| ?Background?Traumatic brain injury(TBI)occurs when a force transmitted to the head or body results in neuropathologic damage and dysfunction,and it also has high incidence,high morbidity and high mortality of “three high” characteristics,especially in young and middle-aged men.The etiology of TBI includes fall,traffic accident,gunshot wound,domestic violence and sport-related injury.According to damage mechanism,TBI is divided into primary brain injury and secondary brain injury.Interestingly,it is estimated that TBI is projected by the World Health Organization(WHO)to become the third leading cause of global mortality and disability by the year 2020.TBI is a common and multiple clinical condition,besides,TBI has become a staggering health issue that imposes serious threats and medical concerns to public health.Brain edema often occurs after TBI and it is harmful because it causes not only the cell swelling but also the tissue parenchyma,there is a rapid increase in intracranial pressure(ICP)or even the appearance of refractory intracranial hypertension,which results in compression of brain blood vessels,decreased cerebral perfusion pressure(CCP),reduced tissue blood flow,reduced oxygenation in nerve tissue and caused secondary brain damage,further deteriorated the hydrocephalus and eventually shifts tissue down pressure herniations that may crush vital brain centers such as those involved in respiration and cardiac function.Literatures reported that the formation of cerebral edema and even the refractory intracranial hypertension is one of the major factors leading to the high mortality and morbidity in affected individuals.Therefore,how to effectively prevent and even reverse the intractable intracranial hypertension after TBI that is the key to solve the problem.Decompressive craniectomy(DC)was first introduced in 1971 as a management option for traumatic subdural hematoma.After that,DC is considered to be an effective measure to reduce ICP,which can allow brain tissue to expand,consequently facilitating control of increased ICP and reducing the risk of herniation,this may improve the outcome of neurocritical care patients.However,several complications,such as “syndrome of the sinking skin flap”,have emerged in patients with large cranial defects after decompressive craniectomy,which may cause neurological deterioration,so cranioplasty(CP)is required to restore the cranium.CP is defined as the surgical repair of a defect in the cranium,which may restore the physiological structure.Recently,however,CP,a historically cosmetic and protective procedure,has been shown to have therapeutic benefits when performed after DC,as measured by an improvement of cerebral blood flow(CBF),cerebrospinal fluid(CSF)circulation,cerebral glucose metabolism,neuropsychological and cognitive.It has generally been recommended that CP be performed at least 3 to 6 months after initial DC because of severe adhesion dissecting in trouble,increased blood loss,infection risks,or complications in the interim period.Many neurosurgeons try to explore the advantages of cranial repair at early stage(1-3 months after DC)in terms of complications and neurological function outcomes.Most studies found that early CP can shorten the operation time,decrease blood loss,reduce the rate of infection and improve patient outcome.Conversely,other studies indicated that early CP was associate with a higher risk of complications.However,the results remain controversially.Moreover,the sample size of early CP is less and the timing of early CP or the outcome differ from each other,so it is difficult to draw a clear conclusion.Thus,in order to figure out the clinical efficacy and related complication of early CP,this study adopts the method of Meta-Analysis to systematically evaluate clinical articles about the efficacy and complication of early CP in recent 10 years,providing more scientific and reliable evidence for the future clinical application.?Objective?To systematically evaluate the efficacy and safety of the early CP in patients on 3 indicators for operative time,neurological outcome and complications.?Method?Through detailed experimental design,strict inclusion and exclusion criteria,researchers independently searching 9 international authoritative database.Randomized controlled clinical trial or nonrandomized controlled clinical trial of early CP with 3 indicators for operative time,neurological outcome and complications were conducted.Meta-analysis was done by using Review Manager 5.1 software.?Results?1.Through detailed search strategy and strict inclusion and exclusion criteria,the Meta-analysis ultimately included 18 qualified clinical articles,including 5 English and 13 Chinses literatures.Only 1 article was prospective study,the other articles were retrospective cohort studies,in which a total of 1414 subjects were involved.And all of the literatures had a clear definition of timing of early CP,and were used the overall complication rate,KPS score and GOS score as outcome indicators.2.Neurological outcomes:1)KPS score: The result of this Meta-analysis showed that the early CP group was superior to the late CP group in improving the KPS score(MD=11.28(95% CI(9.48,13.07)),P<0.00001),the difference was statistically significant;2)GOS score: The result of this Meta-analysis showed that the early CP group was superior to the late CP group in improving the GOS score(MD=0.69(95% CI(0.46,0.93),P<0.00001,the difference was statistically significant.3.Complications:1)Overall complication: The result of this Meta-analysis showed that the early CP group was superior to the late CP group in reducing the incidence of overall complication(RR=0.52(95% CI(0.41,0.66)),P<0.00001),the difference was statistically significant;2)Good prognosis: The result of this Meta-analysis showed that the early CP group was superior to the late CP group in improving the incidence of good prognosis(RR=1.23(95% CI(1.04,1.45)),P=0.01),the difference was statistically significant;3)Poor prognosis: The result of this Meta-analysis showed that the early CP group was superior to the late CP group in reducing the incidence of poor prognosis(RR=0.57(95% CI(0.45,0.72)),P<0.00001),the difference was statistically significant;4)Hydrocephalus: The result of this Meta-analysis showed that the early CP group was inferior to the late CP group in reducing the incidence of hydrocephalus(RR=2.47(95% CI(1.05,5.83)),P=0.04),the difference was statistically significant;No significant difference was found between two groups in other indicators such as epilepsy,seroma,poor wound healing,wound infection,intracranial infection and subdural collection of fluid.4.Operation time: The result of this Meta-analysis showed that the early CP group was superior to the late CP group in shortening the operation time(MD=-34.10(95% CI(-42.36,-25.85)),P<0.00001),the difference was statistically significant.?Conclusion?1.Early CP enhances KPS and GOS score and significantly improves prognosis;2.Early CP significantly reduces the incidence of overall complication,but plays no role on indicators for epilepsy,seroma,poor wound healing,wound infection,intracranial infection and subdural collection of fluid,however,it can increases the incidence of hydrocephalus;3.Early CP significantly shorten the operation time. |
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