A Delayed Twist in Pediatric Cranioplasty: Four-Year Titanium Mesh Survival Followed by MRSA Infection
Dr. Azhar Uddin *, Dr.Yaseen Rauf1, Ayesha Ashar2, Muhammad Faiq Khan3
1. Consultant Neurosurgery, Patel Hospital.
2. MBBS student, Sindh Medical College.
3. MBBS student, Sindh Medical College.
*Correspondence to: Dr. Azhar Uddin, Resident General Surgery, Patel Hospital.
Copyright.
© 2026 Dr. Azhar Uddin, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 13 October 2026
Published: 01 November 2026
DOI: https://doi.org/10.5281/zenodo.23906575
Abstract
Pediatric cranial reconstruction following decompressive craniectomy presents unique challenges, particularly when autologous bone cannot be reused because of infection. We report a child who developed delayed infection and extrusion of titanium mesh four years after cranioplasty. A 2-year-old boy presented following a fall from the first floor with a declining Glasgow Coma Scale score. Computed tomography demonstrated a left subdural hematoma, left parietotemporal fracture and left cerebral parenchymal laceration. Emergency decompressive craniectomy and evacuation of the hematoma were performed, and the bone flap was preserved in the abdominal wall. Subsequently, the abdominal wound became infected, rendering the stored bone flap unsuitable for cranial reconstruction. Therefore, titanium mesh was used for cranioplasty. Four years later, the child presented with scalp swelling followed by spontaneous rupture, purulent discharge and extrusion of the titanium mesh. Surgical exploration revealed frank purulence surrounding the mesh. The infected mesh was completely removed, and culture of the purulent material grew methicillin-resistant Staphylococcus aureus. Intravenous vancomycin was initiated. The patient recovered clinically and was discharged in stable condition. This case highlights the challenges of staged pediatric cranial reconstruction when autologous bone is lost because of donor-site infection and demonstrates the possibility of delayed infection of titanium mesh several years after implantation.
Introduction
Decompressive craniectomy is an accepted medical treatment for selected patients with severe traumatic brain injury and refractory intracranial hypertension. Later, cranioplasty repairs the cranial defect, reestablishes the protective barrier of the skull, and may influence cerebrospinal fluid dynamics and neurological recovery [1,2]. Autologous bone still remains a common reconstructive option. However, the infection, resorption or loss of the bone flap may prevent its reuse [3,4]. In the absence of or in the presence of unsuitable autologous bone for reimplantation, alloplastic materials (e.g. titanium mesh) may be used for cranial reconstruction [4,5].
Titanium mesh is a well-established alloplastic material for cranial reconstruction and has shown favorable outcomes in pediatric patients including good cranial contour and protection of the underlying brain [5]. But surgical-site infection and implant exposure are still recognized complications of titanium cranioplasty [6,7]. Titanium mesh has generally given good results in pediatric patients, but wound infections and late soft-tissue complications have been reported [5].
We report a rare case of a sequence of events in a child who developed infection of the abdominal bone-storage site, rendering the autologous bone flap unsuitable for reimplantation, necessitating titanium mesh cranioplasty. This was followed by delayed mesh exposure and microbiologically confirmed methicillin-resistant Staphylococcus aureus infection approximately 4 years later.
Case Report
A 2-year-old boy weighing 10 kg presented to the emergency department following an accidental fall from the first floor of his house. His Glasgow Coma Scale score was 7/15 and was progressively deteriorating. Computed tomography of the brain revealed a left-sided subdural hematoma, left parietotemporal skull fracture and left cerebral parenchymal laceration. In view of the deteriorating neurological status, he underwent emergency decompressive craniectomy and evacuation of the hematoma.
Postoperatively, the child required mechanical ventilation, sedation and paralysis. He was subsequently weaned from ventilatory support and extubated. During his recovery, he developed one episode of generalized tonic-clonic seizure, which was aborted with diazepam. Electroencephalography demonstrated moderate-to-severe left-sided diffuse cerebral dysfunction with focal slowing and left focal pathology. Medial deviation of the right eye was also noted, suggestive of left sixth cranial nerve palsy. He received intravenous antibiotics and supportive treatment, with gradual neurological improvement. Enteral feeding was initiated through a nasogastric tube and subsequently advanced to a soft diet. He was discharged in a clinically stable condition with a Glasgow Coma Scale score of 15/15.
Following decompressive craniectomy, the autologous bone flap was preserved in the abdominal wall with the intention of subsequent reimplantation during cranioplasty. During the postoperative period, however, the abdominal wound developed infection. Because of the infection at the bone-storage site, the preserved autologous bone flap was considered unsuitable for reimplantation. Consequently, approximately four months after the initial decompressive craniectomy, the patient underwent cranial reconstruction using titanium mesh and titanium plates instead of the stored autologous bone flap. The postoperative course following cranioplasty was initially uneventful.
Approximately four years after titanium mesh placement, at the age of 6 years, the patient presented with protrusion of the titanium mesh through the scalp(Image 1.0). Initially, the protrusion was concealed by an overlying fluctuant swelling. The swelling subsequently ruptured, resulting in purulent discharge from the mesh site(Image 2.0) The presentation was associated with intermittent fever over the preceding month and localized sharp pain.
Complete blood count and renal function tests were within normal limits. Contrast-enhanced computed tomography of the brain with bone-window images demonstrated a large left frontoparietotemporal skull defect covered by metallic prosthesis. Extensive encephalomalacia and gliosis were present involving the left frontoparietal and temporal lobes, with ipsilateral ex-vacuo dilatation of the lateral ventricle. No midline shift or significant mass effect was identified.
The patient was admitted with the diagnosis of infected titanium mesh. The previous surgical incision was explored under general anesthesia. Intraoperatively, the titanium mesh was found to be grossly infected, with frank purulent material surrounding the implant.(Image 3.0) A specimen of the purulent material was obtained and sent for microbiological culture and sensitivity. The infected titanium mesh was carefully dissected and completely removed(Image 4.0).The operative field was thoroughly irrigated with copious amounts of normal saline.
Culture of the purulent material grew methicillin-resistant Staphylococcus aureus. Intravenous vancomycin was subsequently initiated. The postoperative course was uneventful. The patient remained clinically and hemodynamically stable, with no postoperative fever, tolerated a regular diet and was mobilized. He was subsequently discharged in stable condition with follow-up arranged in the neurosurgical outpatient clinic.
Discussion
This case demonstrates a complex sequence of complications following decompressive craniectomy in a young child. The initial indication for surgery was severe traumatic brain injury with subdural hematoma, skull fracture and cerebral parenchymal injury. Following decompressive craniectomy, the autologous bone flap was preserved with the intention of using it for subsequent cranioplasty. Autologous bone is frequently used in pediatric cranioplasty due to its biocompatibility, but pediatric patients are at high risk for delayed bone-flap resorption after autologous reconstruction [8,9].
In the present case the autologous bone flap was primarily placed in the abdominal wall for re-implantation, but became no longer suitable due to infection of the storage site. The subcutaneous space of the abdomen is a preferred location for preserving autologous bone flaps, but surgical-site infection is a known complication of this technique [10].] In a retrospective cohort of patients who had cranioplasty with abdominally preserved bone flaps, the rate of surgical site infection was 15.7%, implying that infection at the storage site could have considerable consequences for subsequent reconstruction [10]. Alloplastic reconstruction is an option when autologous bone cannot be reused. Titanium mesh is one of the materials for pediatric cranial reconstruction [4,5].
The clinical satisfactory function of titanium mesh in the following four years is remarkable. Pediatric data suggest that titanium mesh provides good cranial reconstruction with relatively favorable intermediate-term results; however, late soft-tissue complications and wound infections have been reported [5]. Late soft-tissue complications requiring resection of part of the mesh occurred in 2 patients in a pediatric series of 33 titanium mesh cranioplasties, with follow-up extending to more than 6 years in some patients [5]. These findings highlight the necessity of long-term follow-up even in the absence of complications in the immediate postoperative period.
The present case is of particular interest because of the delayed presentation at approximately four years post-implantation with progression of the swelling to spontaneous rupture, purulent discharge and extrusion of the mesh. Implant exposure is a known complication of titanium cranioplasty and a systematic review and meta-analysis found that titanium cranioplasty was associated with a significantly increased risk of implant exposure compared to non-titanium material [6]. Long-term outcome data also suggest that titanium mesh can provide durable reconstruction in isolated cranial defects, but that outcomes may be less favorable when there are significant soft-tissue problems as well [7].
In our patient, routine laboratory investigations were not markedly abnormal despite clinically significant localized infection. This underscores the fact that normal systemic laboratory parameters do not exclude the presence of an implant-associated infection in the face of local signs such as swelling, pain, wound breakdown, purulent discharge or implant exposure. Diagnosis in this case was finally made on the basis of operative findings of frank purulence and microbiological isolation of methicillin-resistant Staphylococcus aureus.
Management of infected neurosurgical implants has to take into account surgical and antimicrobial therapy. Treatment depends on the extent of infection, implant involvement and the clinical condition [11]]. In this patient, source control was achieved surgically by complete removal followed by irrigation and culture directed antimicrobial therapy as the titanium mesh was grossly infected and exposed. Although there are reported cases of cranioplasty-associated infection with retained implants, wound drainage and other clinical factors may affect the probability of successful implant salvage [11,12].
In this case the sequence was unusual, with infection first involving the abdominal bone-storage site, thus requiring alloplastic reconstruction, and a separate late infection occurred around the titanium implant around four years later. This highlights two distinct infectious risks at different points in staged cranial reconstruction: complications that impact preservation of the autologous bone flap and subsequent complications involving the alloplastic implant.
This case emphasizes that titanium mesh can serve as a durable solution for cranial reconstruction in pediatric patients when autologous bone is not available, but may be associated with late wound complications and implant infection even years after a clinically uneventful course.
Therefore, long-term clinical surveillance is important and the development of a new scalp swelling, tenderness, wound breakdown, purulent drainage or implant exposure should prompt evaluation for a possible cranial implant infection.
Conclusion
This case presents a challenging situation in paediatric cranial reconstruction where infection at the abdominal storage site of the bone necessitated replacement of the planned autologous cranioplasty with titanium mesh, with subsequent delayed infection and extrusion of the titanium implant about four years later. Titanium mesh can be a good option for cranioplasty in paediatric patients. However, complications such as infection, wound problems and implant related complications have been reported [1,2].
Although the titanium mesh remained clinically stable for several years, but late scalp swelling, pain, wound breakdown, and purulent drainage ultimately heralded a deep, implant-related infection. However, in this patient, important localised infection could not be ruled out using normal routine laboratory parameters. Microbiological confirmation of MRSA underscores the need for intraoperative cultures in case of suspected infection of a cranial implant.
Because the mesh was heavily infected and exposed, total removal, copious irrigation, and culture-directed antimicrobial therapy were performed. The patient recovered clinically. Infections of neurosurgical implants necessitate assessment of the extent of infection and appropriate combined surgical and antimicrobial therapy [3].
This case emphasises the need for long-term clinical follow-up of paediatric patients undergoing staged cranioplasty, particularly when alloplastic materials are used secondary to unavailability of autologous bone. Early evaluation for possible cranial implant infection is indicated in the setting of new scalp swelling, tenderness, wound breakdown, purulent drainage, or exposure of the implant [1,2].
Reference