Perioperative and Delayed Complications of Decompressive Craniectomy: A Sequential Analysis from a Tertiary Neurosurgical Centre in India

Objectives Decompressive craniectomy (DC) is a life-saving neurosurgical procedure for refractory raised intracranial pressure. Despite its proven efficacy, DC carries significant perioperative and delayed morbidity. This study aimed to document the spectrum, frequency, and predictors of complications following DC and subsequent cranioplasty (CP) in a tertiary referral centre in India. Materials and Methods A prospective observational cohort study was conducted at the Department of Neurosurgery, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, India. Seventy-six consecutive patients who underwent DC for traumatic and non-traumatic indications were enrolled; 51 subsequently underwent CP. Complications were classified as intraoperative, early (≤ 4 weeks), and late (> 4 weeks). Statistical Analysis Associations between risk factors and outcome variables were evaluated by Pearson's chi-square test or Fisher's exact test. A two-tailed p-value < 0.05 was considered statistically significant. Results The cohort comprised predominantly young males (mean age 40.2 years; 77.6% male). Traumatic brain injury accounted for 35.5% of indications. Early DC complications were frequent: tracheostomy requirement (42.1%), prolonged mechanical ventilation (35.5%), dyselectrolytaemia (32.9%), and systemic infection (18.4%). Early mortality was 13.2%. Late DC complications included hydrocephalus (HCP; 14.5%) and pseudomeningocele/CSF leak (11.8%). Small bone flap size was significantly associated with both late HCP (p = 0.010) and pseudomeningocele (p = 0.001). Prior pseudomeningocele predicted HCP development (55.6% vs. 10.4%; p = 0.003). Low admission GCS predicted ventilatory dependence, tracheostomy, and early mortality (all p < 0.05). Among CP patients, autologous bone was used in 70.5%. CP complications included cosmetic defects (9.8%), intracranial haemorrhage (7.8%), and implant dislodgement (5.9%). Mesh as CP material strongly predicted dislodgement/exposure (50% vs. 4.1%; p = 0.007). Conclusions DC and CP carry substantial complication burdens in the Indian tertiary care setting. Small craniectomy size, low GCS, and advanced age are key modifiable risk indicators. Mesh alone should be avoided as cranioplasty material. These findings inform perioperative risk stratification and surgical planning in resource-constrained settings.