Cranioplasty: Timing, Outcomes and Patient Experience

Thesis summary This thesis explores the impact of cranial reconstruction, also known as cranioplasty, across three themes: timing, outcomes, and patient experience. It is a mixed methods thesis, with both quantitative and qualitative studies, describing the importance of cranial reconstruction in the rehabilitation process. The thesis utilises a mixed methodology, linking different aspects of the rehabilitation process together, from timing to patient experience. Introduction Chapter 1 The first chapter presents an overview of cranioplasty, outlining the procedure, its complications, and rehabilitation considerations. This lays the foundation for this thesis by describing why cranioplasty is important and how it has the potential to influence the trajectory of recovery of an individual. It also outlines the complications and surgical challenges associated with cranioplasty and how these can impact a patient’s recovery and quality of life, as well as the importance of outcomes and how core outcome sets can help standardise outcome collection. SECTION 1: Timing This section explores the timing of cranioplasty and its impact on recovery, neurological outcome, and quality of life. Chapter 2 The second chapter uses hospital episode statistics (2014-19) to investigate the longitudinal trends of decompressive craniectomy following traumatic brain injury or stroke, analysing the timing of cranioplasty and whether these have an impact on revision or removal rates. Chapter 3 The third chapter analyses the results of a feasibility study that was undertaken at Cambridge University Hospitals NHS Trust, exploring whether there is an optimal time frame to perform cranioplasty by randomising patients to receive the procedure within 3 months from decompression (early) or after 6 months (late). Unfortunately, this study was stopped early because of the pandemic; however, 14 patients were randomised, and the outcomes were collected. It lays the foundation for a substantial randomised study, which is being planned and outlined in Appendix 5: RETELL Study project plan. SECTION 2: Outcomes This section outlines the development of a core outcome set for cranioplasty, split across two phases and four work packages. Phase 1 focuses on information gathering, whereas Phase 2 focuses on consensus building. Chapter 4 Chapter 4 outlines the results of a systematic review of cranioplasty-related outcomes reported in the literature from 1990 to 2022. It is the first work package in the core outcome set (COS) development process and forms part of phase 1. The aim of this study was to collate the outcomes reported in the cranioplasty literature to form a list of outcomes which could be used for phase 2. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was adhered to, with full-text English studies with more than ten patients (prospective) or more than 20 patients (retrospective) published after 1990 examining outcomes in cranioplasty were eligible for inclusion. Chapter 5 Chapter 5 reports on a multi-centre qualitative study aiming to ensure a comprehensive list of cranioplasty outcomes have been collated. Focus groups and one-to-one semi-structured interviews were conducted with the following: patients who had undergone cranial reconstruction, healthcare professionals (HCPs), researchers, and allied health professionals. Thematic analysis was performed to extract relevant outcomes for inclusion in the outcome list. Chapter 6 Phase 2 of the COS development focuses on consensus building and finalising the outcomes which make up the COS. The chapter describes the use of a methodologically based, consensus-driven, collaborative approach utilised to improve the standardisation of outcome collection and reporting for clinical services and research studies on cranioplasty. The scope of the study was defined according to the criteria recommended by the Core Outcome Measures in Effectiveness Trials (COMET) Initiative. SECTION 3: Patient experience Chapter 7 Chapter 7 presents a qualitative study aimed at a better understanding of the lived experiences of patients who have undergone cranial reconstruction. An interpretive phenological analysis methodology was employed to improve the understanding around the lived experiences of patients following cranial reconstruction. Patients were interviewed at varying time points following cranioplasty to gain an understanding of the different challenges that may be encountered following cranial reconstruction. Discussions and conclusions Chapter 8 Chapter 8 draws the thesis together, discussing each chapter in turn and forming conclusions, while outlining future plans based on the work of this thesis.In summary, this thesis has contributed to the literature by: 1. Delineating the landscape in England regarding the total numbers of decompressive craniectomy and cranioplasty procedures. 2. Establishing the possibility of functional neurological improvement following cranioplasty and demonstrating that randomising patients to early vs late cranioplasty is feasible 3. Elucidating the heterogeneity in outcomes following cranioplasty and developing predefined domains for outcome collection. 4. Developing a core outcome set to facilitate standardisation of outcome collection for future cranioplasty studies. 5. Describing the lived experience of cranioplasty and its impact on a patient's recovery. Longitudinal evaluation of patients is crucial for a more comprehensive understanding of the impact of cranioplasty on the trajectory of recovery. With this understanding of the patients lived experience and the core outcome set developed in section 2 of this thesis, there is a foundation upon which to commence collecting these long-term, patient-relevant outcomes to help improve the quality of life of patients following cranioplasty.

Name dc:type.qualificationname

Doctor of Philosophy (PhD)

Level dc:type.qualificationlevel

Doctoral

Grantor dc:publisher.institution

University of Cambridge

Year dc:date.issued

2025

Author dc:creator

• Mee, Harry

Advisors dc:contributor.advisor

• Hutchinson, Peter
• Kolias, Angelos

• Cranioplasty
• Outcomes
• Core Outcome Set

Licence

• https://www.repository.cam.ac.uk/bitstreams/c16941c0-1989-40b9-b139-654c63d48f12/download
• http://purl.org/NET/rdflicense/allrightsreserved

Language dc:language

eng

DOI dc:identifier.doi

https://doi.org/10.17863/CAM.121422

OAI identifier oai:identifier

oai:www.repository.cam.ac.uk:1810/389592