Autologous skull graft resorption following cranioplasty: a case report and literature review.

Background: Autologous cranioplasty remains the first-line option for skull defect repair after decompressive craniectomy, with well-documented advantages of excellent biocompatibility, no immune reaction, and favorable cosmetic outcomes. Autologous skull graft resorption (ASGR) is a common postoperative complication that may lead to recurrent defects, poor cosmesis, and even neurological compromise. Patients with prior ventriculoperitoneal (VP) shunt are at substantially higher risk, yet long-term follow-up data and optimal management strategies in this subgroup remain poorly defined. Case description: A 27-year-old male presented with spontaneous intracerebral hemorrhage secondary to cerebral arteriovenous malformation. He underwent emergency hematoma evacuation, AVM resection, decompressive craniectomy, and ePTFE duraplasty. Postoperatively, VP shunt was placed for communicating hydrocephalus. Autologous cranioplasty was performed two months later. Serial cranial CT follow-up revealed progressive ASGR starting at six months, with marked regional predominance in the occipital stress-bearing area. One year postoperatively, shunt pressure was adjusted upward for decompression window depression. The patient remained asymptomatic throughout a 3-year follow-up without revision cranioplasty. Conclusion: ASGR in VP-shunted patients is driven primarily by chronic intracranial hypotension. This case demonstrates that long-term conservative surveillance with individualized shunt pressure titration is safe and effective for asymptomatic moderate-to-severe ASGR, and that timely pressure adjustment may significantly slow resorption progression. Regional mechanical stress further exacerbates resorption. Routine imaging and close intracranial pressure monitoring are essential for high-risk patients.