Title: Early versus Late Cranioplasty Following Decompressive Craniectomy: A Systematic Review and Meta-analysis
Authors: Muhammad Hassan Waseem, Zain ul Abideen, Sania Aimen, Justin Chen, Jamir Pitton Rissardo, Brandon Lucke-Wold
Conference: 2025 CNS Annual Meeting, Los Angeles, CA
Introduction
Following decompressive craniectomy, a subsequent cranioplasty is required. Complications associated with cranioplasty may arise independent of the initial craniectomy performed.
Objectives
This meta-analysis aims to compare the safety and effectiveness of early versus late cranioplasty following decompressive craniectomy.
Methods
A literature search was performed on PubMed, ScienceDirect, and the Cochrane Library from inception till October 2024. The Risk Ratios (RR) and Mean Differences (MD), along with the 95 % Confidence Interval (CI), were pooled under the random effects model using the Review Manager version 5.4.1 for the dichotomous and continuous outcomes, respectively. The primary outcome was overall complications. The secondary endpoints analyzed were postoperative infections, postoperative subdural fluid collections, mean operative time, and incidence of hydrocephalus. The quality assessment was conducted using the Newcastle-Ottawa Scale (NOS). A sensitivity analysis was performed to investigate the source of heterogeneity. Publication bias was assessed visually through the funnel plots and statistically through Egger’s regression test.
Results
Twenty-one studies, pooling 3,178 patients, were included in this meta-analysis. Early cranioplasty was comparable to late cranioplasty regarding the overall complications (RR= 1.15; 95% CI: [0.86,1.54]; p= 0.35; I2 = 59%), postoperative infections (RR= 0.88; 95% CI: [0.52,1.47]; p=0.62; I2 =0%), and hydrocephalus (RR=1.22; 95% CI: [0.57,2.60]; p=0.60; I2 =74%). Regarding the postoperative subdural fluid collection, the early cranioplasty was significantly superior to the late cranioplasty with an RR of 0.29 (95% CI: [0.11,0.78]; p=0.01; I2 =0%). The mean operative time was also comparable between the two arms (MD= -14.98 min; 95% CI: [-36.98,7.02]; p=0.18; I2 =90%).
Conclusions
Early cranioplasty was comparable to late cranioplasty in terms of overall complications, postoperative infections, hydrocephalus, and mean operative time. The risk of postoperative subdural fluid collection was significantly reduced in early cranioplasty.
Citation
Waseem MH, Abideen Z, Aimen S, Chen J, Pitton Rissardo J, Lucke-Wold B. Early versus Late Cranioplasty Following Decompressive Craniectomy: A Systematic Review and Meta-analysis. CNS Annual Meeting 2025;2025:4327. https://www.cns.org/poster-search?id=4327
Figure. Forest plots comparing risk ratios for overall complications and hydrocephalus between early and late cranioplasty after decompressive craniectomy.
Figure. Forest plots comparing post-operative infections, subdural fluid collection, and operative time between early (EC) and delayed (DC) cranioplasty.