J Korean Neurosurg Soc.  2024 Jan;67(1):103-114. 10.3340/jkns.2023.0143.

Risk Factor Analysis of Cryopreserved Autologous Bone Flap Resorption in Adult Patients Undergoing Cranioplasty with Volumetry Measurement Using Conventional Statistics and Machine-Learning Technique

• Son Y
• Chung J

• KMID: 2550464
• DOI: http://doi.org/10.3340/jkns.2023.0143

Abstract

Objective
: Decompressive craniectomy (DC) with duroplasty is one of the common surgical treatments for life-threatening increased intracranial pressure (ICP). Once ICP is controlled, cranioplasty (CP) with reinsertion of the cryopreserved autologous bone flap or a synthetic implant is considered for protection and esthetics. Although with the risk of autologous bone flap resorption (BFR), cryopreserved autologous bone flap for CP is one of the important material due to its cost effectiveness. In this article, we performed conventional statistical analysis and the machine learning technique understand the risk factors for BFR.
Methods
: Patients aged >18 years who underwent autologous bone CP between January 2015 and December 2021 were reviewed. Demographic data, medical records, and volumetric measurements of the autologous bone flap volume from 94 patients were collected. BFR was defined with absolute quantitative method (BFR-A) and relative quantitative method (BFR%). Conventional statistical analysis and random forest with hyper-ensemble approach (RF with HEA) was performed. And overlapped partial dependence plots (PDP) were generated.
Results
: Conventional statistical analysis showed that only the initial autologous bone flap volume was statistically significant on BFR-A. RF with HEA showed that the initial autologous bone flap volume, interval between DC and CP, and bone quality were the factors with most contribution to BFR-A, while, trauma, bone quality, and initial autologous bone flap volume were the factors with most contribution to BFR%. Overlapped PDPs of the initial autologous bone flap volume on the BRF-A crossed at approximately 60 mL, and a relatively clear separation was found between the non-BFR and BFR groups. Therefore, the initial autologous bone flap of over 60 mL could be a possible risk factor for BFR.
Conclusion
: From the present study, BFR in patients who underwent CP with autologous bone flap might be inevitable. However, the degree of BFR may differ from one to another. Therefore, considering artificial bone flaps as implants for patients with large DC could be reasonable. Still, the risk factors for BFR are not clearly understood. Therefore, chronological analysis and pathophysiologic studies are needed.

Keyword

Bone flap resorption; Cranioplasty; Random forest; Machine learning

Figure

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  Fig. 1. Chronological presentation of relative autologous bone flap volume. The spaghetti plot autologous bone flap volume shows that most of the autologous bone flap volume decreases over time.

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  Fig. 2. Importance of variable on impact of bone flap resorption (BFR). Importance of variable on impact of BFR is calculated with MDA (A and B) and MDG (C and D). Initial bone flap volume and interval between DC and CP was the most impact variable in BFR-A (A and C). Top ranked variables in MDA and MDG were not constant in BFR%. MDA : mean decreased accuracy, BFR-A : definition of BFR in absolute quantitative method, HU : Hounsfield unit, GCS : Glasgow coma scale, KPS : Karnofsky performance scale, HTN : hypertension, DM : diabetes mellitus, Op. : operation, MDG : mean decreased Gini, BFR% : definition of BFR in and relative quantitative method, DC : decompressive craniectomy, CP : cranioplasty.

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  Fig. 3. Overlapped partial dependence plots (PDP) of result of random forest with hyper-ensemble approach (RF with HEA). Top ranked variables from importance calculation according to mean decreased accuracy from RF with HEA are visualize with overlapped PDPs to reveal the effect of individual factors on the target. If the PDP plot widely apart, the factor is more capable of classifying bone flap resorption (BFR). However, initial bone flap volume seems to be the only potential risk factor for bone flap resorption. BFR-A : definition of BFR in absolute quantitative method, BFR% : definition of BFR in and relative quantitative method, DC : decompressive craniectomy, CP : cranioplasty, HU : Hounsfield unit, GCS : Glasgow coma scale.

Reference

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