Neurosurgical and Scalp Reconstructive Challenges During Craniotomy in the Setting of Cutis Verticis Gyrata

Cutis verticis gyrata (CVG) is a rare condition of the scalp in which thickening of the dermis induces rigid folds and furrows resembling the cerebral cortex. Two forms of primary CVG exist: essential, in which CVG is the only presenting problem, and nonessential, in which the scalp condition occurs along with neuropsychiatric ailments. CVG can also occur secondary to a variety of causes including inflammatory, neoplastic, and metabolic conditions or drug use. A review of the available literature, including description of the epidemiology, pathophysiology, histology, and typical management of CVG, is provided. However, we identified no literature describing the complications of CVG in the setting of a craniotomy.

The patient presented here is a 54-year-old man with CVG who presented with occlusion of the M2/M2 branches of the middle cerebral artery, resulting in malignant cerebral edema, requiring emergent management via decompressive craniectomy. Because of the thickening of the scalp, skin incision was complicated by bleeding and difficulty in achieving hemostasis using Raney clips. Plastic surgery was consulted intraoperatively for assistance with complex closure of the wound in a multilayered fashion. Despite this, the patient's postoperative course was complicated by cerebrospinal fluid leakage due to difficulty in approximating the incision during closure. Subsequent cranioplasty was performed jointly between neurosurgery and plastic surgery.

Despite its rarity, CVG is an important issue for neurosurgeons to understand as it can present complications in performing craniotomy, most notably during the scalp exposure and closure. CVG may also complicate the postoperative course if adequate approximation of the tissues cannot be achieved, resulting in wound infection and/or cerebrospinal fluid leak. The presented patient benefited from a combined neurosurgical and plastic surgical approach that was implemented intraoperatively and continued through the postoperative stages and the subsequent cranioplasty.