Selection of Cranial Repair Materials Based on Preoperative Imaging Indicators and Analysis of Risk Factors for Complications

Background Cranioplasty is a common neurosurgical procedure, yet managing postoperative complications remains a significant clinical challenge. A definitive consensus is lacking on the choice of repair materials and the factors influencing complications. Objective This study aimed to identify independent risk factors for complications following cranioplasty and to establish evidence-based criteria for the individualized selection between titanium mesh (Ti) and polyether ether ketone (PEEK), based on preoperative imaging indicators. Methods We included 211 patients who underwent cranioplasty (110 Ti, 101 PEEK) at our institution between January 2018 and May 2024. Demographic, imaging, and surgical data were collected. Univariate and multivariate logistic regression models identified risk factors for complications. Generalized Additive Models (GAM) and piecewise regression analysis were employed to characterize the nonlinear relationship between the abnormal volume ratio and the efficacy of material choice, and to identify critical thresholds. Results Age (OR = 1.03, P  = 0.010) and brain collapse volume (OR = 1.03, P  = 0.042) were independent risk factors for postoperative complications. GAM revealed a significant interaction between material type and abnormal volume ratio ( P  = 0.019). Piecewise regression identified a key threshold: when the abnormal volume ratio exceeded 3.47%, the number of complications was significantly lower in the Ti group than in the PEEK group ( P  < 0.05). Conclusion Age and brain collapse volume are independent predictors of complications after cranioplasty. For patients with an abnormal volume ratio greater than 3.47%, selecting Ti may reduce postoperative complication risk.