Cranioplasty complications in severe traumatic brain injury: implications of timing of surgery, implant material and incidence of vetriculomegaly versus Post-Traumatic hydrocephalus

Salvatore Chibbaro^{1

2}, Ismail Zaed^#^{3

4}, Guillaume Dannhoff^#³, Julien Todeschi³, Charles-Henry Mallereau³, Lara Prisco⁵, Alex Alfieri⁶, Keeley Bernhardt^{6

7}, Elisabeth Sartoretti⁶, Marc-Eric Halatsch^{6

7}, Giorgio Spatola⁸, Andrea Cardia⁴, Carmen Bruno⁹, Nikolaos Syrmos¹⁰, Biagio Roberto Carangelo¹¹, Alessandro Zalaffi¹¹, Franco Moruzzi¹¹, Laura Lippa¹¹, Giacomo Tiezi¹¹, Franco Servadei¹², Andrew Reisner¹³, Smita Khilar⁵, Corrado Iaccarino¹⁴, Andres Rubiano¹⁵, Giuseppe Maria Vincenzo Barbagallo¹⁶, Francesca Tarantino¹⁷, Rebecca Tinturini¹⁷, Chiara Bartolozzi¹⁷, Alfonso Cerase¹⁸, Giacomo Gualtieri¹⁹, Mario Ganau^{5

20}

Affiliations

¹ Neurosurgery Department, Strasbourg University Hospital, Strasbourg, France. schibbaro@hotmail.com.
² Neurosurgery Unit of "Dipartimento di Scienze Mediche, Chirurgiche e Neuroscienze" University of Siena, Azienda Ospedaliera Universitaria , Siena , Italy. schibbaro@hotmail.com.
³ Neurosurgery Department, Strasbourg University Hospital, Strasbourg, France.
⁴ Neurosurgery Department, Neurocenter of South Switzerland, Lugano, Switzerland.
⁵ Neurosurgery Department and Neuro ITU, Oxford University Hospital, Oxford, UK.
⁶ Neurosurgery Department, Kantonspital Winterthur, Winterthur, Switzerland.
⁷ Neurosurgery Department, Uhlm University Hospital, Uhlm, Germany.
⁸ Neurosurgery Department, Fondazione Poliambulanza, Brescia, Italy.
⁹ Neurosurgery Department, Lorenzo Bonomo Hospital, Andria, Italy.
¹⁰ Neurosurgery Department, Aristotle University Hospital, Thessaloniki, Greece.
¹¹ Neurosurgery Unit of "Dipartimento di Scienze Mediche, Chirurgiche e Neuroscienze" University of Siena, Azienda Ospedaliera Universitaria , Siena , Italy.
¹² Neurosurgery Department, Humanitas University Hospital, Milan, Italy.
¹³ Neurosurgery Department, Children's Healthcare Hospital Atlanta, Atlanta, USA.
¹⁴ Neurosurgery Department, University of Modena and Reggio Emilia, Modena, Italy.
¹⁵ Neurosciences Institute, El Bosque University, Bogotá, Colombia.
¹⁶ Neurosurgery Department, Policlinico G. Rodolico-San Marco, Catania, Italy.
¹⁷ Neuro-ITU Department, Siena University Hospital, Siena, Italy.
¹⁸ Diagnostic and Therapeutic Neuroradiology Department, Siena University Hospital, Siena, Italy.
¹⁹ Forensic Medicine Unit of "Dipartimento di Scienze Mediche, Chirurgiche e Neuroscienze" University of Siena, Siena, Italy.
²⁰ Faculty of Medicine, BAU International University, Batumi, Georgia.

^# Contributed equally.

PMID: 40974389
DOI: 10.1007/s10143-025-03832-3

Observational Study

Cranioplasty complications in severe traumatic brain injury: implications of timing of surgery, implant material and incidence of vetriculomegaly versus Post-Traumatic hydrocephalus

Salvatore Chibbaro et al. Neurosurg Rev. 2025.

. 2025 Sep 20;48(1):659.

doi: 10.1007/s10143-025-03832-3.

Authors

Affiliations

¹ Neurosurgery Department, Strasbourg University Hospital, Strasbourg, France. schibbaro@hotmail.com.
² Neurosurgery Unit of "Dipartimento di Scienze Mediche, Chirurgiche e Neuroscienze" University of Siena, Azienda Ospedaliera Universitaria , Siena , Italy. schibbaro@hotmail.com.
³ Neurosurgery Department, Strasbourg University Hospital, Strasbourg, France.
⁴ Neurosurgery Department, Neurocenter of South Switzerland, Lugano, Switzerland.
⁵ Neurosurgery Department and Neuro ITU, Oxford University Hospital, Oxford, UK.
⁶ Neurosurgery Department, Kantonspital Winterthur, Winterthur, Switzerland.
⁷ Neurosurgery Department, Uhlm University Hospital, Uhlm, Germany.
⁸ Neurosurgery Department, Fondazione Poliambulanza, Brescia, Italy.
⁹ Neurosurgery Department, Lorenzo Bonomo Hospital, Andria, Italy.
¹⁰ Neurosurgery Department, Aristotle University Hospital, Thessaloniki, Greece.
¹¹ Neurosurgery Unit of "Dipartimento di Scienze Mediche, Chirurgiche e Neuroscienze" University of Siena, Azienda Ospedaliera Universitaria , Siena , Italy.
¹² Neurosurgery Department, Humanitas University Hospital, Milan, Italy.
¹³ Neurosurgery Department, Children's Healthcare Hospital Atlanta, Atlanta, USA.
¹⁴ Neurosurgery Department, University of Modena and Reggio Emilia, Modena, Italy.
¹⁵ Neurosciences Institute, El Bosque University, Bogotá, Colombia.
¹⁶ Neurosurgery Department, Policlinico G. Rodolico-San Marco, Catania, Italy.
¹⁷ Neuro-ITU Department, Siena University Hospital, Siena, Italy.
¹⁸ Diagnostic and Therapeutic Neuroradiology Department, Siena University Hospital, Siena, Italy.
¹⁹ Forensic Medicine Unit of "Dipartimento di Scienze Mediche, Chirurgiche e Neuroscienze" University of Siena, Siena, Italy.
²⁰ Faculty of Medicine, BAU International University, Batumi, Georgia.

^# Contributed equally.

PMID: 40974389
DOI: 10.1007/s10143-025-03832-3

Abstract

Background Despite the increasing number of decompressive craniectomy (DC) in neurotrauma, the optimal timing for elective cranioplasty (CP) is still debated. Little is known about the CP complications related to surgery, implant material, and post-traumatic hydrocephalus. Objectives To explore the correlation between CP timing, implant material, and the incidence of postoperative complications in patients undergoing CP after DC for severe head injuries. Materials and methods A retrospective multicenter study was conducted from January 2010 to December 2021 across 9 European neurosurgical centers. A cohort of 4007 patients who underwent CP following DC for severe head injury was analyzed. Timing was categorized as: ultra-early (< 30 days), early (31-90 days), late (> 90 days). Complications were defined according to Clavien-Dindo classification, requiring revision surgery and/or hospital readmissions. Results Among the 4007 patients, 352 (8.8%) had ultra-early CP, 1627 (40.5%), and 2028 (51.7%) had early and late CP respectively. Cerebrospinal fluid (CSF) derangement was more frequently associated with large defects and the incidence of Sinking Skin Flap Syndrome (SSFS). SSFS was more frequently diagnosed in patients undergoing late surgery whereas hydrocephalus and epilepsy were less frequently encountered in the ultra-early and early groups (p < 0,05). The overall complication rate was 24.6% (985 patients) including internal hydrocephalus (20%), infection (18%), external hydrocephalus (15%), epilepsy (15%), acute extradural (14%) or subdural hematomas (10%), and subdural hygroma (8%). CP stabilized CSF derangement in 80% of cases, which did not progress into overt hydrocephalus, whereas 17% with definite diagnosis of post-traumatic hydrocephalus required a Ventriculo-Peritoneal shunt (VPS). Simultaneous CP and VPS led to infections in all cases, regardless of implant material. Conclusion Surgery timing has a greater impact on CP complications than implant material. CSF derangement represents the single most relevant factor influencing the clinical course of patients undergoing CP.

Keywords: Cranioplasty complications; Decompressive craniectomy; Implant material in neurosurgery; Post-traumatic hydrocephalus; Surgical timing.

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Conflict of interest statement

Declarations: By employing a robust multicenter design, standardized data collection protocols, and rigorous statistical methodologies, this study aimed to provide a nuanced understanding of the impact of cranioplasty timing and material choice on postoperative outcomes in patients undergoing reconstructive surgery after decompressive craniectomy. Human ethics: This study adhered to the Ethical Principles for Medical Research Involving Human Subjects as outlined in the Declaration of Helsinki, with the original issuance in 2004 and subsequent revisions in 2008 and 2013. The reporting of our findings complied with the STROCSS (Strengthening the Reporting of Observational Cohort Studies in Surgery) guidelines. The study received ethical approval n° IRB00011687 from the Institutional Review Board (IRB) of the French National Neurosurgery Society (SFNC). Clinical trial number: Not applicable Consent to participate: This is an observational study and utilized only aggregated patient data, ensuring that no individual patient could be identified. As such, obtaining informed consent was not required. Competing interests: The authors declare no competing interests. Conflict of interest: The authors declare that they have no conflicts of interest related to the content of this manuscript

References

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Cranioplasty complications in severe traumatic brain injury: implications of timing of surgery, implant material and incidence of vetriculomegaly versus Post-Traumatic hydrocephalus

Affiliations

Cranioplasty complications in severe traumatic brain injury: implications of timing of surgery, implant material and incidence of vetriculomegaly versus Post-Traumatic hydrocephalus

Authors

Affiliations

Abstract

Conflict of interest statement

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical

Miscellaneous