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Table of Contents    
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 672-674

Four-quadrant osteoplastic decompressive craniotomy: A novel technique for decompressive craniectomy avoiding revision cranioplasty after surgery

1 Department of Neurosurgery, Trivandrum Medical College, Regional Cancer Centre, Trivandrum, Kerala, India
2 Department of Imagiology, Regional Cancer Centre, Trivandrum, Kerala, India

Date of Submission05-Oct-2012
Date of Decision25-Oct-2012
Date of Acceptance19-Nov-2012
Date of Web Publication29-Dec-2012

Correspondence Address:
Anil Kumar Peethambaran
Department of Neurosurgery, Trivandrum Medical College, Regional Cancer Centre, Trivandrum, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.105221

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How to cite this article:
Peethambaran AK, Valsalmony J. Four-quadrant osteoplastic decompressive craniotomy: A novel technique for decompressive craniectomy avoiding revision cranioplasty after surgery. Neurol India 2012;60:672-4

How to cite this URL:
Peethambaran AK, Valsalmony J. Four-quadrant osteoplastic decompressive craniotomy: A novel technique for decompressive craniectomy avoiding revision cranioplasty after surgery. Neurol India [serial online] 2012 [cited 2021 Mar 9];60:672-4. Available from:


There are several surgical procedures to reduce elevated intracranial pressure (ICP) in patients with traumatic brain injury. Decompressive craniectomy (DC) with duroplasty is the most widely accepted surgical procedure. [1] This procedure may be associated with morbidity in the immediate postoperative period as the large bone defect may pose a risk of potential injuries to the underlying brain. [2] Cranioplasty may also be associated with complications that follow any brain surgery. We designed a surgical procedure, the four-quadrant osteoplastic decompressive craniotomy (FoQOsD), which mimics a communited fracture and may not cause a significant resistance to the expanding brain thus reducing elevated ICP. This technique does not require a second surgery to replace the bone flap.

Skin incision is the standard question mark incision [Figure 1]a. Bone flap like the decompressive craniectomy flap is made keeping the temporal part attached to the muscle. The portion of the bone flap removed is as shown in [Figure 1]b, and temporal craniectomy extends to the floor of the middle cranial fossa (with rongeurs) at the origin of the zygomatic arch. The bone flap is then divided into four quadrants with the periosteum in situ [Figure 1]c. Then, the periosteum of the free bone pieces are sutured with loose prolene/silk sutures [Figure 1]d to the other pieces so as to connect all the four bone pieces together by the periosteum and then connected to the periosteum of the calvaria under the galea [Figure 1]e. The dura is opened in a stellate fashion and a synthetic dural patch is kept tucked under the original dura over the brain to prevent the brain from bulging out [Figure 1]f. The bone flap is now in its place as four pieces sutured together with loose sutures and connected by the periosteum only [Figure 1]g. As the brain expands, the bone flaps float out in all four different directions giving space for the swollen brain [Figure 1]h.
Figure 1: Technique of four-quadrant osteoplastic decompressive craniectomy

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A 24-year-old man presented with an acute subdural hematoma (SDH) of over 10 mm thickness and about 12 mm mid-line shift following a road traffic accident. He underwent FoQOsD craniotomy [Figure 2]a-d. His postoperative scans showed significant reduction in midline shift [Figure 3]a and b. Midline shift in computed tomography (CT) scan is a good marker of raised ICP. [3] This new technique provided almost similar results regarding the normalization of the mid-line shift in CT when compared with the conventional DC technique. However, ICP was not monitored in this patient. This is a major limitation. Further studies including a large number of patients with ICP measurement are warranted to establish that this technique is associated with reduction in ICP.
Figure 2: Four-quadrant osteoplastic decompressive craniectomy: Operative photographs (a-d) and schematic representation of effect of bone flap on raised intracranial pressure e) Brain expansion after FoQOsD craniotomy f) Brain expansion after hinge craniotomy

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Figure 3: Computed tomography scans of the four-quadrant osteoplastic decompressive craniectomy (FoQOsD) before (a) and after (b) surgery. Conventional craniectomy before (c) and after (d) surgery. Postoperative appearance on follow-up FoQOsD (e) and conventional surgery (f)

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Compared with the hinge craniotomy, [4] our procedure is likely to give lesser resistance for the brain to expand, which usually takes place maximally at the center of the opening where the stellate durotomy is performed. As the brain expands in a hemispheric fashion out of the craniotomy defect, the bone flap pieces curtain outwards in four different directions offering minimum resistance to the brain swelling out of the durotomy site [Figure 2]e, whereas in the hinge craniotomy the expanding brain is resisted to a certain extent by the bone flap directly over it [Figure 2]f. After a few months, the bone pieces gradually fall in place like a jigsaw and fuse by the time the swelling of the brain subsides. [Figure 3]a and b shows the preoperative and postoperative CT scans of FoQOsD craniotomy and [Figure 3]c and d shows the preoperative and postoperative CT scans of conventional DC, which are comparable. The final appearance of the patient 3 months after FoQOsD craniotomy [Figure 3]e is comparable to that of a patient who underwent conventional DC [Figure 3]f. This is a single case report. Further studies comparing FoQOsD with conventional techniques with ICP monitoring are required to establish the place of this new technique in the treatment of elevated ICP.

 » References Top

1.Skoglund TS, Eriksson-Ritzen C, Jensen C, Rydenhag B. Aspects on decompressive craniectomy in patients with traumatic head injuries. J Neurotrauma 2006;23:1502-9.  Back to cited text no. 1
2.Joseph V, Reilly P. Syndrome of the trephined. J Neurosurg 2009;111:650-2.  Back to cited text no. 2
3.Eisenberg HM, Gary HE Jr, Aldrich EF, Saydjari C, Turner B, Foulkes MA, et al. Initial CT findings in 753 patients with severe head injury: A report from the NIH traumatic coma data bank. J Neurosurg 1990;73:688-98.  Back to cited text no. 3
4.Adeleye AO, Azeez AL. Decompressive craniectomy bone flap hinged on the temporalis muscle: A new inexpensive use for an old neurosurgical technique. Surg Neurol Int 2011;2:150.  Back to cited text no. 4
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  [Figure 1], [Figure 2], [Figure 3]

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