Cranioplasty for patients with disorders of consciousness

Cranioplasty (CP) is necessary for patients with disorders of consciousness (DOC) and skull defects. However, due to the complexity of these conditions, the surgical indications are conservative, and there are few published reports. This study aimed to assess the outcomes and complications of CP in patients with DOC, and to optimize the management of transcalvarial herniation (TCH) and hydrocephalus.

A total of 87 patients with DOC who underwent CP at our center between December 2016 and April 2019 were selected. The patients were divided into traumatic brain injury (TBI) and non-TBI groups, and the complications, outcomes, and costs were compared. Factors associated with prognosis and surgical complications were identified using multivariate logistic regression analysis.

Postoperative complications occurred in 18 patients (20.7%). The complication rate was higher in the TBI group than in the non-TBI group (P=0.031). Preoperative ventriculoperitoneal shunt (VPS) was identified as a risk factor for incision complication (P=0.032), and non-traumatic cause tended to be a protective factor against postoperative hydrocephalus (P=0.055). One year after CP, 25 patients (28.7%) regained full consciousness [Extended Glasgow Outcome Scale (GOSE) ≥3] and 10 patients (11.5%) achieved partial self-care (GOSE =4). Multivariate analyses revealed that minimally conscious state (MCS) vs. vegetative state/unresponsive wakefulness syndrome (VS/UWS) (P=0.000) and early CP (P=0.023) were potential indicators for the recovery of consciousness.

Our findings suggest that CP is safe in patients with DOC and may be beneficial for the recovery of consciousness. Early surgery and surgery for MCS provide better results. Timely CP in patients with TCH can help to reduce preoperative VPS, control incision complications, and detect and intervene in potential hydrocephalus.