A Delayed Twist in Pediatric Cranioplasty: Four-Year Titanium Mesh Survival Followed by MRSA Infection

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.