

American Association of Neurological Surgeons

Language:

English

Submitter:

Nicole Söll

Date Deposited:

04 Feb 2019 17:57

Last Modified:

04 Feb 2019 17:57

Publisher DOI:

10.3171/2018.6.JNS172605

PubMed ID:

30497161

Uncontrolled Keywords:

AC = autologous cranioplasty ACE-inhibitors ACEI = angiotensin-converting enzyme inhibitor BFR = bone flap resorption CI = confidence interval CVI = cerebrovascular ischemia DC = decompressive craniectomy EFP = event-free probability HR = hazard ratio ICH = intracerebral hemorrhage IQR = interquartile range PTH = parathyroid hormone RAAS = renin-angiotensin-aldosterone system RR = relative risk SAH = subarachnoid hemorrhage TBI = traumatic brain injury VP = ventriculoperitoneal aseptic osteolysis autologous cranioplasty bone flap resorption bone preservation craniectomy mTTE = median time to event surgical technique

URI:

https://boris.unibe.ch/id/eprint/123027

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