SynthesisNeurosurgical review2026
Bone flap preservation versus removal with immediate mesh cranioplasty for post-craniotomy infections: a systematic review and meta-analysis.
Synthesis in Neurosurgical review, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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7 authors.
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Abstract
Post-craniotomy infections are serious complications that often require complex surgical decision-making. The optimal management strategy-whether to retain the infected bone flap with antibiotics or remove it and perform mesh cranioplasty-remains unclear. We conducted a systematic review and meta-analysis of studies reporting outcomes for patients with post-craniotomy infections managed with either bone flap retention and antibiotic therapy or bone flap removal followed by immediate mesh cranioplasty. Outcomes of interest included treatment failure, postoperative complications, and mortality. Subgroup analyses were performed based on radiation exposure, tumor pathology, and sex. We performed a proportional meta-analysis, pooling the proportion of outcomes across the included studies using a random-effects model. The ROBINS-I tool was used to assess the risk of bias, and all included studies were found to have a moderate to high risk of bias. Sixteen observational studies including 250 patients were analyzed (138 retention, 112 removal with immediate mesh cranioplasty). Treatment failure occurred in 16.0% of patients with bone flap retention versus 5.1% with flap removal with mesh cranioplasty. Complication rates were comparable (11.5% vs. 13.1%), while mortality was higher in the flap removal with mesh cranioplasty group (9.0% vs. 4.4%). Subgroup analyses showed higher failure rates in patients with prior radiation (14.7% vs. 5.0%), malignant tumors (12.7%vs. 6.4%), and female sex (6.1% vs. 3.0%). Bone flap retention consistently had higher failure rates across all subgroups. Both surgical strategies can be safe when appropriately selected, but bone flap retention maybe associated with increased treatment failure in high-risk subgroups. These findings highlight the importance of individualized management and shed the light on the need for further research to guide treatment decisions in post-craniotomy infections. However, these findings should be interpreted with caution given the observational nature of the included studies and their risk of bias.
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