Early Versus Late Cranioplasty Following Decompressive Craniectomy: A Propensity-Matched Postoperative Outcome Analysis

Objective: Postoperative complications following cranioplasty occur in nearly 30% of patients requiring decompressive craniectomy (DC). Controversy exists regarding the procedure’s timing, particularly whether performing cranioplasty closer to or further from the craniectomy reduces morbidity. Both strategies offer distinct benefits and associated risks; however, the literature remains inconclusive regarding postoperative complication rates. Methods: We performed a retrospective cohort study using the TriNetX database. Patients were identified as undergoing early (0–90 d) or late (91 d–1 y) cranioplasty following craniectomy. Propensity score adjustment was used to match cohorts on demographics, significant preoperative comorbidities, and anticoagulant use. Postoperative outcomes, such as seizures, intracerebral hemorrhage, hydrocephalus, and infection, were measured within 6 months following cranioplasty. Complication rates were compared between groups using unadjusted odds ratios (OR) and 95% confidence intervals (CI). Kaplan-Meier survival analysis and log-rank tests were used to compare mortality. Results: A total of 2761 patients were included in this analysis (1140 early; 1621 late). Mean ages at cranioplasty were 42.5 and 43 years for early and late cohorts, respectively. Sixty-six percent and 69% were male, respectively. After matching, 994 patients remained in each cohort. Patients undergoing early cranioplasty had significantly higher rates of intracerebral hemorrhage (OR, 2.06; CI, 1.05–4.05) and hydrocephalus (OR, 1.76; CI, 1.05–2.96). Rates of seizure (16.39% versus 12.59%; OR, 1.36; CI, 0.97–1.91), wound infection (7.64% versus 6.13%; OR, 1.27; CI, 0.89–1.80), and intracranial infection (2.33% versus 1.12%; OR, 2.11; CI, 0.99–4.50) were all higher in the early cohort. Six-month mortality was significantly higher in the early cohort compared with the late cohort (OR, 2.11; CI, 1.32–3.37; P = 0.0007). Conclusions: These findings suggest that late cranioplasty may reduce postoperative morbidity. The timing of cranioplasty appears to be implicated in outcomes, and prospective studies that involve patient goals and perspectives are needed to validate these results.