The grim truth in Murphýs law: Routine subgaleal suction drain may cause rapid and fatal brain damage

Purpose: Cranioplasty is most commonly performed after decompressive hemicraniectomy and serves on the one hand for protection of the underlying brain tissue, on the other hand this surgery is also indicated for cosmetic reasons. In addition, patients may experience clinical improvement after this procedure, which can be explained by normalization of the CSF (Cerebrospinal fluid) and cerebral blood flow. However, this (usually underestimated) procedure is associated with one of the the highest complication rates in neurosurgery. Results: We report a case with a fatal outcome after routine cranioplasty utilizing PEEK (polyetheretherketone) implant due to a cerebrospinal fluid fistula. Conclusion: Cranioplasty after decompressive hemicraniectomy can restore aesthetics, ensures protection, and often leads to neurologic improvement in patients. However, it is one of the procedures with the highest complication rates in neurosurgery, and it should not be underestimated. The use of a drain with suction can have fatal consequences, especially when dural integrity is compromised and when there is intracranial room for considerable volume shift, e.g. after hemispheric infarction.