Hinge craniotomy versus decompressive craniectomy for the neurosurgical management of traumatic brain injury and stroke: A systematic review and meta-analysis.

BACKGROUND: Traumatic brain injury (TBI) and stroke are major contributors to global morbidity and mortality, particularly in low- and middle-income countries. Decompressive craniectomy (DC) is an established neurosurgical intervention for reducing elevated intracranial pressure and preventing secondary neurological injury in the context of trauma and stroke. However, DC is a financially cumbersome two-stage procedure that requires specialised infrastructure, post-operative intensive care, and access to delayed cranioplasty, rendering it largely inaccessible to patients in resource-limited settings. Hinge craniotomy (HC) has emerged as a practical and potentially cost-effective alternative, mitigating the need for reoperation and long-term implant storage. This systematic review and meta-analysis aimed to evaluate the safety and clinical efficacy of HC compared to DC. METHODS: PubMed, Embase, and CENTRAL databases were electronically searched to identify all relevant primary studies comparing HC versus DC. Primary outcomes of interest were decompressive efficacy (mean post-operative ICP and intracranial volume expansion), reoperation, and infection. Secondary outcomes of interest included functional recovery (Glasgow Outcome Score), mortality, operative time, length of hospital stay, duration of follow-up, and other post-operative complications, including hydrocephalus, haematoma, and radiological midline shift. Methodological quality and risk of bias were assessed. A random-effects meta-analysis was conducted. RESULTS: Twelve studies including 1546 patients were analysed. HC and DC achieved equivalent decompressive control, but HC significantly reduced postoperative infection risk (RR 0.55; 95 % CI: 0.31-0.96) and avoided the need for secondary cranioplasty, thereby lowering overall reoperation burden. Functional recovery showed a non-significant trend towards favouring HC, while mortality was similar overall, though subgroup analysis suggested improved survival in TBI patients undergoing HC. No significant differences were observed in operative time, length of hospital stay, hydrocephalus, haematoma, or radiological midline shift. Collectively, these findings indicate that HC offers clinical outcomes comparable to DC, with added advantages of lower infection risk and reduced need for reoperation. CONCLUSION: HC provides a safe and effective alternative to DC for the management of elevated intracranial pressure in TBI and stroke. By achieving comparable efficacy whilst reducing infection risk and eliminating the need for delayed cranioplasty, HC offers distinct clinical and economic advantages, particularly in low- and middle-income countries. These findings support broader consideration of HC as a feasible alternative decompressive strategy, warranting further validation in large, high-quality randomised trials.