In Reply: Early Cranioplasty is Associated With Greater Neurological Improvement: A Systematic Review and Meta-Analysis

In Reply: Early Cranioplasty is Associated With Greater Neurological Improvement: A Systematic... CORRESPONDENCE Regardless of the state of literature on this subject, we think that In Reply: Early Cranioplasty is Associated With it is a valuable exercise to identify gaps in our collective knowledge Greater Neurological Improvement: A and help direct future research. We join the authors in encour- Systematic Review and Meta-Analysis aging future studies to firm up the methods and protocols by To the Editor: which we seek to study and improve outcomes in this vulnerable We thank the authors for taking interest and commenting population. on our research. This topic has received much attention in the last decade: How and when should we perform cranioplasty to improve neurological outcomes while decreasing morbidity? As Disclosure they point out, there have been dozens of studies on the topic in The authors have no personal, financial, or institutional interest in any of the the last decade that look to define an optimal timeframe, and there 2-5 drugs, materials, or devices described in this article. is growing consensus that earlier is better; however, little has been published beyond the low-level evidence from retrospective, James G. Malcolm, MD, PhD poorly matched cohort studies (Class IIb, Level C). Rima S. Rindler, MD When it comes to assessing neurological outcomes, we agree Faiz U. Ahmad, MD, MCh that the literature is heterogenous, and we thank the authors for Department of Neurosurgery constructing a Funnel plot to help visualize this phenomenon. Emory University There are varied choices on which neurocognitive assessment Atlanta, Georgia tools to use (comprehensive tests such as the Barthel Index or Functional Independence Measure compared with more coarse Glasgow Outcome Score or Karnofsky Performance Scale) and REFERENCES when to perform this assessment (days vs months after cranio- 1. Ganau M, Ligarotti GKI, Ganau L, Prisco L. Letter: Early cranioplasty is plasty). Most studies combine patients who underwent a variety of associated with greater neurological improvement: a systematic review and meta- initial insults, eg, trauma, ischemic, and hemorrhagic. We raised analysis. Neurosurgery. 2018. doi: 10.1093/neuros/nyy205 [published online ahead of print]. these same concerns in our original publication and suggested 2. Malcolm JG, Rindler RS, Chu JK, et al. Early cranioplasty is associated with that future studies use comprehensive neurological assessments, greater neurological improvement: a systematic review and meta-analysis. Neuro- match patients by primary pathology, and perform neurocog- surgery. 2018;82(3):278-288. 3. Yadla S, Campbell PG, Chitale R, Maltenfort MG, Jabbour P, Sharan AD. Effect nitive assessment at a consistent and later time point. of early surgery, material, and method of flap preservation on cranioplasty infections: There are some mischaracterizations in this letter that we would a systematic review. Neurosurgery. 2011;68(4):1124-1130. 2,5 like to respectfully point out. Both of our reviews and that of 4. Xu H, Niu C, Fu X, et al. Early cranioplasty vs. late cranioplasty for the Xu et al in 2015 shared the same definition of “early” cranio- treatment of cranial defect: a systematic review. Clin Neurol Neurosurg. 2015;136:33- plasty, namely within 90 d of decompression. Our study included 5. Malcolm JG, Rindler RS, Chu JK, Grossberg JA, Pradilla G, Ahmad FU. Compli- several additional studies not found in Xu et al because we made a cations following cranioplasty and relationship to timing: a systematic review and systematic effort to contact authors for original data. Further, our meta-analysis. J Clin Neurosci. 2016;33:39-51. 5 4 2016 review andthatofXuetal were in agreement on all shared 6. Mustroph CM, Malcolm JG, Rindler RS, et al. Cranioplasty infection and resorption are associated with the presence of a ventriculoperitoneal analysis, including the increased risk of hydrocephalus with early shunt: a systematic review and meta-analysis. World Neurosurg. 2017;103:686- cranioplasty. Our separate analyses of ventriculoperitoneal shunts were unrelated to cranioplasty timing but instead identified the presence of a shunt as a risk factor for complications, specifically 10.1093/neuros/nyy208 resorption. NEUROSURGERY VOLUME 0 | NUMBER 0 | 2018 | 1 Downloaded from https://academic.oup.com/neurosurgery/advance-article-abstract/doi/10.1093/neuros/nyy208/5006486 by Ed 'DeepDyve' Gillespie user on 11 July 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Neurosurgery Oxford University Press

In Reply: Early Cranioplasty is Associated With Greater Neurological Improvement: A Systematic Review and Meta-Analysis

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Publisher
Oxford University Press
Copyright
Copyright © 2018 by the Congress of Neurological Surgeons
ISSN
0148-396X
eISSN
1524-4040
D.O.I.
10.1093/neuros/nyy208
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Abstract

CORRESPONDENCE Regardless of the state of literature on this subject, we think that In Reply: Early Cranioplasty is Associated With it is a valuable exercise to identify gaps in our collective knowledge Greater Neurological Improvement: A and help direct future research. We join the authors in encour- Systematic Review and Meta-Analysis aging future studies to firm up the methods and protocols by To the Editor: which we seek to study and improve outcomes in this vulnerable We thank the authors for taking interest and commenting population. on our research. This topic has received much attention in the last decade: How and when should we perform cranioplasty to improve neurological outcomes while decreasing morbidity? As Disclosure they point out, there have been dozens of studies on the topic in The authors have no personal, financial, or institutional interest in any of the the last decade that look to define an optimal timeframe, and there 2-5 drugs, materials, or devices described in this article. is growing consensus that earlier is better; however, little has been published beyond the low-level evidence from retrospective, James G. Malcolm, MD, PhD poorly matched cohort studies (Class IIb, Level C). Rima S. Rindler, MD When it comes to assessing neurological outcomes, we agree Faiz U. Ahmad, MD, MCh that the literature is heterogenous, and we thank the authors for Department of Neurosurgery constructing a Funnel plot to help visualize this phenomenon. Emory University There are varied choices on which neurocognitive assessment Atlanta, Georgia tools to use (comprehensive tests such as the Barthel Index or Functional Independence Measure compared with more coarse Glasgow Outcome Score or Karnofsky Performance Scale) and REFERENCES when to perform this assessment (days vs months after cranio- 1. Ganau M, Ligarotti GKI, Ganau L, Prisco L. Letter: Early cranioplasty is plasty). Most studies combine patients who underwent a variety of associated with greater neurological improvement: a systematic review and meta- initial insults, eg, trauma, ischemic, and hemorrhagic. We raised analysis. Neurosurgery. 2018. doi: 10.1093/neuros/nyy205 [published online ahead of print]. these same concerns in our original publication and suggested 2. Malcolm JG, Rindler RS, Chu JK, et al. Early cranioplasty is associated with that future studies use comprehensive neurological assessments, greater neurological improvement: a systematic review and meta-analysis. Neuro- match patients by primary pathology, and perform neurocog- surgery. 2018;82(3):278-288. 3. Yadla S, Campbell PG, Chitale R, Maltenfort MG, Jabbour P, Sharan AD. Effect nitive assessment at a consistent and later time point. of early surgery, material, and method of flap preservation on cranioplasty infections: There are some mischaracterizations in this letter that we would a systematic review. Neurosurgery. 2011;68(4):1124-1130. 2,5 like to respectfully point out. Both of our reviews and that of 4. Xu H, Niu C, Fu X, et al. Early cranioplasty vs. late cranioplasty for the Xu et al in 2015 shared the same definition of “early” cranio- treatment of cranial defect: a systematic review. Clin Neurol Neurosurg. 2015;136:33- plasty, namely within 90 d of decompression. Our study included 5. Malcolm JG, Rindler RS, Chu JK, Grossberg JA, Pradilla G, Ahmad FU. Compli- several additional studies not found in Xu et al because we made a cations following cranioplasty and relationship to timing: a systematic review and systematic effort to contact authors for original data. Further, our meta-analysis. J Clin Neurosci. 2016;33:39-51. 5 4 2016 review andthatofXuetal were in agreement on all shared 6. Mustroph CM, Malcolm JG, Rindler RS, et al. Cranioplasty infection and resorption are associated with the presence of a ventriculoperitoneal analysis, including the increased risk of hydrocephalus with early shunt: a systematic review and meta-analysis. World Neurosurg. 2017;103:686- cranioplasty. Our separate analyses of ventriculoperitoneal shunts were unrelated to cranioplasty timing but instead identified the presence of a shunt as a risk factor for complications, specifically 10.1093/neuros/nyy208 resorption. NEUROSURGERY VOLUME 0 | NUMBER 0 | 2018 | 1 Downloaded from https://academic.oup.com/neurosurgery/advance-article-abstract/doi/10.1093/neuros/nyy208/5006486 by Ed 'DeepDyve' Gillespie user on 11 July 2018

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NeurosurgeryOxford University Press

Published: May 26, 2018

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