Reconsidering Surgical Intervention for Infection After Cranioplasty in Older Adults: A Case Report

Post-cranioplasty infection with scalp breakdown in older adults poses a difficult reconstructive problem, particularly when frailty and cognitive impairment may limit tolerance for staged procedures. Although debridement, infection control, and delayed cranioplasty are often considered standard management, the extent of reconstruction that should be pursued in elderly patients remains uncertain. We report the case of a woman in her late 80s who developed scalp loss with exposure of a synthetic cranial implant eight months after cranioplasty following surgery for acute subdural hematoma. On admission, head computed tomography showed no intracranial infection, while three-dimensional computed tomography angiography demonstrated preserved patency of the superficial temporal artery with residual blood supply around the defect. Because her advanced age, cognitive impairment, and the anticipated burden of staged reconstruction raised concern about tolerance for repeated procedures, treatment was directed toward infection control and durable wound closure without repeat cranioplasty. Removal of the implant revealed an epidural abscess, and thorough debridement was performed. Under the infected artificial dura, a well-formed fibrous capsule was identified and used for duraplasty. The scalp defect was reconstructed with a free latissimus dorsi musculocutaneous flap and split-thickness skin grafting. No recurrent infection developed, although postoperative delirium limited rehabilitation and functional recovery. This case highlights that delayed recognition of wound complications in cognitively vulnerable older adults can allow progression to extensive defects and that omission of cranioplasty may be a reasonable endpoint in selected patients when durable soft-tissue coverage and infection control take precedence over anatomical restoration.