Impact of Cranioplasty on Cerebral Blood Flow, CSF Dynamics, and Neurocognitive Recovery: A Prospective Imaging-based Study

Abstract Decompressive craniectomy (DC) is a life-saving procedure for severe traumatic brain injury and stroke but results in loss of cranial integrity, impaired cerebral blood flow (CBF), altered cerebrospinal fluid (CSF) dynamics, and cognitive dysfunction. Cranioplasty is believed to restore these physiological disturbances. However, prospective imaging-based evaluations remain limited in this context, particularly in Indian populations. This study prospectively assessed the impact of cranioplasty on CBF, CSF flow dynamics, and neurocognitive recovery. A prospective observational study was conducted on 100 patients undergoing cranioplasty following DC. CBF was quantified using arterial spin-labeling MRI across bilateral frontal, temporal, parietal, and occipital lobes. CSF dynamics including peak positive velocity (PPV), peak negative velocity (PNV), and net flow were measured at the aqueduct and foramen of Magendie using phase-contrast MRI. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) preoperatively, early postoperatively, and at 3 months. Pre–post changes were analyzed using paired tests with significance set at p < 0.05. Cranioplasty resulted in significant improvement in CBF across all lobes bilaterally (p < 0.001) with more pronounced gains on the ipsilateral side. CSF flow showed marked increase in PPV and PNV at both anatomical levels (p < 0.001) accompanied by improved net flow. MoCA scores improved significantly from baseline, with 90% of patients achieving scores in the normal cognitive range at 3 months (p < 0.001). No major postoperative complications were observed. Cranioplasty significantly enhances cerebral perfusion, CSF dynamics, and cognitive function following DC. These findings underscore the physiological value of cranioplasty and support the integration of advanced imaging to guide postoperative recovery and optimize timing of reconstruction.