The global state of cranioplasty practice following cranial decompression for traumatic brain injury: a provider survey

Objective: For patients undergoing decompressive craniectomy for TBI, cranioplasty facilitates rehabilitation and reintegration into society. Cranioplasty practice is poorly documented globally. Challenges including lack of materials and technical skills disproportionately affect LMICs. This study evaluates global cranioplasty practice and the extent to which barriers preclude patients from accessing cranial reconstruction. Methods: An international survey was disseminated to centres performing cranioplasty for TBI. Survey questions addressed baseline hospital information, cranioplasty indications, barriers and techniques, follow-up. Centres in HICs and LMICs were compared. Results: 101 responses were received (86 individual institutions, 39 countries). Variation in practice was seen globally, and between HICs and LMICs. Autologous bone was the most common material used. Titanium and polymethylmethacrylate were the most used artificial implants. LMIC sites were more likely to store bone flaps in the patient's abdomen, while HICs had more access to 3D printing. Lack of infection and good neurological recovery were the commonest eligibility criteria. Cost of materials/operation and unavailable materials were the commonest barriers. Responders suggested easier access to cheaper materials would significantly improve access. Cranioplasty associated costs were higher than the country's GNI per capita in 7 cases. Less than 50 % of patients without cranioplasty had access to protective equipment. Less than a quarter of respondents stated patients had access to brain injury charities, and over 50 % believed stigma affects their patients. Conclusions: Variation in cranioplasty practice was confirmed. Barriers limiting access were identified, specifically, availability of materials and operation-related costs. These findings can inform context-specific interventions to overcome current challenges.