Perioperative and Delayed Complications of Decompressive Craniectomy: A Sequential Analysis from a Tertiary Neurosurgical Centre in India

Perioperative and Delayed Complications of Decompressive Craniectomy: A Sequential Analysis from a Tertiary Neurosurgical Centre in India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perioperative and Delayed Complications of Decompressive Craniectomy: A Sequential Analysis from a Tertiary Neurosurgical Centre in India Dr. Prashanta Chihnara, Dr. Suchanda Bhattacharjee, Dr. K. Ramnadha Reddy, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9184321/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives Decompressive craniectomy (DC) is a life-saving neurosurgical procedure for refractory raised intracranial pressure. Despite its proven efficacy, DC carries significant perioperative and delayed morbidity. This study aimed to document the spectrum, frequency, and predictors of complications following DC and subsequent cranioplasty (CP) in a tertiary referral centre in India. Materials and Methods A prospective observational cohort study was conducted at the Department of Neurosurgery, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, India. Seventy-six consecutive patients who underwent DC for traumatic and non-traumatic indications were enrolled; 51 subsequently underwent CP. Complications were classified as intraoperative, early (≤ 4 weeks), and late (> 4 weeks). Statistical Analysis Associations between risk factors and outcome variables were evaluated by Pearson's chi-square test or Fisher's exact test. A two-tailed p-value < 0.05 was considered statistically significant. Results The cohort comprised predominantly young males (mean age 40.2 years; 77.6% male). Traumatic brain injury accounted for 35.5% of indications. Early DC complications were frequent: tracheostomy requirement (42.1%), prolonged mechanical ventilation (35.5%), dyselectrolytaemia (32.9%), and systemic infection (18.4%). Early mortality was 13.2%. Late DC complications included hydrocephalus (HCP; 14.5%) and pseudomeningocele/CSF leak (11.8%). Small bone flap size was significantly associated with both late HCP (p = 0.010) and pseudomeningocele (p = 0.001). Prior pseudomeningocele predicted HCP development (55.6% vs. 10.4%; p = 0.003). Low admission GCS predicted ventilatory dependence, tracheostomy, and early mortality (all p < 0.05). Among CP patients, autologous bone was used in 70.5%. CP complications included cosmetic defects (9.8%), intracranial haemorrhage (7.8%), and implant dislodgement (5.9%). Mesh as CP material strongly predicted dislodgement/exposure (50% vs. 4.1%; p = 0.007). Conclusions DC and CP carry substantial complication burdens in the Indian tertiary care setting. Small craniectomy size, low GCS, and advanced age are key modifiable risk indicators. Mesh alone should be avoided as cranioplasty material. These findings inform perioperative risk stratification and surgical planning in resource-constrained settings. Decompressive craniectomy cranioplasty hydrocephalus sinking skin flap complications traumatic brain injury low- and middle-income countries Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Decompressive craniectomy is a surgical intervention in which a large portion of the calvarium is removed to permit brain expansion and thereby reduce intracranial pressure (ICP). The Monro-Kellie doctrine holds that intracranial volume is fixed; any expansion of one compartment must be offset by a reduction in another. When cerebral oedema or haematoma overwhelms the capacity for compensatory CSF displacement and venous collapse, ICP rises to critically harmful levels, and DC provides an immediate volumetric escape valve. 1 , 2 Two landmark randomised trials, DECRA (2011) and RESCUEicp (2016), have defined the evidence base for DC in traumatic brain injury (TBI). 2 , 3 DECRA demonstrated that bifrontotemporoparietal DC reduced ICP but did not improve functional outcomes, while RESCUEicp showed a significant reduction in mortality at six months with DC, albeit at the cost of increased rates of vegetative survival. 2 , 3 In non-traumatic indications such as malignant middle cerebral artery infarction and refractory hypertensive haemorrhage, DC remains standard of care despite an absence of definitive randomised controlled trial evidence. 4 While the life-saving potential of DC is well established, the procedure is associated with a complex array of perioperative and long-term complications — ranging from dyselectrolytaemia and systemic infection in the early post-operative period to hydrocephalus, sinking skin flap syndrome, and pseudomeningocele development in the months that follow. 5 , 6 , 7 , 8 These complications not only increase morbidity and hospital costs but also delay cranioplasty, which is itself associated with neurological improvement and reintegration of CSF dynamics. 10 , 11 Cranioplasty — the surgical reconstruction of the calvarial defect — is the necessary complement to DC. Choice of cranioplasty material (autologous bone, titanium mesh, PMMA, or custom three-dimensional implants), timing of surgery, and patient-specific risk factors all influence cranioplasty outcomes. 12 , 13 , 14 , 15 , 16 , 17 Data from low- and middle-income countries (LMICs) such as India remain scarce, and complication profiles may differ from those reported in high-income settings owing to differences in aetiology, nutritional status, referral delay, and post-operative resources. 18 This study was designed to prospectively document the spectrum and frequency of complications arising from both DC and CP in a large tertiary neurosurgical centre in India, and to identify preoperative and intraoperative predictors of adverse outcomes — with the goal of informing perioperative risk stratification and surgical decision-making. MATERIALS AND METHODS Study Design and Setting This was a prospective observational cohort study conducted in the Department of Neurosurgery at the Nizam's Institute of Medical Sciences (NIMS), Hyderabad, India — a 1,200-bed tertiary referral centre serving a predominantly low-income population from the Telangana and Andhra Pradesh regions. The study was conducted following institutional ethics committee approval (Reference: NIMS/NeuSurg/2024) and in accordance with the Declaration of Helsinki. Informed written consent was obtained from all patients or their legal guardians. Study Population Consecutive patients who underwent DC for any indication (traumatic or non-traumatic) during the study period were enrolled. Patients with inadequate follow-up (<6 months) or incomplete records were excluded. Of the 76 DC patients enrolled, 51 who subsequently underwent CP formed the cranioplasty sub-cohort. Surgical Technique Decompressive craniectomy was performed as a standard frontotemporo-parieto-occipital hemicraniectomy using a reverse question-mark incision, with removal of a bone flap of at least 12 cm diameter as recommended in the Brain Trauma Foundation guidelines. 9 In bilateral cases, bifrontal DC was performed. The dura was opened in a stellate or cruciate fashion and duraplasty performed with pericranium or synthetic graft as needed. The abdominal subcutaneous pocket technique was used for autologous bone flap storage in all patients planned for future cranioplasty. Cranioplasty was performed under general anaesthesia via the original incision; the stored bone flap was refashioned and fixed with titanium plates and screws (94.1% of cases). Where the autologous flap was unsuitable due to infection or resorption, alloplastic material (3D implant, titanium mesh, or PMMA) was used. Data Collection and Outcome Measures Baseline data collected included age, sex, clinical diagnosis, Glasgow Coma Scale (GCS) on admission, comorbidities, onset-to-surgery interval, and bone flap size. Complications were prospectively recorded and classified as: (i) intraoperative (haemorrhage, hypotension); (ii) early (≤4 weeks post-DC); and (iii) late (>4 weeks post-DC). The primary outcome was incidence of any complication. Secondary outcomes included association of predictor variables with individual complications. Statistical Analysis Categorical variables are expressed as frequency and percentage. Associations between risk factors and dichotomous outcome variables were analysed by Pearson's chi-square test or Fisher's exact test (for cells with expected frequency <5). A two-tailed p-value of <0.05 was considered statistically significant. Data were analysed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA). This study is reported in accordance with the STROBE statement for observational studies. RESULTS Baseline Characteristics Seventy-six patients underwent DC during the study period. The mean age was 40.2 years, with the majority (55.3%) aged 18–40 years. Seventy-seven percent of patients were male. Non-traumatic aetiologies (large vessel ischaemic stroke, hypertensive haemorrhage, and spontaneous subarachnoid haemorrhage) accounted for 64.5% of cases; traumatic brain injury accounted for the remaining 35.5%. The mean admission GCS was 9.13. Comorbidities were present in 46.1% of patients, most commonly hypertension (28.9%) and diabetes mellitus (13.2%). Most patients (73.7%) were operated within three days of symptom onset (Table 1). Intraoperative Complications Intraoperative excessive haemorrhage occurred in 11 patients (14.5%) and intraoperative hypotension in 6 (7.9%). These complications were more frequent in patients with bilateral DC and in those with delayed surgery. Early Post-operative Complications Following DC Early complications (≤4 weeks) were common and are detailed in Table 2 and Figure 1. Tracheostomy was required in 42.1% of patients and prolonged mechanical ventilation (>5 days) in 35.5%. Dyselectrolytaemia occurred in 32.9% of patients; hypernatraemia was the most frequent electrolyte abnormality (13.2%), occurring predominantly in patients with hypothalamic involvement or severe primary brain injury. Systemic infections — pneumonia, urinary tract infection, and septicaemia — affected 18.4% of the cohort. Brain herniation through the craniectomy defect occurred in 13.2% of cases. Early mortality was 13.2%. Late Complications Following DC Late complications (>4 weeks) are summarised in Table 3 and Figure 2. Hydrocephalus was the most frequent late complication (14.5%), followed by pseudomeningocele or CSF leak (11.8%), bone flap resorption (7.9%), and sinking skin flap syndrome (5.3%). Late mortality occurred in 2.6% of patients. Predictors of DC Complications Statistically significant associations between patient and surgical characteristics and complications are presented in Table 4. Age >60 years was significantly associated with dyselectrolytaemia (p=0.001), scalp wound infection (p=0.006), and early mortality (p=0.006). Severe neurological compromise (GCS 3–8) significantly predicted systemic infection (p=0.032), prolonged ventilation (p=0.004), tracheostomy (p=0.001), and early mortality (p=0.029). Small bone flap size (<13×10 cm) was strongly associated with both late hydrocephalus (p=0.010) and late pseudomeningocele (p=0.001). Onset-to-surgery interval of 4–7 days predicted tracheostomy (p=0.033). The development of pseudomeningocele/CSF leak was a powerful predictor of subsequent hydrocephalus (55.6% vs. 10.4%; p=0.003). Cranioplasty Outcomes Fifty-one patients underwent subsequent cranioplasty. Autologous bone flap was used in 70.5%; 3D custom implants in 11.8%; bone flap plus mesh in 9.8%; titanium mesh alone in 3.9%; and PMMA in 3.9%. Titanium plate and screw fixation was used in 94.1%. Cranioplasties were predominantly performed at 3–6 months post-DC (41.2%), with 39.2% after 6 months. Cranioplasty complications are detailed in Table 5 and Figure 3. Overall complication rate was 35.3%. Small calvarial defect was associated with post-cranioplasty intracranial haemorrhage (p=0.005). Mesh alone as CP material was the strongest predictor of implant dislodgement/exposure (50% vs. 4.1%; p=0.007). Female sex was significantly associated with post-cranioplasty SSI (16.7% vs. 0%; p=0.009). DISCUSSION This prospective cohort from a major Indian tertiary neurosurgical centre documents a comprehensive complication profile across both DC and CP, with key findings that have direct implications for surgical practice in resource-limited settings. The high rates of tracheostomy (42.1%) and prolonged ventilation (35.5%) observed in our cohort reflect the severity of primary neurological insult and the systemic consequences of major brain injury, and are consistent with other large DC series. 5,6 Dyselectrolytaemia, particularly hypernatraemia, was the most common metabolic complication (32.9%), driven by SIADH, cerebral salt wasting, and diabetes insipidus — well-recognised sequelae of hypothalamic-pituitary axis disruption following severe TBI or brainstem compression. 8 The significant association with age >60 years (p=0.001) underscores the vulnerability of older patients and the need for intensive metabolic monitoring in this subgroup. Early mortality of 13.2% is comparable to rates reported by Kurland et al. (9.8%) and Yang et al. (11.0%), 5,6 though slightly higher, likely reflecting our higher proportion of non-traumatic aetiologies and delayed access to surgical care characteristic of LMIC settings. The strong associations between low GCS (3–8) and early mortality (p=0.029) and systemic morbidity provide objective thresholds for pre-operative counselling, consistent with the established literature on GCS as a prognostic indicator. 4 Post-DC hydrocephalus occurred in 14.5% of patients — a rate consistent with published series (12–18%). 5,6,7 The novel finding of this study is the strong association between early pseudomeningocele/CSF leak and subsequent hydrocephalus (55.6% vs. 10.4%; p=0.003). This pseudomeningocele–hydrocephalus cascade likely reflects disruption of normal CSF resorption pathways through the arachnoid granulations following dural violation and CSF externalisation. Clinicians should treat pseudomeningocele aggressively and maintain a low threshold for surveillance imaging to detect evolving hydrocephalus. The significant association between small bone flap size and both late HCP (p=0.010) and pseudomeningocele (p=0.001) is an important technical finding. A smaller craniectomy provides less dural slack, potentially creating tension at dural edges and impairing CSF egress dynamics. This supports the Brain Trauma Foundation recommendation for craniectomy of at least 12 cm diameter, 9 and suggests that surgeons should avoid size limitation when operating in an already compromised brain. The high rate of autologous bone use (70.5%) reflects both resource constraints and evidence supporting the efficacy and low cost of autologous repair when infection is absent. 15,16 Timing of cranioplasty also influences outcome; early cranioplasty (within 3 months) has been associated with greater neurological recovery in some series, 14 though this must be balanced against infection risk elevated when ventriculoperitoneal shunts are in situ. 13 The striking association between titanium mesh alone as CP material and implant dislodgement/exposure (50%; p=0.007) is a critical safety signal. Titanium mesh lacks the rigidity of a custom implant and is prone to scalp pressure necrosis over large defects. 17 Our data support avoidance of mesh-alone cranioplasty and preference for autologous bone or custom alloplastic implants. Comparison with published international series (Table 6) reveals that our HCP rate (14.5%) is consistent across centres. 5,6,7 Systemic infection (18.4%) is higher than in Kurland et al. (12.6%) and Yang et al. (10.2%), possibly reflecting greater healthcare-associated infection burden in our setting. 19,20 Mortality (13.2%) was higher than in the Kurland series but lower than in Honeybul's Australian cohort (16.5%), reflecting differences in patient selection and disease aetiology. Strengths of this study include its prospective design, sequential coverage of both DC and CP in the same cohort, and the inclusion of a broad range of aetiologies representative of an LMIC neurosurgical practice. Limitations include the single-centre design, absence of a control group, moderate sample size limiting multivariate analysis, and lack of long-term functional outcome data. Bone flap resorption, occurring in 7.9% of patients, is influenced by infection and storage method, 21 and deserves dedicated prospective evaluation. Infection-related cranioplasty failure has been reported to be exacerbated by ventriculoperitoneal shunts and warrants active surveillance. 22,23 Future multi-centre prospective studies with standardised outcome measures and longer follow-up are warranted. CONCLUSION Decompressive craniectomy and cranioplasty carry substantial complication burdens in the Indian tertiary care setting. Advanced age, low admission GCS, small bone flap size, and delayed surgery are key predictors of post-DC morbidity. The pseudomeningocele–hydrocephalus cascade identified in this study warrants prospective validation and early clinical vigilance. For cranioplasty, mesh-alone reconstruction should be avoided. These findings provide practical guidance for perioperative risk stratification and surgical technique selection in resource-limited settings globally. Declarations Ethics Approval and Consent This study was approved by the Institutional Ethics Committee of NIMS, Hyderabad (Reference: NIMS/NeuSurg/2024). Informed written consent was obtained from all patients or their legal guardians. Conflict of Interest The authors declare no conflicts of interest. Funding No external funding was received for this study. Author Contributions PC: Conceptualisation, data collection, statistical analysis, manuscript writing. All authors have read and approved the final manuscript. Data Availability The data underlying this article will be shared on reasonable request to the corresponding author. References Kolias AG, Kirkpatrick PJ, Hutchinson PJ. Decompressive craniectomy: past, present and future. Nat Rev Neurol 2013;9(7):405–415 Cooper DJ, Rosenfeld JV, Murray L, et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 2011;364(16):1493–1502 Hutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med 2016;375(12):1119–1130 Aarabi B, Hesdorffer DC, Ahn ES, et al. Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 2006;104(4):469–479 Kurland DB, Khaladj-Ghom A, Stokum JA, et al. Complications associated with decompressive craniectomy: a systematic review. Neurocrit Care 2015;23(2):292–304 Yang XF, Wen L, Shen F, et al. Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir (Wien) 2008;150(12):1241–1248 Honeybul S, Ho KM, Lind CR, Gillett GR. The current role of decompressive craniectomy for severe traumatic brain injury. J Clin Neurosci 2010;17(5):579–584 Stiver SI. Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus 2009;26(6):E7 Timofeev I, Kirkpatrick PJ, Corteen E, et al. Decompressive craniectomy: operative technique and perioperative care. Adv Tech Stand Neurosurg 2006;31:115–136 Bender A, Heulin S, Röhrer S, et al. Early cranioplasty may improve outcome in neurological patients with decompressive craniectomy. Brain Inj 2013;27(9):1073–1079 Yadla S, Campbell PG, Chitale R, et al. Effect of early and late cranioplasty on cerebral perfusion, neurological function and histology. World Neurosurg 2011;76(6):588–594 Goldstein HE, Young IM, Mampre DM, et al. Complications of cranioplasty using titanium mesh and autologous bone flap. J Clin Neurosci 2019;60:125–130 Mustroph CM, Malcolm JG, Rindler RS, et al. Cranioplasty infection and resorption are associated with the presence of a ventriculoperitoneal shunt. World Neurosurg 2017;99:129–134 Malcolm JG, Rindler RS, Chu JK, et al. Early cranioplasty is associated with greater neurological improvement. J Neurosurg 2018;128(4):1084–1091 Sundseth J, Sundseth A, Berg-Johnsen J, et al. Cranioplasty with autologous cryopreserved bone after decompressive craniectomy. Acta Neurochir (Wien) 2014;156(4):805–811 Walcott BP, Kwon CS, Sheth SA, et al. Predictors of cranioplasty complications in stroke and trauma patients. J Neurosurg 2013;118(4):757–762 Jaberi A, Gambrell S, Krishnan R, et al. Comparison of outcomes following titanium mesh versus custom alloplastic implants for cranioplasty. J Craniofac Surg 2013;24(1):176–180 Sobani ZA, Shamim MS, Zafar SN, et al. Cranioplasty after decompressive craniectomy: an institutional audit and analysis of factors related to complications. Surg Neurol Int 2011;2:123 Piazza M, Grady MS. Cranioplasty. Neurosurg Clin N Am 2017;28(2):257–265 Schuss P, Vatter H, Marquardt G, et al. Cranioplasty after decompressive craniectomy: the effect of timing on postoperative complications. J Neurotrauma 2012;29(6):1090–1095 Dünisch P, Walter J, Sakr Y, et al. Risk factors of aseptic bone resorption: a study after autologous bone flap reinsertion due to decompressive craniotomy. J Neurosurg 2013;118(5):1141–1147 Wachter D, Reineke K, Behm T, Rohde V. Cranioplasty after decompressive hemicraniectomy: underestimated surgery-associated complications? Clin Neurol Neurosurg 2013;115(8):1293–1297 Jiang F, Jiang P, Xu G, et al. Impact of infectious complications on cranioplasty outcomes. Front Neurol 2021;12:726468 Tables Table 1. Baseline demographic and clinical characteristics of patients undergoing decompressive craniectomy (n=76) Variable n % Age group (years) 60 11 14.5 Sex Male 59 77.6 Female 17 22.4 Aetiology Traumatic (TBI) 27 35.5 Non-traumatic 49 64.5 Pre-op GCS 3–8 (severe) 30 39.5 9–12 (moderate) 23 30.3 13–15 (mild) 23 30.3 Comorbidities Hypertension 22 28.9 Diabetes mellitus 10 13.2 Onset-to-surgery interval ≤3 days 56 73.7 4–7 days 16 21.1 >7 days 4 5.3 Bone flap size Small (15×10 cm) 14 18.4 Total 76 100 GCS = Glasgow Coma Scale. TBI = traumatic brain injury. Data expressed as n (%). Table 2. Early complications (≤4 weeks) following decompressive craniectomy (n=76) Complication n % Tracheostomy requirement 32 42.1 Mechanical ventilation >5 days 27 35.5 Dyselectrolytaemia (total) 25 32.9 — Hypernatraemia 10 13.2 — Hyponatraemia 8 10.5 — Hypokalaemia 7 9.2 Systemic infection 14 18.4 Brain herniation through defect 10 13.2 Early mortality (≤4 weeks) 10 13.2 Haemorrhagic expansion 7 9.2 Increased cerebral oedema 6 7.9 Scalp wound infection 4 5.3 Abdominal wound infection 4 5.3 Pseudomeningocele / CSF leak 2 2.6 Subdural hygroma 2 2.6 Scalp flap necrosis 2 2.6 Hydrocephalus (HCP) 1 1.3 Intraoperative excess bleeding 11 14.5 Intraoperative hypotension 6 7.9 Data expressed as n (%). HCP = hydrocephalus; CSF = cerebrospinal fluid. Table 3. Late complications (>4 weeks) following decompressive craniectomy (n=76) Complication n % Hydrocephalus (HCP) 11 14.5 Pseudomeningocele / CSF leak 9 11.8 Bone flap resorption 6 7.9 Sinking skin flap syndrome 4 5.3 External cerebral herniation 3 3.9 Bone flap infection 3 3.9 Late mortality (>4 weeks post-DC) 2 2.6 Data expressed as n (%). HCP = hydrocephalus; DC = decompressive craniectomy. Table 4. Statistically significant associations between clinical/surgical factors and DC complications Risk factor Complication Association p-value Age >60 years Dyselectrolytaemia Significant 0.001 Age >60 years Scalp wound infection Significant 0.006 Age >60 years Early mortality Significant 0.006 GCS 3–8 Systemic infection Significant 0.032 GCS 3–8 Ventilation >5 days Significant 0.004 GCS 3–8 Tracheostomy Significant 0.001 GCS 3–8 Early mortality Significant 0.029 Small bone flap size Late HCP Significant 0.010 Small bone flap size Late pseudomeningocele Significant 0.001 Onset-to-surgery 4–7 days Tracheostomy Significant 0.033 Pseudomeningocele Late HCP 55.6% vs 10.4% 0.003 All associations determined by chi-square or Fisher's exact test. p<0.05 considered significant. HCP = hydrocephalus; GCS = Glasgow Coma Scale. Table 5. Cranioplasty complications, material used, timing, and significant associations (n=51) Complication / Factor n % p-value Complications (n=51) Cosmetic defect 5 9.8 — Intracranial haematoma (ICH) 4 7.8 — Implant dislodgement/exposure 3 5.9 — Hydrocephalus (post-CP) 3 5.9 — Surgical site infection 2 3.9 — Post-operative seizure 1 2.0 — Significant associations Small calvarial defect → ICH 26.7% vs 0% 0.005 Mesh CP material → dislodgement 50% vs 4.1% 0.007 Bone flap+mesh → seizure 20% vs 0% 0.002 Female sex → infection 16.7% vs 0% 0.009 CP material used Autologous bone flap 36 70.5 — 3D custom implant 6 11.8 — Bone flap + mesh 5 9.8 — Titanium mesh alone 2 3.9 — PMMA 2 3.9 — CP timing 6 months 20 39.2 — PMMA = polymethylmethacrylate. p-values derived from Fisher's exact test. — indicates not statistically tested. ICH = intracranial haematoma; CP = cranioplasty. Table 6. Comparison of major complication rates with published decompressive craniectomy series Series (Year) n (DC) HCP % SSI % Mortality % Setting Present study (2024) 76 14.5 18.4 13.2 India (LMIC) Kurland et al. (2015) 214 15.1 12.6 9.8 USA Yang et al. (2008) 118 17.8 10.2 11.0 Taiwan Honeybul et al. (2010) 91 12.1 8.8 16.5 Australia HCP = hydrocephalus; SSI = surgical site infection; LMIC = low- and middle-income country. All rates expressed as percentage of DC patients. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9184321","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":610504769,"identity":"a2867da4-8cf9-4865-a2d8-d97c62675c09","order_by":0,"name":"Dr. Prashanta Chihnara","email":"data:image/png;base64,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","orcid":"","institution":"Nizam's Institute of Medical Sciences","correspondingAuthor":true,"prefix":"Dr.","firstName":"Prashanta","middleName":"","lastName":"Chihnara","suffix":""},{"id":610504770,"identity":"b4329de7-9e81-429a-88d6-7e810bdada79","order_by":1,"name":"Dr. Suchanda Bhattacharjee","email":"","orcid":"","institution":"Nizam's Institute of Medical Sciences","correspondingAuthor":false,"prefix":"Dr.","firstName":"Suchanda","middleName":"","lastName":"Bhattacharjee","suffix":""},{"id":610504771,"identity":"f513e5a1-aa15-47f4-802b-e07cc5fbfc6c","order_by":2,"name":"Dr. K. Ramnadha Reddy","email":"","orcid":"","institution":"Nizam's Institute of Medical Sciences","correspondingAuthor":false,"prefix":"Dr.","firstName":"K.","middleName":"Ramnadha","lastName":"Reddy","suffix":""},{"id":610504772,"identity":"29e10545-e07e-4310-94ea-9a95c047d156","order_by":3,"name":"Dr Udbhav Bansal","email":"","orcid":"","institution":"Nizam's Institute of Medical Sciences","correspondingAuthor":false,"prefix":"Dr","firstName":"Udbhav","middleName":"","lastName":"Bansal","suffix":""}],"badges":[],"createdAt":"2026-03-21 08:23:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9184321/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9184321/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105718976,"identity":"84fe3553-96d2-4e89-8a10-54a5ce77be2d","added_by":"auto","created_at":"2026-03-30 09:15:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2839379,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative clinical and radiological findings of early post-operative complications (≤4 weeks) following decompressive craniectomy (DC). (A) Axial computed tomography (CT) demonstrating haematoma expansion: pre-operative scan (left) and post-operative scan (right) showing interval increase in haemorrhagic volume. (B) Serial axial CT scans from a 43-year-old male with deranged coagulation profile showing progressive haematoma expansion with scalp haematoma after right fronto-temporal DC. (C) Axial CT demonstrating external cerebral herniation through the craniectomy defect in a patient with severe cerebral oedema; this complication is more pronounced with small craniectomy size and is minimised by sufficiently large decompression. (D) Intraoperative photograph showing infected bone flap (left) and non-healing abdominal wound/sinus at the bone storage site (right). (E) Intraoperative photograph demonstrating bone flap resorption encountered at the time of planned cranioplasty following abdominal storage. (F) Clinical photograph showing scalp flap necrosis post-DC due to compromised blood supply along the posterior temporal incision limb. CT = computed tomography; DC = decompressive craniectomy.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9184321/v1/d5744791e64c5f2c67d172e5.png"},{"id":105719004,"identity":"e1df58cd-6f87-4dd5-9405-590c52e9535f","added_by":"auto","created_at":"2026-03-30 09:15:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2262517,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative radiological findings of late post-operative complications (\u0026gt;4 weeks) following decompressive craniectomy (DC). (A) Axial CT demonstrating communicating hydrocephalus (HCP) with marked ventriculomegaly following right fronto-temporal DC; development of HCP predicts unfavourable outcome and early cranioplasty aids restoration of normal ICP dynamics. (B) CT scan series of a 50-year-old male (right thalamic haemorrhage, ICH, and IVE) presenting with scalp swelling and drowsiness following DC, demonstrating HCP with concomitant pseudomeningocele; treated with programmable VP shunt and bone flap replacement. (C) Serial axial CT images of a 10-year-old male (traumatic right frontal contusion, GCS E2V2M5) following right fronto-temporal DC, demonstrating pseudomeningocele with hydrocephalus; treated with left Kocher's EVD and bone flap replacement. (D) Axial CT showing bilateral subdural effusion/hygroma — a late CSF complication predominantly seen in paediatric DC patients, typically self-resolving; augmentative duroplasty at the time of decompression decreases incidence. (E) Serial axial CT images demonstrating progressive sinking skin flap syndrome (syndrome of the trephined) in a 25-year-old male following left fronto-temporal DC, with associated neurological deterioration; resolved following early cranioplasty. CT = computed tomography; DC = decompressive craniectomy; HCP = hydrocephalus; ICH = intracerebral haemorrhage; IVE = intraventricular extension; ICP = intracranial pressure; VP = ventriculoperitoneal; EVD = external ventricular drain; CSF = cerebrospinal fluid; GCS = Glasgow Coma Scale.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9184321/v1/2d3961457210c65e820e633b.png"},{"id":105718845,"identity":"79670343-0cef-467a-920a-91df29ea0dae","added_by":"auto","created_at":"2026-03-30 09:15:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2065954,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative clinical findings of complications following cranioplasty (CP). (A) Clinical photograph showing surgical site infection (SSI) with wound discharge and dehiscence following cranioplasty. (B) Intraoperative photograph of infected bone flap at explantation demonstrating purulent discharge (left), and post-debridement clinical view with the wound following bone flap removal (right). (C) Clinical photograph showing exposed alloplastic implant through wound breakdown — a complication significantly more frequent with titanium mesh-alone cranioplasty (50% vs. 4.1%; p=0.007 in the present series). (D) Clinical photographs showing scalp flap necrosis post-cranioplasty with wound breakdown over the cranioplasty site; attributed to limited blood supply of the scalp flap. (E) Clinical photograph showing bone flap depression with cosmetic deformity (left) and corresponding CT demonstrating bone flap resorption requiring revision cranioplasty with alloplastic implant (right). (F) Intraoperative photographs showing severely resorbed autologous bone flap at revision cranioplasty (left) and titanium mesh implant replacement in situ (right). CP = cranioplasty; SSI = surgical site infection; CT = computed tomography.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9184321/v1/c4b1d2943f35f9ab78195f58.png"},{"id":106401804,"identity":"5f898849-5e49-475f-95fb-2e9d570c61da","added_by":"auto","created_at":"2026-04-08 09:09:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7645207,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9184321/v1/78d52493-f643-480c-af4b-d3c8e30f5a81.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perioperative and Delayed Complications of Decompressive Craniectomy: A Sequential Analysis from a Tertiary Neurosurgical Centre in India","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDecompressive craniectomy is a surgical intervention in which a large portion of the calvarium is removed to permit brain expansion and thereby reduce intracranial pressure (ICP). The Monro-Kellie doctrine holds that intracranial volume is fixed; any expansion of one compartment must be offset by a reduction in another. When cerebral oedema or haematoma overwhelms the capacity for compensatory CSF displacement and venous collapse, ICP rises to critically harmful levels, and DC provides an immediate volumetric escape valve.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTwo landmark randomised trials, DECRA (2011) and RESCUEicp (2016), have defined the evidence base for DC in traumatic brain injury (TBI).\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e DECRA demonstrated that bifrontotemporoparietal DC reduced ICP but did not improve functional outcomes, while RESCUEicp showed a significant reduction in mortality at six months with DC, albeit at the cost of increased rates of vegetative survival.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e In non-traumatic indications such as malignant middle cerebral artery infarction and refractory hypertensive haemorrhage, DC remains standard of care despite an absence of definitive randomised controlled trial evidence.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile the life-saving potential of DC is well established, the procedure is associated with a complex array of perioperative and long-term complications \u0026mdash; ranging from dyselectrolytaemia and systemic infection in the early post-operative period to hydrocephalus, sinking skin flap syndrome, and pseudomeningocele development in the months that follow.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e These complications not only increase morbidity and hospital costs but also delay cranioplasty, which is itself associated with neurological improvement and reintegration of CSF dynamics.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCranioplasty \u0026mdash; the surgical reconstruction of the calvarial defect \u0026mdash; is the necessary complement to DC. Choice of cranioplasty material (autologous bone, titanium mesh, PMMA, or custom three-dimensional implants), timing of surgery, and patient-specific risk factors all influence cranioplasty outcomes.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Data from low- and middle-income countries (LMICs) such as India remain scarce, and complication profiles may differ from those reported in high-income settings owing to differences in aetiology, nutritional status, referral delay, and post-operative resources.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study was designed to prospectively document the spectrum and frequency of complications arising from both DC and CP in a large tertiary neurosurgical centre in India, and to identify preoperative and intraoperative predictors of adverse outcomes \u0026mdash; with the goal of informing perioperative risk stratification and surgical decision-making.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a prospective observational cohort study conducted in the Department of Neurosurgery at the Nizam\u0026apos;s Institute of Medical Sciences (NIMS), Hyderabad, India \u0026mdash; a 1,200-bed tertiary referral centre serving a predominantly low-income population from the Telangana and Andhra Pradesh regions. The study was conducted following institutional ethics committee approval (Reference: NIMS/NeuSurg/2024) and in accordance with the Declaration of Helsinki. Informed written consent was obtained from all patients or their legal guardians.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsecutive patients who underwent DC for any indication (traumatic or non-traumatic) during the study period were enrolled. Patients with inadequate follow-up (\u0026lt;6 months) or incomplete records were excluded. Of the 76 DC patients enrolled, 51 who subsequently underwent CP formed the cranioplasty sub-cohort.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDecompressive craniectomy was performed as a standard frontotemporo-parieto-occipital hemicraniectomy using a reverse question-mark incision, with removal of a bone flap of at least 12 cm diameter as recommended in the Brain Trauma Foundation guidelines.\u003csup\u003e9\u003c/sup\u003e In bilateral cases, bifrontal DC was performed. The dura was opened in a stellate or cruciate fashion and duraplasty performed with pericranium or synthetic graft as needed. The abdominal subcutaneous pocket technique was used for autologous bone flap storage in all patients planned for future cranioplasty. Cranioplasty was performed under general anaesthesia via the original incision; the stored bone flap was refashioned and fixed with titanium plates and screws (94.1% of cases). Where the autologous flap was unsuitable due to infection or resorption, alloplastic material (3D implant, titanium mesh, or PMMA) was used.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection and Outcome Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaseline data collected included age, sex, clinical diagnosis, Glasgow Coma Scale (GCS) on admission, comorbidities, onset-to-surgery interval, and bone flap size. Complications were prospectively recorded and classified as: (i) intraoperative (haemorrhage, hypotension); (ii) early (\u0026le;4 weeks post-DC); and (iii) late (\u0026gt;4 weeks post-DC). The primary outcome was incidence of any complication. Secondary outcomes included association of predictor variables with individual complications.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCategorical variables are expressed as frequency and percentage. Associations between risk factors and dichotomous outcome variables were analysed by Pearson\u0026apos;s chi-square test or Fisher\u0026apos;s exact test (for cells with expected frequency \u0026lt;5). A two-tailed p-value of \u0026lt;0.05 was considered statistically significant. Data were analysed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA). This study is reported in accordance with the STROBE statement for observational studies.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eBaseline Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeventy-six patients underwent DC during the study period. The mean age was 40.2 years, with the majority (55.3%) aged 18\u0026ndash;40 years. Seventy-seven percent of patients were male. Non-traumatic aetiologies (large vessel ischaemic stroke, hypertensive haemorrhage, and spontaneous subarachnoid haemorrhage) accounted for 64.5% of cases; traumatic brain injury accounted for the remaining 35.5%. The mean admission GCS was 9.13. Comorbidities were present in 46.1% of patients, most commonly hypertension (28.9%) and diabetes mellitus (13.2%). Most patients (73.7%) were operated within three days of symptom onset (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntraoperative Complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIntraoperative excessive haemorrhage occurred in 11 patients (14.5%) and intraoperative hypotension in 6 (7.9%). These complications were more frequent in patients with bilateral DC and in those with delayed surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEarly Post-operative Complications Following DC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEarly complications (\u0026le;4 weeks) were common and are detailed in Table 2 and Figure 1. Tracheostomy was required in 42.1% of patients and prolonged mechanical ventilation (\u0026gt;5 days) in 35.5%. Dyselectrolytaemia occurred in 32.9% of patients; hypernatraemia was the most frequent electrolyte abnormality (13.2%), occurring predominantly in patients with hypothalamic involvement or severe primary brain injury. Systemic infections \u0026mdash; pneumonia, urinary tract infection, and septicaemia \u0026mdash; affected 18.4% of the cohort. Brain herniation through the craniectomy defect occurred in 13.2% of cases. Early mortality was 13.2%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLate Complications Following DC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLate complications (\u0026gt;4 weeks) are summarised in Table 3 and Figure 2. Hydrocephalus was the most frequent late complication (14.5%), followed by pseudomeningocele or CSF leak (11.8%), bone flap resorption (7.9%), and sinking skin flap syndrome (5.3%). Late mortality occurred in 2.6% of patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePredictors of DC Complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistically significant associations between patient and surgical characteristics and complications are presented in Table 4. Age \u0026gt;60 years was significantly associated with dyselectrolytaemia (p=0.001), scalp wound infection (p=0.006), and early mortality (p=0.006). Severe neurological compromise (GCS 3\u0026ndash;8) significantly predicted systemic infection (p=0.032), prolonged ventilation (p=0.004), tracheostomy (p=0.001), and early mortality (p=0.029). Small bone flap size (\u0026lt;13\u0026times;10 cm) was strongly associated with both late hydrocephalus (p=0.010) and late pseudomeningocele (p=0.001). Onset-to-surgery interval of 4\u0026ndash;7 days predicted tracheostomy (p=0.033). The development of pseudomeningocele/CSF leak was a powerful predictor of subsequent hydrocephalus (55.6% vs. 10.4%; p=0.003).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCranioplasty Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFifty-one patients underwent subsequent cranioplasty. Autologous bone flap was used in 70.5%; 3D custom implants in 11.8%; bone flap plus mesh in 9.8%; titanium mesh alone in 3.9%; and PMMA in 3.9%. Titanium plate and screw fixation was used in 94.1%. Cranioplasties were predominantly performed at 3\u0026ndash;6 months post-DC (41.2%), with 39.2% after 6 months. Cranioplasty complications are detailed in Table 5 and Figure 3. Overall complication rate was 35.3%. Small calvarial defect was associated with post-cranioplasty intracranial haemorrhage (p=0.005). Mesh alone as CP material was the strongest predictor of implant dislodgement/exposure (50% vs. 4.1%; p=0.007). Female sex was significantly associated with post-cranioplasty SSI (16.7% vs. 0%; p=0.009).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis prospective cohort from a major Indian tertiary neurosurgical centre documents a comprehensive complication profile across both DC and CP, with key findings that have direct implications for surgical practice in resource-limited settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe high rates of tracheostomy (42.1%) and prolonged ventilation (35.5%) observed in our cohort reflect the severity of primary neurological insult and the systemic consequences of major brain injury, and are consistent with other large DC series.\u003csup\u003e5,6\u003c/sup\u003e Dyselectrolytaemia, particularly hypernatraemia, was the most common metabolic complication (32.9%), driven by SIADH, cerebral salt wasting, and diabetes insipidus \u0026mdash; well-recognised sequelae of hypothalamic-pituitary axis disruption following severe TBI or brainstem compression.\u003csup\u003e8\u003c/sup\u003e The significant association with age \u0026gt;60 years (p=0.001) underscores the vulnerability of older patients and the need for intensive metabolic monitoring in this subgroup.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEarly mortality of 13.2% is comparable to rates reported by Kurland et al. (9.8%) and Yang et al. (11.0%),\u003csup\u003e5,6\u003c/sup\u003e though slightly higher, likely reflecting our higher proportion of non-traumatic aetiologies and delayed access to surgical care characteristic of LMIC settings. The strong associations between low GCS (3\u0026ndash;8) and early mortality (p=0.029) and systemic morbidity provide objective thresholds for pre-operative counselling, consistent with the established literature on GCS as a prognostic indicator.\u003csup\u003e4\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePost-DC hydrocephalus occurred in 14.5% of patients \u0026mdash; a rate consistent with published series (12\u0026ndash;18%).\u003csup\u003e5,6,7\u003c/sup\u003e The novel finding of this study is the strong association between early pseudomeningocele/CSF leak and subsequent hydrocephalus (55.6% vs. 10.4%; p=0.003). This pseudomeningocele\u0026ndash;hydrocephalus cascade likely reflects disruption of normal CSF resorption pathways through the arachnoid granulations following dural violation and CSF externalisation. Clinicians should treat pseudomeningocele aggressively and maintain a low threshold for surveillance imaging to detect evolving hydrocephalus.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe significant association between small bone flap size and both late HCP (p=0.010) and pseudomeningocele (p=0.001) is an important technical finding. A smaller craniectomy provides less dural slack, potentially creating tension at dural edges and impairing CSF egress dynamics. This supports the Brain Trauma Foundation recommendation for craniectomy of at least 12 cm diameter,\u003csup\u003e9\u003c/sup\u003e and suggests that surgeons should avoid size limitation when operating in an already compromised brain.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe high rate of autologous bone use (70.5%) reflects both resource constraints and evidence supporting the efficacy and low cost of autologous repair when infection is absent.\u003csup\u003e15,16\u003c/sup\u003e Timing of cranioplasty also influences outcome; early cranioplasty (within 3 months) has been associated with greater neurological recovery in some series,\u003csup\u003e14\u003c/sup\u003e though this must be balanced against infection risk elevated when ventriculoperitoneal shunts are in situ.\u003csup\u003e13\u003c/sup\u003e The striking association between titanium mesh alone as CP material and implant dislodgement/exposure (50%; p=0.007) is a critical safety signal. Titanium mesh lacks the rigidity of a custom implant and is prone to scalp pressure necrosis over large defects.\u003csup\u003e17\u003c/sup\u003e Our data support avoidance of mesh-alone cranioplasty and preference for autologous bone or custom alloplastic implants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eComparison with published international series (Table 6) reveals that our HCP rate (14.5%) is consistent across centres.\u003csup\u003e5,6,7\u003c/sup\u003e Systemic infection (18.4%) is higher than in Kurland et al. (12.6%) and Yang et al. (10.2%), possibly reflecting greater healthcare-associated infection burden in our setting.\u003csup\u003e19,20\u003c/sup\u003e Mortality (13.2%) was higher than in the Kurland series but lower than in Honeybul\u0026apos;s Australian cohort (16.5%), reflecting differences in patient selection and disease aetiology.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStrengths of this study include its prospective design, sequential coverage of both DC and CP in the same cohort, and the inclusion of a broad range of aetiologies representative of an LMIC neurosurgical practice. Limitations include the single-centre design, absence of a control group, moderate sample size limiting multivariate analysis, and lack of long-term functional outcome data. Bone flap resorption, occurring in 7.9% of patients, is influenced by infection and storage method,\u003csup\u003e21\u003c/sup\u003e and deserves dedicated prospective evaluation. Infection-related cranioplasty failure has been reported to be exacerbated by ventriculoperitoneal shunts and warrants active surveillance.\u003csup\u003e22,23\u003c/sup\u003e Future multi-centre prospective studies with standardised outcome measures and longer follow-up are warranted.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eDecompressive craniectomy and cranioplasty carry substantial complication burdens in the Indian tertiary care setting. Advanced age, low admission GCS, small bone flap size, and delayed surgery are key predictors of post-DC morbidity. The pseudomeningocele\u0026ndash;hydrocephalus cascade identified in this study warrants prospective validation and early clinical vigilance. For cranioplasty, mesh-alone reconstruction should be avoided. These findings provide practical guidance for perioperative risk stratification and surgical technique selection in resource-limited settings globally.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Ethics Committee of NIMS, Hyderabad (Reference: NIMS/NeuSurg/2024). Informed written consent was obtained from all patients or their legal guardians.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePC: Conceptualisation, data collection, statistical analysis, manuscript writing. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data underlying this article will be shared on reasonable request to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKolias AG, Kirkpatrick PJ, Hutchinson PJ. Decompressive craniectomy: past, present and future. Nat Rev Neurol 2013;9(7):405\u0026ndash;415\u003c/li\u003e\n\u003cli\u003eCooper DJ, Rosenfeld JV, Murray L, et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 2011;364(16):1493\u0026ndash;1502\u003c/li\u003e\n\u003cli\u003eHutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med 2016;375(12):1119\u0026ndash;1130\u003c/li\u003e\n\u003cli\u003eAarabi B, Hesdorffer DC, Ahn ES, et al. Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 2006;104(4):469\u0026ndash;479\u003c/li\u003e\n\u003cli\u003eKurland DB, Khaladj-Ghom A, Stokum JA, et al. Complications associated with decompressive craniectomy: a systematic review. Neurocrit Care 2015;23(2):292\u0026ndash;304\u003c/li\u003e\n\u003cli\u003eYang XF, Wen L, Shen F, et al. Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir (Wien) 2008;150(12):1241\u0026ndash;1248\u003c/li\u003e\n\u003cli\u003eHoneybul S, Ho KM, Lind CR, Gillett GR. The current role of decompressive craniectomy for severe traumatic brain injury. J Clin Neurosci 2010;17(5):579\u0026ndash;584\u003c/li\u003e\n\u003cli\u003eStiver SI. Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus 2009;26(6):E7\u003c/li\u003e\n\u003cli\u003eTimofeev I, Kirkpatrick PJ, Corteen E, et al. Decompressive craniectomy: operative technique and perioperative care. Adv Tech Stand Neurosurg 2006;31:115\u0026ndash;136\u003c/li\u003e\n\u003cli\u003eBender A, Heulin S, R\u0026ouml;hrer S, et al. Early cranioplasty may improve outcome in neurological patients with decompressive craniectomy. Brain Inj 2013;27(9):1073\u0026ndash;1079\u003c/li\u003e\n\u003cli\u003eYadla S, Campbell PG, Chitale R, et al. Effect of early and late cranioplasty on cerebral perfusion, neurological function and histology. World Neurosurg 2011;76(6):588\u0026ndash;594\u003c/li\u003e\n\u003cli\u003eGoldstein HE, Young IM, Mampre DM, et al. Complications of cranioplasty using titanium mesh and autologous bone flap. J Clin Neurosci 2019;60:125\u0026ndash;130\u003c/li\u003e\n\u003cli\u003eMustroph CM, Malcolm JG, Rindler RS, et al. Cranioplasty infection and resorption are associated with the presence of a ventriculoperitoneal shunt. World Neurosurg 2017;99:129\u0026ndash;134\u003c/li\u003e\n\u003cli\u003eMalcolm JG, Rindler RS, Chu JK, et al. Early cranioplasty is associated with greater neurological improvement. J Neurosurg 2018;128(4):1084\u0026ndash;1091\u003c/li\u003e\n\u003cli\u003eSundseth J, Sundseth A, Berg-Johnsen J, et al. Cranioplasty with autologous cryopreserved bone after decompressive craniectomy. Acta Neurochir (Wien) 2014;156(4):805\u0026ndash;811\u003c/li\u003e\n\u003cli\u003eWalcott BP, Kwon CS, Sheth SA, et al. Predictors of cranioplasty complications in stroke and trauma patients. J Neurosurg 2013;118(4):757\u0026ndash;762\u003c/li\u003e\n\u003cli\u003eJaberi A, Gambrell S, Krishnan R, et al. Comparison of outcomes following titanium mesh versus custom alloplastic implants for cranioplasty. J Craniofac Surg 2013;24(1):176\u0026ndash;180\u003c/li\u003e\n\u003cli\u003eSobani ZA, Shamim MS, Zafar SN, et al. Cranioplasty after decompressive craniectomy: an institutional audit and analysis of factors related to complications. Surg Neurol Int 2011;2:123\u003c/li\u003e\n\u003cli\u003ePiazza M, Grady MS. Cranioplasty. Neurosurg Clin N Am 2017;28(2):257\u0026ndash;265\u003c/li\u003e\n\u003cli\u003eSchuss P, Vatter H, Marquardt G, et al. Cranioplasty after decompressive craniectomy: the effect of timing on postoperative complications. J Neurotrauma 2012;29(6):1090\u0026ndash;1095\u003c/li\u003e\n\u003cli\u003eD\u0026uuml;nisch P, Walter J, Sakr Y, et al. Risk factors of aseptic bone resorption: a study after autologous bone flap reinsertion due to decompressive craniotomy. J Neurosurg 2013;118(5):1141\u0026ndash;1147\u003c/li\u003e\n\u003cli\u003eWachter D, Reineke K, Behm T, Rohde V. Cranioplasty after decompressive hemicraniectomy: underestimated surgery-associated complications? Clin Neurol Neurosurg 2013;115(8):1293\u0026ndash;1297\u003c/li\u003e\n\u003cli\u003eJiang F, Jiang P, Xu G, et al. Impact of infectious complications on cranioplasty outcomes. Front Neurol 2021;12:726468\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eBaseline demographic and clinical characteristics of patients undergoing decompressive craniectomy (n=76)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eAge group (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003e\u0026lt;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003e18\u0026ndash;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e55.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003e41\u0026ndash;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003e\u0026gt;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e77.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e22.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eAetiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eTraumatic (TBI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e35.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eNon-traumatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e64.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003ePre-op GCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003e3\u0026ndash;8 (severe)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e39.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003e9\u0026ndash;12 (moderate)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e30.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003e13\u0026ndash;15 (mild)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e30.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e28.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eOnset-to-surgery interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003e\u0026le;3 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e73.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003e4\u0026ndash;7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e21.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003e\u0026gt;7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eBone flap size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eSmall (\u0026lt;13\u0026times;10 cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e26.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eNormal (13\u0026ndash;15\u0026times;10 cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e55.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eLarge (\u0026gt;15\u0026times;10 cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 55.5927%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.2037%;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eGCS = Glasgow Coma Scale. TBI = traumatic brain injury. Data expressed as n (%).\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eEarly complications (\u0026le;4 weeks) following decompressive craniectomy (n=76)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eTracheostomy requirement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e42.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eMechanical ventilation \u0026gt;5 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e35.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eDyselectrolytaemia (total)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e32.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026mdash; Hypernatraemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026mdash; Hyponatraemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026mdash; Hypokalaemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eSystemic infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eBrain herniation through defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eEarly mortality (\u0026le;4 weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eHaemorrhagic expansion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eIncreased cerebral oedema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eScalp wound infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eAbdominal wound infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003ePseudomeningocele / CSF leak\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eSubdural hygroma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eScalp flap necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eHydrocephalus (HCP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eIntraoperative excess bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eIntraoperative hypotension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eData expressed as n (%). HCP = hydrocephalus; CSF = cerebrospinal fluid.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eLate complications (\u0026gt;4 weeks) following decompressive craniectomy (n=76)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eHydrocephalus (HCP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003ePseudomeningocele / CSF leak\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eBone flap resorption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eSinking skin flap syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eExternal cerebral herniation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eBone flap infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57.7371%;\"\u003e\n \u003cp\u003eLate mortality (\u0026gt;4 weeks post-DC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eData expressed as n (%). HCP = hydrocephalus; DC = decompressive craniectomy.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eStatistically significant associations between clinical/surgical factors and DC complications\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.787%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk factor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6223%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4592%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssociation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.787%;\"\u003e\n \u003cp\u003eAge \u0026gt;60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6223%;\"\u003e\n \u003cp\u003eDyselectrolytaemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4592%;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.787%;\"\u003e\n \u003cp\u003eAge \u0026gt;60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6223%;\"\u003e\n \u003cp\u003eScalp wound infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4592%;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.787%;\"\u003e\n \u003cp\u003eAge \u0026gt;60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6223%;\"\u003e\n \u003cp\u003eEarly mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4592%;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.787%;\"\u003e\n \u003cp\u003eGCS 3\u0026ndash;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6223%;\"\u003e\n \u003cp\u003eSystemic infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4592%;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.787%;\"\u003e\n \u003cp\u003eGCS 3\u0026ndash;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6223%;\"\u003e\n \u003cp\u003eVentilation \u0026gt;5 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4592%;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.787%;\"\u003e\n \u003cp\u003eGCS 3\u0026ndash;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6223%;\"\u003e\n \u003cp\u003eTracheostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4592%;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.787%;\"\u003e\n \u003cp\u003eGCS 3\u0026ndash;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6223%;\"\u003e\n \u003cp\u003eEarly mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4592%;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.787%;\"\u003e\n \u003cp\u003eSmall bone flap size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6223%;\"\u003e\n \u003cp\u003eLate HCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4592%;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.787%;\"\u003e\n \u003cp\u003eSmall bone flap size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6223%;\"\u003e\n \u003cp\u003eLate pseudomeningocele\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4592%;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.787%;\"\u003e\n \u003cp\u003eOnset-to-surgery 4\u0026ndash;7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6223%;\"\u003e\n \u003cp\u003eTracheostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4592%;\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.787%;\"\u003e\n \u003cp\u003ePseudomeningocele\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6223%;\"\u003e\n \u003cp\u003eLate HCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.4592%;\"\u003e\n \u003cp\u003e55.6% vs 10.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1314%;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAll associations determined by chi-square or Fisher\u0026apos;s exact test. p\u0026lt;0.05 considered significant. HCP = hydrocephalus; GCS = Glasgow Coma Scale.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.\u0026nbsp;\u003c/strong\u003eCranioplasty complications, material used, timing, and significant associations (n=51)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication / Factor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplications (n=51)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003eCosmetic defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003eIntracranial haematoma (ICH)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003eImplant dislodgement/exposure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003eHydrocephalus (post-CP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003eSurgical site infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003ePost-operative seizure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificant associations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003eSmall calvarial defect \u0026rarr; ICH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e26.7% vs 0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003eMesh CP material \u0026rarr; dislodgement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e50% vs 4.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003eBone flap+mesh \u0026rarr; seizure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e20% vs 0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale sex \u0026rarr; infection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e16.7% vs 0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.009\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCP material used\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003eAutologous bone flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e70.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003e3D custom implant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003eBone flap + mesh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003eTitanium mesh alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePMMA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026mdash;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCP timing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003e\u0026lt;3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e19.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003e3\u0026ndash;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e41.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44.5%;\"\u003e\n \u003cp\u003e\u0026gt;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.8333%;\"\u003e\n \u003cp\u003e39.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.8333%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003ePMMA = polymethylmethacrylate. p-values derived from Fisher\u0026apos;s exact test. \u0026mdash; indicates not statistically tested. ICH = intracranial haematoma; CP = cranioplasty.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6.\u0026nbsp;\u003c/strong\u003eComparison of major complication rates with published decompressive craniectomy series\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.8333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeries (Year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (DC)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHCP %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSSI %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.5%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMortality %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.8333%;\"\u003e\n \u003cp\u003ePresent study (2024)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.5%;\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.6667%;\"\u003e\n \u003cp\u003eIndia (LMIC)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.8333%;\"\u003e\n \u003cp\u003eKurland et al. (2015)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e15.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.5%;\"\u003e\n \u003cp\u003e9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.6667%;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.8333%;\"\u003e\n \u003cp\u003eYang et al. (2008)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e17.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.5%;\"\u003e\n \u003cp\u003e11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.6667%;\"\u003e\n \u003cp\u003eTaiwan\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27.8333%;\"\u003e\n \u003cp\u003eHoneybul et al. (2010)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.3333%;\"\u003e\n \u003cp\u003e8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.5%;\"\u003e\n \u003cp\u003e16.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.6667%;\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eHCP = hydrocephalus; SSI = surgical site infection; LMIC = low- and middle-income country. All rates expressed as percentage of DC patients.\u003c/em\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Decompressive craniectomy, cranioplasty, hydrocephalus, sinking skin flap, complications, traumatic brain injury, low- and middle-income countries","lastPublishedDoi":"10.21203/rs.3.rs-9184321/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9184321/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eDecompressive craniectomy (DC) is a life-saving neurosurgical procedure for refractory raised intracranial pressure. Despite its proven efficacy, DC carries significant perioperative and delayed morbidity. This study aimed to document the spectrum, frequency, and predictors of complications following DC and subsequent cranioplasty (CP) in a tertiary referral centre in India.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eA prospective observational cohort study was conducted at the Department of Neurosurgery, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, India. Seventy-six consecutive patients who underwent DC for traumatic and non-traumatic indications were enrolled; 51 subsequently underwent CP. Complications were classified as intraoperative, early (\u0026le;\u0026thinsp;4 weeks), and late (\u0026gt;\u0026thinsp;4 weeks).\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAssociations between risk factors and outcome variables were evaluated by Pearson's chi-square test or Fisher's exact test. A two-tailed p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe cohort comprised predominantly young males (mean age 40.2 years; 77.6% male). Traumatic brain injury accounted for 35.5% of indications. Early DC complications were frequent: tracheostomy requirement (42.1%), prolonged mechanical ventilation (35.5%), dyselectrolytaemia (32.9%), and systemic infection (18.4%). Early mortality was 13.2%. Late DC complications included hydrocephalus (HCP; 14.5%) and pseudomeningocele/CSF leak (11.8%). Small bone flap size was significantly associated with both late HCP (p\u0026thinsp;=\u0026thinsp;0.010) and pseudomeningocele (p\u0026thinsp;=\u0026thinsp;0.001). Prior pseudomeningocele predicted HCP development (55.6% vs. 10.4%; p\u0026thinsp;=\u0026thinsp;0.003). Low admission GCS predicted ventilatory dependence, tracheostomy, and early mortality (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Among CP patients, autologous bone was used in 70.5%. CP complications included cosmetic defects (9.8%), intracranial haemorrhage (7.8%), and implant dislodgement (5.9%). Mesh as CP material strongly predicted dislodgement/exposure (50% vs. 4.1%; p\u0026thinsp;=\u0026thinsp;0.007).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDC and CP carry substantial complication burdens in the Indian tertiary care setting. Small craniectomy size, low GCS, and advanced age are key modifiable risk indicators. Mesh alone should be avoided as cranioplasty material. These findings inform perioperative risk stratification and surgical planning in resource-constrained settings.\u003c/p\u003e","manuscriptTitle":"Perioperative and Delayed Complications of Decompressive Craniectomy: A Sequential Analysis from a Tertiary Neurosurgical Centre in India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-30 09:11:53","doi":"10.21203/rs.3.rs-9184321/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f02c0480-6ebd-4dec-b944-ff8ff10c98b5","owner":[],"postedDate":"March 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-01T23:24:02+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-30 09:11:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9184321","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9184321","identity":"rs-9184321","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}