Complications associated with early cranioplasty for patients with traumatic brain injury: a 25-year single-center analysis

Abstract

OBJECTIVE Cranioplasty is a technically simple procedure, although one with potentially high rates of complications. The ideal timing of cranioplasty should minimize the risk of complications, but research investigating cranioplasty timing and risk of complications has generated diverse findings. Previous studies have included mixed populations of patients undergoing cranioplasty following decompression for traumatic, vascular, and other cerebral insults, making results challenging to interpret. The objective of the current study was to examine rates of complications associated with cranioplasty, specifically for patients with traumatic brain injury (TBI) receiving this procedure at the authors’ high-volume level 1 trauma center over a 25-year time period. METHODS A single-institution retrospective review was conducted of patients undergoing cranioplasty after decompression for trauma. Patients were identified and clinical and demographic variables obtained from 2 neurotrauma databases. Patients were categorized into 3 groups based on timing of cranioplasty: early (≤ 90 days after craniectomy), intermediate (91–180 days after craniectomy), and late (> 180 days after craniectomy). In addition, a subgroup analysis of complications in patients with TBI associated with ultra-early cranioplasty (< 42 days, or 6 weeks, after craniectomy) was performed. RESULTS Of 435 patients identified, 141 patients underwent early cranioplasty, 187 patients received intermediate cranioplasty, and 107 patients underwent late cranioplasty. A total of 54 patients underwent ultra-early cranioplasty. Among the total cohort, the mean rate of postoperative hydrocephalus was 2.8%, the rate of seizure was 4.6%, the rate of postoperative hematoma was 3.4%, and the rate of infection was 6.0%. The total complication rate for the entire population was 16.8%. There was no significant difference in complications between any of the 3 groups. No significant differences in postoperative complications were found comparing the ultra-early cranioplasty group with all other patients combined. CONCLUSIONS In this cohort of patients with TBI, early cranioplasty, including ultra-early procedures, was not associated with higher rates of complications. Early cranioplasty may confer benefits such as shorter or fewer hospitalizations, decreased financial burden, and overall improved recovery, and should be considered based on patient-specific factors.

Clinical Outcomes After Ultra-Early Cranioplasty Using Craniectomy Contour Classification as a Patient Selection Criterion

“…Interestingly, older age was associated with having a class A or B flap, whereas younger patients with less atrophic brains were more likely to belong to class C. Although elderly patients are otherwise known to have impaired functional recovery after decompressive craniectomy, 23 our findings may offer an opportunity to offset this effect with earlier cranioplasty for appropriate patients. Notably, the association of younger age with delayed cranioplasty in our population was not mirrored in the trauma-centric populations analyzed in the studies by Eaton et al and Sethi et al 8,9…”

“…Interestingly, older age was associated with having a class A or B flap, whereas younger patients with less atrophic brains were more likely to belong to class C. Although elderly patients are otherwise known to have impaired functional recovery after decompressive craniectomy, 23 our findings may offer an opportunity to offset this effect with earlier cranioplasty for appropriate patients. Notably, the association of younger age with delayed cranioplasty in our population was not mirrored in the traumacentric populations analyzed in the studies by Eaton et al and Sethi et al 8,9 Indication for craniectomy is another important consideration for selecting ultra-early cranioplasty candidates. In our population, patients who were decompressed for subdural hemorrhage or contusion were significantly more likely to undergo ultra-early cranioplasty, whereas patients decompressed for poststroke cerebral edema were more likely to undergo intermediate or late cranioplasty.…”

“…These findings can add further nuance to the results reported in previous studies that focus predominantly on trauma populations. 8,9…”

“…The time point of 6 weeks was chosen as the "ultra-early" end point to include all patients who underwent cranioplasty before the traditionally scheduled 4-to 6-week follow-up appointment, mirroring similar studies. 8,18 Although all patients' bone flaps are stored in a bone bank and were available for use, in select patients, the decision was made to use a custom synthetic polyetheretherketone bone flap for better cosmesis. Cranioplasty operations were performed by 13 neurosurgeons, without the assistance of plastic surgery.…”

The Need for Head Protection Protocols for Craniectomy Patients during Rest, Transfers and Turning

“…Research may also influence surgical decision-making, including cranioplasty timing. Recent systematic-level evidence suggests that performing a cranioplasty earlier (typically before 90 days) is associated with enhanced neurological function ( 6 ) and is likely to better restore cerebral homeostasis ( 15 ) without additional risk of complications ( 16 ). If the arguments outlined in this article are valid, they would add further support toward earlier timing of cranioplasty, here as a means of providing comprehensive and lasting brain protection for the patient.…”