title: Four-quadrant osteoplastic decompressive craniotomy: A novel technique for refractory intracranial hypertension - A pilot study.
abstract: BACKGROUND
  Decompressive craniectomy (DC) with duroplasty is the gold standard for refractory intracranial hypertension despite paucity of randomized controlled trials. There are several morbidities associated with DC of which the persistence of bony defect is of paramount importance. Studies have shown that many of the morbidities associated with DC get reversed following replacement of the bone flap.
  
  
  OBJECTIVE
  To design a novel technique for control of refractory intracranial pressure (ICP), as well as to study its safety and efficacy compared to the conventional DC technique.
  
  
  METHODS
  We conducted a prospective, comparative, observational pilot study comparing four-quadrant osteoplastic decompressive craniotomy (FoQOsD) with conventional DC. The demographic features, postoperative variables such as operating time, number of days of intensive care unit (ICU) stay and survival, as well as radiographic variables such as change in the midline shift (MLS) and expansion of the compressed brain were analyzed using relevant statistical tests.
  
  
  RESULTS
  Twenty patients were selected and grouped into two groups of 10 patients each. The male: female ratio in the two groups were 8:2 and 7:3, respectively, and the mean age at presentation was 42.7 ± 1.45 years in the FoQOsD group and 43.6 ± 1.32 years in the DC group. Both the groups were comparable in relation to the duration of surgery, duration of ICU stay, and survival (P > 0.05). There was significant brain expansion and reversal of MLS (P < 0.001) in the FoQOsD group, factors which were comparable to that in the DC group.
  
  
  CONCLUSIONS
  FoQOsD may be as effective as conventional DC in managing intracranial hypertension. This procedure mainly avoids a revision cranioplasty. A prospective randomized controlled trial with a large sample size may be initiated for obtaining more accurate data.
authors.affiliation: Department of Neurosurgery, Government Medical College, Trivandrum, Kerala, India.
authors.forename: Anil Kumar
authors.initials: AK
authors.lastname: Peethambaran
authors.forename: Vinu V
authors.initials: VV
authors.lastname: Gopal
authors.forename: Jiji
authors.initials: J
authors.lastname: Valsalamony