# Early Versus Delayed Cranioplasty After Decompressive Craniectomy: A Systematic Review and Meta‐Analysis

## TL;DR

This study compares the timing of skull reconstruction surgery after a decompressive craniectomy and finds mixed results on which approach is better.

## Contribution

The paper provides a meta-analysis comparing early and delayed cranioplasty to guide evidence-based surgical timing decisions.

## Key findings

- Early cranioplasty had a non-significantly higher risk of complications and infections.
- Early cranioplasty was associated with shorter operative time and less blood loss.
- Neurological outcomes favored delayed cranioplasty or showed no significant difference.

## Abstract

Decompressive craniectomy (DC) is a surgical procedure that involves the removal of a portion of the skull and is used to treat various conditions. However, this creates a significant defect in the skull that requires subsequent reconstruction through a procedure called cranioplasty. Cranioplasty aims to improve cerebral blood flow and enhance neurological functions. The timing of cranioplasty is still a topic of debate and can generally be classified into two categories: “early cranioplasty” and “delayed cranioplasty.” To provide evidence‐based recommendations for the optimal timing of cranioplasty, our meta‐analysis compares the safety and efficacy of early and delayed cranioplasty.

An electronic search was conducted on PubMed, Embase, and Cochrane. Multiple reviewers independently screened the studies using Rayyan software, and any conflicts were resolved through mutual discussion. Quality assessment was performed using the Newcastle–Ottawa Scale (NOS). Statistical analysis was carried out using Review Manager version 5.41, with I
2 statistics applied to evaluate heterogeneity.

Early cranioplasty was associated with increased risk of overall complications 1.43 (95% CI: 0.81 to 2.53; p = 0.22) and postoperative infections 1.36 (95% CI: 0.36 to 5.11; p = 0.65), shorter operative time −26.76 (95% CI: −41.20 to −12.32; p = 0.0003), and a reduced intraoperative blood loss −21.53 (95% CI: −38.30 to −4.77; p = 0.01). The neurological outcomes, that is, MMSE and GOS scores, favored the delayed cranioplasty or showed no significant difference, respectively.

The meta‐analysis produced mixed results and required a prospective, multicenter, randomized controlled trial with specified outcome measures to establish a balance between surgical safety and functional recovery.

Overall Complications

• Early cranioplasty showed a higher (but non‐significant) risk

• RR 1.43 (95% CI: 0.81–2.53)

• Heterogeneity: I
2 = 57%

Post‐operative Infection

• Early cranioplasty associated with a non‐significant increase

• RR 1.36 (95% CI: 0.36–5.11)

• Heterogeneity: I
2 = 38%

Operative Time

• Early cranioplasty resulted in a significantly shorter duration

• MD –26.76 min (95% CI: –41.20 to –12.32)

• Heterogeneity: I
2 = 80%.