Functional Outcomes and Complications Following Very Delayed Cranioplasty: Clinical Challenges and Surgical Considerations.

Abstract

Cranioplasty (CP) following decompressive craniectomy (DC) is associated with improved cerebral autoregulation and functional recovery. Although long-term functional outcomes are similar, CP performed in the early postoperative period is widely advocated. In contrast, the clinical impact of CP performed at a very delayed stage has not yet been sufficiently investigated. To evaluate the functional outcomes, complication rates, and surgical difficulties of cranioplasty in cases where cranial reconstruction was performed more than 2 years after decompressive craniectomy. A retrospective analysis was conducted on patients who underwent cranioplasty at least 24 months after decompressive craniectomy (mean 33 ± 6 months). Functional outcomes were assessed using the Modified Rankin Scale (mRS) and the Glasgow Outcome Scale Expanded (GOSE). Aesthetic outcomes were assessed using the Numeric Rating Scale (NRS). Perioperative variables, complication rates, and implant characteristics were analyzed. A total of 42 patients were included in the study. Improvements were observed in mRS scores and GOSE scores, which serve as measures of functional recovery, during the postoperative period. The overall complication rate was 29%, which was consistent with the current literature. Early-stage complications included seizures (10%) and epidural hematoma (5%); none of these required surgical intervention. Late complications, including infection (7%) and implant exposure (5%), were primarily related to soft tissue integrity. One patient (2%) developed hydrocephalus, necessitating the placement of a programmable ventriculoperitoneal shunt (VPS). Favorable cosmetic outcomes were reported in 38 of 42 patients (91%). Cranial reconstruction performed at a very late-stage is technically feasible provided that challenges such as temporal muscle atrophy, scalp issues, infection, intracranial hematoma, and changes in cerebrospinal fluid dynamics are properly addressed. Although technical challenges may be present, delayed reconstruction does not appear to adversely affect overall complication rates.