Sequencing of Cranioplasty and Shunt Surgery After Decompressive Craniectomy: A Swedish Multicenter Study

Klas Holmgren; Alexander Fletcher-Sandersjöö; Bjartur Sæmundsson; Robert Nilsson; Richard Ågren; Peter Lindvall; David Bark; Fredrik Vedung; Alba Corell; Teodor Svedung Wettervik

doi:10.1227/neu.0000000000003910

Sequencing of Cranioplasty and Shunt Surgery After Decompressive Craniectomy: A Swedish Multicenter Study

Neurosurgery. 2026 Jan 26. doi: 10.1227/neu.0000000000003910. Online ahead of print.

Authors

Klas Holmgren¹, Alexander Fletcher-Sandersjöö^{2

3}, Bjartur Sæmundsson^{2

3}, Robert Nilsson^{2

3}, Richard Ågren^{2

4}, Peter Lindvall¹, David Bark⁵, Fredrik Vedung⁵, Alba Corell^{6

7}, Teodor Svedung Wettervik⁵

Affiliations

¹ Department of Clinical Science-Neurosciences, Umeå University, Umeå, Sweden.
² Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
³ Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
⁴ Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
⁵ Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden.
⁶ Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
⁷ Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.

PMID: 41586594
DOI: 10.1227/neu.0000000000003910

Abstract

Background and objectives: Patients with severe brain injury requiring decompressive craniectomy are at increased risk of developing chronic hydrocephalus, often necessitating both cranioplasty and shunt surgery. The optimal sequence of these procedures remains unclear, with limited and conflicting evidence on associated complication rates and outcomes. The aim of this study was to investigate clinical practices and outcomes associated with 3 procedural sequences: (1) cranioplasty before shunt, (2) simultaneous cranioplasty and shunt, and (3) shunt before cranioplasty.

Methods: In this multicenter retrospective cohort study, 99 patients from 4 Swedish neurosurgical centers who underwent both cranioplasty and shunt surgery over 15 years (2008-2022; only the first 10 years at 1 center) were included. Clinical data, surgical details, complications, and functional outcomes (modified Rankin Scale) were analyzed by each sequence group.

Results: Of 99 patients, 37 (37%) underwent cranioplasty before shunt, 37 (37%) had simultaneous procedures, and 25 (25%) received a shunt before cranioplasty. There was no significant difference in complications rates after cranioplasty or shunt surgery between these groups (P > .05). However, shunt before cranioplasty was associated with slightly higher rates of shunt complications (36% revision) but lower rates of cranioplasty removal (8%), whereas the inverse pattern was observed in the cranioplasty before shunt group (24% shunt revision; 30% cranioplasty removal). There was no difference in functional outcomes before or after cranioplasty or shunt surgery between the groups (P > .05).

Conclusion: The sequence of cranioplasty and shunt surgery did not significantly influence overall risks of implant revision or functional outcome, although complication patterns and their clinical severity differed between approaches. Cranioplasty implant removal remains a particularly serious event, while shunt infections can be equally detrimental. Future studies should refine sequencing strategies considering hydrocephalus type, timing, and procedural factors to minimize risk and improve patient outcomes.

Keywords: Complications; Cranioplasty; Decompressive craniectomy; Hydrocephalus; Shunt.