The current state of cranioplasty in Europe - Results from a European cranioplasty survey

Abstract

Introduction: Cranioplasty, a surgical procedure to restore skull integrity and aesthetic contour following decompressive craniectomy, poses challenges in material selection and timing, driven by the lack of guidelines and ongoing regulatory changes.

Research question: This study aimed to provide an overview of current cranioplasty practices in Europe, explicitly addressing a potential shift towards alloplastic materials and the management of patients with concomitant hydrocephalus.

Material and methods: An online survey was conducted among European neurosurgical centers from January to March 2024, collecting data on material preferences, timing of procedures, and management strategies for cranioplasty. Descriptive and statistical analyses were performed on 110 complete responses.

Results: Respondents favored alloplastic materials over autologous bone for cranioplasty, citing regulatory constraints and reduced infection risk as primary reasons. Variability was observed in the timing of procedures and the management of patients with hydrocephalus, with most centers adopting staged approaches.

Discussion and conclusion: The shift towards alloplastic materials in cranioplasty reflects regulatory pressures rather than material-specific considerations. Despite variability in practice, our findings underscore the need for standardized guidelines and further research to optimize patient outcomes. This study provides valuable insights into current practices and highlights areas for future investigation in cranioplasty.

Keywords: Alloplastic materials; Autologous bone; Cranioplasty; European survey; Hydrocephalus management; Regulatory changes.

Fig. 1

Study participants. A: Demographic information of survey participants (top left). Caseloads of decompressive craniectomy (top right), naïve (bottom left), and revision cranioplasty (bottom right) differed between centers. B: Colored map illustrating the location of practice of participating neurosurgeons; numerical data on the number of participants for each country are provided in Table 1.

Fig. 2

Preferences in material selection for cranioplasty. A:Pie-chart illustrating the distributions of surgeons preferring alloplastic (red) materials or autologous bone (grey) for cranioplasty.B:Pie-chart illustrating the distributions of alloplastic materials used as first-line material in cranioplasty.C:Material preferences were not significantly different between high and low-volume centers (for definition, see text (Fisher's exact test, p = 0.5). D:The reasons for choosing autologous and alloplastic materials were differed between alloplastic materials and autologous CP. Bar graphs denoting the number of responses. Note that participants could provide multiple reasons for each material.E:No significant difference was detected between the preferred time-point for cranioplasty when comparing surgeons preferring alloplastic and autologous bone (Fisher's exact test, p=0.3).

Fig. 3

Practices of bone-fragment storage, pediatric cranioplasty, and management of hydrocephalus A: Management of bone fragment storage.Pie-chart illustrating the practices of bone fragment storage (left). More than half of centers seek informed consent from patients (resp. next of kin) when storing bone fragments (middle, top), but more than 60% do not notify next of kin when bone fragments are discarded (middle, bottom). Maximal storage time was limited by institutional guidelines in most centers (right).B: Management of cranioplasty in children.Survey participants favored an earlier cranioplasty compared to adults (X2, p=0.0007). In pediatric patients, most respondents favored autologous bone cranioplasty (right, top). When alloplastic cranioplasty was conducted, materials similar to those used in adults were used (right, bottom).C + D: Management of patients with hydrocephalus requiring cranioplasty.Most respondents preferred placing a ventriculoperitoneal (VP)-shunt via the contralateral hemisphere (C) when necessary. Additionally, a staged approach was predominantly favored, where cranioplasty (CP) is performed first, followed by VP-shunt placement if required (D).