Cranioplasty after decompressive craniectomy. A prospective series analyzing complications and clinical improvement

Cranioplasty is carried out for cosmetic reasons and for protection, but it may also lead to some neurological improvement after the bone flap placement. Complications of cranioplasty are more frequent than expected for a scheduled neurosurgical procedure. We tried to identify factors associated with both complications and improvement after cranioplasty.

We prospectively studied the cranioplasties performed in our hospital from November 2009 to November 2013. Patients whose initial reason for bone removal was tumor infiltration were excluded. Demographic, clinical and radiological data were collected. The NIH Stroke Scale and Barthel Self-Care Index scores were obtained both before and within 72 h after cranioplasty. The outcome measures were the occurrences of complications and clinical improvement.

Fifty-five cranioplasties were performed. The material used for the cranioplasty was autologous bone in 42 cases, polyetheretherketone (PEEK) in 7 and methacrylate in 6. The average size of the bone defect was 69.5 (19.5-149.5) cm2. The time elapsed between decompressive craniectomy and cranioplasty was 309 (25-1217) days. There were 10 complications (7 severe and 3 mild), an 18.2% complication rate. Statistically significant risk factors of complications were identified as a Barthel≤70 (Odds ratio [OR] 22; 2.5-192; P=0.005), age over 45 years (OR 13.5; 1.5-115; P=0.01) and early surgery (≤85 days; OR 8; 1.69-37.03, P=0.004). After multivariate analysis, Barthel≤70 and age over 45 years remained independent predictors of complications. Twenty-two (40%) of the 55 patients showed objective improvement. Early surgery (<85 days) increased the likelihood of improvement (OR 4.67; 1.05-20.83; P=0.035). Larger bone defects seemed to be related with improvement, but differences in defect size were not statistically significant (75.3 vs 65.6 cm2; P=0.1).

The complication rate of cranioplasty is higher than for other elective neurosurgical procedures. Older age, poorer functional situation (worse Barthel index score) and early surgery (≤85 days) are independent risk factors for complications. However, cranioplasty produces clinical benefits beyond protection and esthetic improvement. Earlier surgery and larger bone defects seem to increase the likelihood of clinical improvement.