颅骨成形术的最佳时机和颅骨成形术后总并发症的预测因素:脑塌陷的影响Optimal Timing of Cranioplasty and Predictors of Overall Complications After Cranioplasty: The Impact of Brain Collapse

Abstract

BACKGROUND: 

The optimal timing of cranioplasty (CP) and predictors of overall postoperative complications are still controversial.

OBJECTIVE: 

To determine the optimal timing of CP.

METHODS: 

Patients were divided into collapsed group and noncollapsed group based on brain collapse or not, respectively. Brain collapse volume was calculated in a 3-dimensional way. The primary outcomes were overall complications and outcomes at the 12-month follow-up after CP.

RESULTS: 

Of the 102 patients in this retrospective observation cohort study, 56 were in the collapsed group, and 46 were in the noncollapsed group. Complications were noted in 30.4% (n = 31), 24 (42.9%) patients in the collapsed group and 7 (15.2%) patients in the noncollapsed group, with a significant difference (P = .003). Thirty-three (58.9%) patients had good outcomes (modified Rankin Scale 0-3) in the collapsed group, and 34 (73.9%) patients had good outcomes in the noncollapsed group without a statistically significant difference (P = .113). Brain collapse (P = .005) and Karnofsky Performance Status score at the time of CP (P = .025) were significantly associated with overall postoperative complications. The cut-off value for brain collapse volume was determined as 11.26 cm³ in the receiver operating characteristic curve. The DC-CP interval was not related to brain collapse volume or postoperative complications.

CONCLUSION: 

Brain collapse and lower Karnofsky Performance Status score at the time of CP were independent predictors of overall complications after CP. The optimal timing of CP may be determined by tissue window based on brain collapse volume instead of time window based on the decompressive craniectomy-CP interval.

背景:

颅骨成形术(CP)的最佳时机和总体术后并发症的预测因素仍然存在争议。

摘要目的:

确定CP的最佳时机。

方法:

根据有无脑塌陷情况将患者分为塌陷组和非塌陷组。脑塌陷体积以三维方式计算。主要结果是总并发症和CP术后12个月随访的结果。

结果:

本回顾性观察队列研究102例患者中，塌陷组56例，非塌陷组46例。塌陷组并发症发生率30.4% (n = 31)，塌陷组24例(42.9%)，非塌陷组7例(15.2%)，差异有统计学意义(P = 0.003)。塌陷组有33例(58.9%)患者预后良好(改良Rankin量表0-3)，未塌陷组有34例(73.9%)患者预后良好，差异无统计学意义(P = 0.113)。CP时脑塌陷(P = 0.005)和Karnofsky Performance Status评分(P = 0.025)与术后总并发症显著相关。在受试者工作特征曲线上确定脑塌陷体积的临界值为11.26 cm3。DC-CP间期与脑塌陷量及术后并发症无关。

结论:

CP时脑塌陷和较低的Karnofsky Performance Status评分是CP后总并发症的独立预测因子。CP的最佳时机可以通过基于脑塌陷体积的组织窗口来确定，而不是基于减压开颅-CP间隔时间的时间窗口。

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ABBREVIATIONS:

AUC area under the curve CP cranioplasty CT computed tomography DCdecompressive craniectomy ICH intracranial hemorrhage OR odds ratio PEEKpolyetheretherketone KPS Karnofsky Performance Status ROC receiver operating characteristic VP ventriculoperitoneal shunt.

Decompressive craniectomy (DC) is a standard neurosurgical procedure to reduce intracranial pressure by removing a variable size of bone, which can be lifesaving in patients with traumatic brain injury, intracranial hemorrhage (ICH), cerebral infarction, aneurysmal subarachnoid hemorrhage, and arteriovenous malformation rupture.^1-5 However, there is a risk of further neurotrauma due to a lack of skull protection after DC.^6-10 Cranioplasty (CP) is performed to restore skull protection and craniofacial cosmesis.^11-17

As a regular procedure after DC, CP is associated with a high incidence of postoperative complications, including infection, epidural hematoma, ICH, hydrocephalus, seizure, and epidural/subdural fluid collections.^18-24 Many studies suggest that the DC-CP interval and surgery materials may be related to complications after CP.^25-27 Whereas factors influencing postoperative complications remain controversial, there are very few reports concerning the relationship between brain collapse and postoperative complications.

CP was usually taken 3 months after DC because the cerebral swelling subsided for most survivors then. Early CP was defined as less than 3 months since DC. Many neurosurgeons reported that early CP is associated with more remarkable neurological improvement and advocated early CP. Nevertheless, the optimal timing of CP remains controversial. Some studies suggested that the proper CP timing should be measured based on the degree of brain collapse after DC rather than a simple passage of time. However, good indicators have not been found to describe the degree of brain collapse.

Therefore, this study aimed to analyze the independent risk factors of complications after CP and elucidate the potential correlation between brain collapse volume and prognosis. We hope that the study can offer some critical insights into CP for determining the optimal timing of CP.

METHODS

Study Design

We designed a retrospective observational single-center cohort study. It was conducted following the Code of Ethics of the World Medical Association (Declaration of Helsinki) and was approved by the Ethics Committee. Given its retrospective nature, no additional patient informed consent specific to this study was required.

All adult patients who underwent CP at our institution between 2018 and 2020 were identified. The inclusion criteria for patient enrollment were as follows: (1) with a unilateral frontotemporoparietal skull defect after DC and (2) underwent CP for the first time. Exclusion criteria were (1) DC for other reasons in addition to traumatic brain injury and stroke, such as tumor or brain abscess, (2) patients younger than 18 years, (3) ventriculoperitoneal shunt (VP-shunt) before CP, (4) underwent other procedures combined with CP, (5) without computed tomography (CT) scan within 2 weeks before CP or 24 hours after CP, and (6) lost to follow-up. Patients were divided into 2 groups based on the brain bulging classification. Patients with brain collapse were in the collapsed group, while others were in the noncollapsed group. We studied and compared the baseline characteristics, surgical details, postoperative complications, and outcomes between the 2 groups. The primary endpoint was postoperative complications at the 12-month follow-up after CP. The secondary endpoint was the modified Rankin Scale (mRS) at 12 months after CP.

Clinical Management

A standardized clinical treatment protocol was used to manage these patients. An experienced neurosurgeon performed CP at an attending level or above using titanium mesh or polyetheretherketone. All patients underwent CP along the original incision under general anesthesia. A subgaleal drain catheter was placed during surgery and removed 24 to 48 hours after surgery. A brain CT scan was performed within 24 hours after surgery to detect postoperative complications.

Data Collection and Definition

Data were collected based on electric medical records, including demographic information (age and sex), medical history (hypertension, diabetes, and epilepsy), craniectomy indication, skull defect side and size, brain collapse volume, brain collapse ratio, preoperative Karnofsky Performance Status (KPS), the DC-CP interval, surgical details (materials used for reconstruction, blood loss, and operative time of CP), postoperative complications (surgical-site infection, epidural hematoma, ICH, postoperative hydrocephalus, postoperative seizure, and epidural/subdural fluid collections), and outcomes (mRS at 12-month follow-up).

Using the “Object Creation” function of Brainlab Planning Station (Brainlab Co), the intracranial volume before CP and 24 hours after CP were reconstructed. Moreover, the brain collapse volume was calculated by intracranial volume difference before and after CP. A positive value indicated brain collapse, and a negative or 0 indicated brain bulge/flaccid (Figure 1). Brain collapse ratio was described as the ratio of the median length from the scalp to the midline to the length from the midline to the contralateral inner table at the CT section of the maximum size of the defect (Figure 2).^28,29

Surgical-site infection is an incision or intracranial infection with symptoms or physical signs. The epidural hematoma was defined as a high-density shadow on postoperative CT and midline shift compared with preoperative CT (Figure 3). Postoperative hydrocephalus was defined as hydrocephalus-related clinical symptoms (headache, nausea, and decreased mental status), the presence of ventriculomegaly on imaging after surgery, and treated by VP shunt. Two experienced neuroradiologists performed an imaging evaluation, unaware of the other variables or outcomes.

Statistical Analysis

All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 19.0 (IBM Corp). Continuous variables were presented as mean ± SD, and categorical variables were expressed as counts with percentages. The independent samples t-test or the Mantel-Haenszel test was used for continuous variables, and the χ² test or the Fisher exact test was used for categorical variables. A binary logistic regression model was performed to identify potential predictors of complications after CP. The receiver operating characteristic curve was used to test the model’s prediction ability and establish the cut-off value of brain collapse volume for predicting overall complications after CP. Linear regression was used to determine the relationship between brain collapse volume, collapse ratio, and the DC-CP interval. Variables with a P < .20 in univariate analysis were entered into the multivariate analysis model. The results with P < .05 were considered statistically significant.

RESULTS

Patient Population

During the study period, 150 consecutive patients with a unilateral frontotemporoparietal skull defect after DC underwent CP for the first time at our institution. Nine patients with DC for tumor, 9 patients were younger than 18 years, 7 patients with VP shunt before CP, 20 patients without CT scan within 2 weeks before CP, and 3 patients were lost to follow-up. Therefore, 102 patients were enrolled in this study (Figure 4).

Patient Characteristics

Baseline characteristics are presented in Table 1. One hundred and two patients were included in this study, including 73 (71.6%) male patients and 29 (23.4%) female patients. The mean age was 49.30 ± 12.26 years. The mean brain collapse volume was −7.83 ± 63.03 cm³. The mean brain collapse ratio was 0.97 ± 0.27. The mean DC-CP interval was 164.01 ± 164.70 days. There were 56 patients in the collapsed group and 46 in the noncollapsed group. DC-CP interval was longer in the collapsed group with a significant difference (P = .003). There was no significant difference (P > .05) in other baseline characteristics in the 2 groups.

TABLE 1. – Baseline Characteristics of Patients

Characteristics	Total	Collapsed group	Noncollapsed group	P value
No. of patients	102	56 (54.9)	46 (45.1)
Age, y				.325
Mean ± SD	49.30 ± 12.26	50.39 ± 11.67	47.98 ± 12.93
Sex, N (%)				.197
Male	73 (71.6)	43 (76.8)	30 (65.2)
Female	29 (28.4)	13 (23.2)	16 (34.8)
Hypertension, N (%)	33 (32.4)	14 (25.0)	19 (41.3)	.080
Diabetes, N (%)	10 (9.8)	7 (12.5)	3 (6.5)	.312
Epilepsy, N (%)	5 (4.9)	2 (3.6)	3 (6.5)	.492
Craniectomy indication, N (%)				.590
Trauma	54 (52.9)	31 (55.4)	23 (50.0)
Stroke	48 (47.1)	25 (44.6)	23 (50.0)
Skull defect side				.076
Left	52 (51.0)	33 (58.9)	19 (41.3)
Right	50 (49.0)	23 (41.1)	27 (58.7)
Skull defect size, cm2				.370
Mean ± SD	86.64 ± 13.43	85.56 ± 13.31	87.96 ± 13.60
Brain collapse volume, cm3				<.001
Mean ± SD	−7.83 ± 63.03	39.33 ± 30.25	−65.24 ± 40.77
Brain collapse ratio				<.001
Mean ± SD	0.97 ± 0.27	0.79 ± 0.18	1.18 ± 0.22
KPS score at the time of CP				.302
Mean ± SD	53.43 ± 32.99	56.25 ± 33.06	50.00 ± 32.93
DC-CP interval, d				.003
Mean ± SD	164.01 ± 164.70	192.14 ± 199.01	129.76 ± 101.43

CP, cranioplasty; DC, decompressive craniectomy; KPS, Karnofsky Performance Status.

Surgical Details

The surgical details are displayed in Table 2. Twenty-six (25.5%) patients underwent early surgery. The operative time was shorter in the collapsed group with a significant difference (P = .006). The materials used for reconstruction and the intraoperative blood loss showed no difference in these 2 groups.

TABLE 2. – Surgical Details of Patients

Surgical details	Total	Collapsed group	Noncollapsed group	P value
Early surgery, N (%)	26 (25.5)	10 (17.9)	16 (34.8)	.051
Materials used for reconstruction, N (%)				.799
Titanium mesh	90 (88.2)	49(87.5)	41 (89.1)
PEEK	12 (11.8)	7 (12.5)	5 (10.9)
Blood loss, mL				.973
Mean ± SD	173.04 ± 103.42	173.21 ± 105.88	172.83 ± 101.49
Operative time, minutes				.006
Mean ± SD	166.25 ± 47.52	156.95 ± 47.72	177.59 ± 45.24

PEEK, polyetheretherketone.

Postoperative Complications

Major postoperative complications are summarized in Table 3. Complications were noted in 30.4% of the patients (n = 31), to be more precise, 24 patients (42.9%) in the collapsed group and 7 patients (15.2%) in the noncollapsed group, with a significant difference (P = .003). The most common complication was postoperative hydrocephalus (n = 10), and it was seen in 14.3% (n = 8) in the collapsed group and 4.3% (n = 2) in the noncollapsed group requiring VP shunt, without a significant difference (P = .093). The epidural hematoma was seen in 7.8% of the patients (n = 8), and these patients were all in the collapsed group with a significant difference (P = .008). The implant failure rate was 1.0% (n = 1), due to surgical-site infection.

TABLE 3. – Postoperative Complications of Patients

Postoperative complications	Total	Collapsed group	Noncollapsed group	P value
Overall complications, N (%)	31 (30.4)	24 (42.9)	7 (15.2)	.003
Surgical-site infection	4 (3.9)	3 (5.4)	1 (2.2)	.410
Epidural hematoma	8 (7.8)	8 (14.3)	0 (0.0)	.008
ICH	4 (3.9)	3 (5.4)	1 (2.2)	.410
Postoperative hydrocephalus	10 (9.8)	8 (14.3)	2 (4.3)	.093
Postoperative seizure	8 (7.8)	5 (8.9)	3 (6.5)	.653
Epidural/subdural fluid collections	7 (6.9)	4 (7.1)	3 (6.5)	.902
Implant failure, N (%)	1 (1.0)	1 (1.8)	0 (0.0)	.362

ICH, intracranial hemorrhage.

Outcomes

At the 12-month follow-up, there were 3 (3.0%) deaths. Two deaths were from lung infections and 1 from cerebral infarction; these patients were all in the collapsed group. Thirty-three (58.9%) patients had good outcomes (mRS 0-3) in the collapsed group, and 34 (73.9%) patients had good outcomes in the noncollapsed group without a statistically significant difference (P = .113) (Figure 5).

Predictors of Overall Complications

The results of the univariate analysis for overall postoperative complications are presented in Table 4. Brain collapse (P = .003), brain collapse volume (P = .001), and brain collapse ratio (P = .003) were associated with overall postoperative complications. All preoperative variables (sex, hypertension, brain collapse, KPS score at the time of CP, materials used for reconstruction, and blood loss) with a significance level at P < .20 in the univariate analysis were included in the multivariate logistic regression model. Owing to the collinearity among brain collapse, brain collapse volume, and brain collapse ratio, only brain collapse was included in the multivariate analysis. After adjustment for potential confounding variables, brain collapse (odds ratio = 4.454, 95% CI = 1.568-12.634, P = .005) and KPS score at the time of CP (odds ratio = 0.982, 95% CI = 0.967-0.998, P = .025) remained significantly associated with overall postoperative complications (Table 5).

TABLE 4. – Univariate Analysis for Overall Postoperative Complications

Characteristics	Complication (−)	Complication (+)	P value
No. of patients	71 (69.6)	31 (30.4)
Age, y			.582
Mean ± SD	48.86 ± 12.10	50.32 ± 12.75
Sex, N (%)			.179
Male	48 (67.6)	25 (80.6)
Female	23 (32.4)	6 (19.4)
Hypertension, N (%)	26 (36.6)	7 (22.6)	.163
Diabetes, N (%)	7 (9.9)	3 (9.7)	.977
Epilepsy, N (%)	4 (5.6)	1 (3.2)	.604
Craniectomy indication, N (%)			.493
Trauma	36 (50.7)	18 (58.1)
Stroke	35 (49.3)	13 (41.9)
Skull defect side			.933
Left	36 (50.7)	16 (51.6)
Right	35 (49.3)	15 (48.4)
Skull defect size, cm2			.278
Mean ± SD	85.68 ± 12.78	88.84 ± 14.79
Brain collapse, N (%)	32 (45.1)	24 (77.4)	.003
Brain collapse volume, cm3			.001
Mean ± SD	−21.34 ± 62.03	23.13 ± 54.54
Brain collapse ratio			.004
Mean ± SD	1.02 ± 0.28	0.86 ± 0.24
KPS score at the time of CP			.186
Mean ± SD	56.06 ± 32.88	47.42 ± 32.96
DC-CP interval, d			.471
Mean ± SD	168.23 ± 183.09	154.35 ± 113.85
Early surgery, N (%)	18 (25.4)	8 (25.8)	.961
Materials used for reconstruction, N (%)			.116
Titanium mesh	65 (91.5)	25 (80.6)
PEEK	6 (8.5)	6 (19.4)
Blood loss, mL			.121
Mean ± SD	163.38 ± 100.11	195.16 ± 109.05
Operative time, min			.365
Mean ± SD	162.21 ± 44.74	175.52 ± 52.97

CP, cranioplasty; DC, decompressive craniectomy; KPS, Karnofsky Performance Status; PEEK, polyetheretherketone.

TABLE 5. – Multivariate Analysis for Predictors of Overall Postoperative Complications

Predictors	Unadjusted		Adjusted
	OR (95% CI)	P value	OR (95% CI)	P value
Sex	0.501 (0.181-1.389)	.184	0.504 (0.155-1.636)	.254
Hypertension	0.505 (0.191-1.332)	.167	0.469 (0.149-1.483)	.198
Brain collapse	4.179 (1.595-10.946)	.004	4.451 (1.568-12.634)	.005
KPS score at the time of CP	0.992 (0.979-1.005)	.224	0.982 (0.967-0.998)	.025
Materials used for reconstruction	2.600 (0.766-8.824)	.125	3.308 (0.790-13.862)	.102
Blood loss	1.003 (0.999-1.007)	.156	1.003 (0.998-1.007)	.250

CP, cranioplasty; KPS, Karnofsky Performance Status; OR, odds ratio.

Brain Collapse Volume

Linear regression analysis showed that the brain collapse ratio was significantly associated with brain collapse volume (Figure 6). The linear regression equation was Brain collapse volume = 166.130 −179.203 × Brain collapse ratio (R² = 0.610, P < .001). The area under the curve of brain collapse volume was 0.708 (95% CI = 0.600-0.816, P < .001), and the area under the curve of brain collapse ratio was 0.678 (95% CI = 0.566-0.790, P < .004). The cut-off value for brain collapse volume as a predictor for overall postoperative complications was determined as 11.26 cm³ in the receiver operating characteristic curve (the sensitivity was 69.0%, and the specificity was 67.7%) (Figure 7). No significant correlation was found between brain collapse volume and the DC-CP interval (R² = 0.032, P = .071) (Figure 8).

DISCUSSION

In this retrospective analysis, we have discussed the predictors of overall complications after CP to determine the optimal timing of CP. Patients were divided into the collapsed group and noncollapsed group based on brain collapse or not, respectively. We found that the collapsed group had a significantly higher incidence of postoperative complications. Brain collapse and lower KPS score at the time of CP were independent predictors of overall postoperative complications. In addition, there was a linear relationship between the brain collapse volume and the collapse ratio, but the brain collapse volume had a test efficiency than the collapse ratio. Furthermore, patients with a brain collapse volume of more than 11.26 cm³ may be more prone to postoperative complications.

The Optimal Timing of CP: Tissue Window and Time Window

Currently, most studies agree that 3 months after DC was the time window for CP. However, the timing of CP remains controversial. Some studies have shown that earlier CP benefits the patients.^30-36 Others have shown that early CP is associated with more complications after CP.^37,38 At the same time, some systematic reviews have indicated no difference in the DC-CP interval.^27,39,40

On the contrary, a recent consensus has suggested that the timing of CP should consider the state of brain collapse, but there is a lack of more clinical evidence.⁴¹ In our study, we found that patients with brain collapse were more prone to postoperative complications than patients with brain bulge/flaccid. No significant correlation was found between the DC-CP interval and postoperative complications. We proposed the concept of tissue window, described by the degree of brain collapse. The tissue window based on the degree of brain collapse rather than the time window predicted overall postoperative complications. In addition, we did not find a relationship between the tissue window and the time window.

A possible explanation is as follows. DC leaves skull defects in the brain, making it vulnerable to atmospheric pressure. Once the effect of intracranial hypertension disappears, this pressure gradient will compress the brain parenchyma, resulting in brain collapse. Brain collapse may alter cerebrospinal fluid (CSF) and hemodynamics, leading to insufficient cerebral blood flow, tissue perfusion damage, and even cortical dysfunction. In general, CP can improve CSF and hemodynamic disorders after DC and significantly improve neurological and cognitive functions.^11,13,14 However, brain compliance decreases when the brain collapses to a certain extent.

Furthermore, this decline in brain compliance has nothing to do with the time window. As a result, even skull reconstruction cannot restore CSF dynamics and hemodynamics, which leads to postoperative complications. Therefore, it seems that the optimal timing of CP should not be determined based on the time window simply but on the tissue window.

Brain Collapse Volume and Brain Collapse Ratio

There are only a few reports describing the degree of brain collapse. Lee et al²⁸ used the brain collapse ratio to represent the degree of brain collapse, and their study showed that a low level of collapse could reduce the rate of postoperative complications. On the contrary, the brain collapse ratio was not associated with postoperative complications in the study by Goedemans et al.²⁹ Nevertheless, Goedemans et al did not analyze the collapse ratio for all patients because of the lack of pre-CP CT scans in many patients.

In our study, both brain collapse volume and ratio were calculated to indicate the degree of brain collapse. We found that brain collapse volume and ratio were independent predictors of postoperative complications and that brain collapse volume was moderately correlated with collapse ratio. Besides, we calculated the cut-off value for brain collapse volume as tissue window. When the brain collapse ratio is close to 0.864, the brain collapse volume is close to 11.26 cm³ (Figure 9A). When the brain collapse ratio is less than 0.864, the volume is greater than 11.26 cm³. Moreover, it is more likely to occur as postoperative complications (Figure 9B). A brain collapse ratio >0.864 indicates a collapse volume <11.26 cm³ or brain bulge/flaccid and a lower rate of postoperative complications (Figure 9C).

However, the brain collapse ratio is a simple measure at the 2-dimensional level and does not effectively represent the degree of brain collapse. Unlike previous research, we also calculated the volume of brain collapse in a 3-dimensional way, more representative of the degree of brain collapse. Although the brain collapse ratio was linearly correlated with the brain collapse volume, the predictive accuracy of mortality predicting postoperative complications by volume was significantly increased.

Limitations

The limitations of this study are as follow: First, owing to the small sample size and short time of follow-up, we did not further analyze other complications, such as postoperative hydrocephalus, seizure, and infection. Second, the study is conducted in a single center with a retrospective design, which may lead to selection bias. In the future, randomized controlled trials using the cut-off value of 11.26 cm³ are needed to validate the effect of brain collapse volume on postoperative complications.

本研究的局限性在于:首先，由于样本量小，随访时间短，我们没有进一步分析其他并发症，如术后脑积水、癫痫发作、感染等。其次，本研究采用单中心回顾性设计，可能导致选择偏倚。未来需要采用11.26 cm3的临界值进行随机对照试验来验证脑塌陷容积对术后并发症的影响。

CONCLUSION

Brain collapse and lower KPS score at the time of CP were independent predictors of overall complications after CP. Patients with a brain collapse volume >11.26 cm³ were prone to postoperative complications. The optimal timing of CP may be determined by tissue window based on brain collapse volume instead of time window based on the DC-CP interval. Further studies with larger case series and longer follow-ups are needed.

脑瘫时脑塌陷和较低的KPS评分是脑瘫后总并发症的独立预测因子，脑塌陷体积为11.26 cm3的患者易发生术后并发症。CP的最佳时机可以由基于脑塌陷体积的组织窗口来确定，而不是基于DC-CP间隔的时间窗口。进一步的研究需要更大的病例系列和更长的随访时间。

Acknowledgments

We are greatly indebted to all patients, doctors, and statistical consultants who were involved in our study.

Funding

This research was funded by Guided project of Science and Technology Department of Fujian Province, Grant Number 2016Y0037, and Scientific Startup Foundation, Fujian Medical University, Grant Number 2018QH1079.

Disclosures

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

REFERENCES

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COMMENTS

The authors present a single-institution retrospective cohort study analyzing the predictors for postoperative complications after cranioplasty in an attempt to better determine the optimal timing for cranioplasty. Prior studies have advocated for utilizing a time window of 3 months which is utilized for the majority of patients at most institutions, including our own.^1a

The authors find that lower KPS and presence of brain collapse are predictors of postoperative complications. They make a compelling case for using brain sunken volume to determine optimal timing of cranioplasty after decompressive craniectomy.

Two major studies have analyzed brain sinking as a predictor of complications after cranioplasty that the authors appropriately cite.^2a,3a This article does expand on this topic as it makes a compelling case for KPS to be included as a predictor and provides a cuto-ff brain sunken volume of 11.26 cm³. A randomized control trial comparing time window vs their proposed cutoff is necessary to further validate this method.

Joseph D. Ciacci

Alexander Tenorio

San Diego, California, USA

References

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Keywords:

Cranioplasty; Surgery; Complication; Brain collapse volume; OutcomeCopyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Congress of Neurological Surgeons.