Timing Matters: A Comprehensive Meta-Analysis on the Optimal Period for Cranioplasty After Severe Traumatic Brain Injury

BACKGROUND AND OBJECTIVES: Craniectomy is a commonly performed procedure in severe traumatic brain injury (TBI) to control intracranial hypertension and reduce mortality. The optimal timing for cranioplasty after craniectomy remains a topic of debate. The aim of this study was to investigate the ideal timing for cranioplasty after severe TBI, focusing on complications associated with temporal aspects and materials used in cranioplasty. METHODS: Multiple databases, including PubMed, Embase, Cochrane, and Web of Science, were searched for studies reporting on the subject. Inclusion criteria involved randomized and observational studies comparing early and late cranioplasty procedures. Quality assessment was performed using the Methodological Index for Non-Randomized Studies scale. Results were pooled in a single-arm meta-analysis and presented as mean and 95% confidence interval. RESULTS: Early cranioplasty was associated with a lower likelihood of subdural effusion (odds ratio [OR] 0.3735 [0.1643; 0.8490], P = .0187). However, no differences were detected for the presence of infection between both groups (OR 0.7460 [0.2065; 2.6945], P = .6548). Cranioplasties performed within or equal to 3 months from the TBI incident were associated with a reduced likelihood of minor complications (OR 0.4471 [0.2467; 0.8102], P = .0080). Paradoxically, this time frame exhibited an elevated risk of hydrocephalus (OR 3.2035 [1.4860; 6.9059], P = .0030), as well as total complications (OR 1.4190 [1.0453; 1.9262] P = .0248). CONCLUSION: This comprehensive review highlights the current lack of consensus on the optimal timing for cranioplasty after severe TBI. Early cranioplasty, within 35 days, showed a reduced risk of subdural effusion, but no disparity in the odds of infection was found. A reduced incidence of minor complications was observed in the earlier approach, however with an elevated risk for hydrocephalus and total complications. The association between timing and complications, including hydrocephalus, highlights the need for further research and standardization in this critical aspect of TBI management.