• Siddharth Vankipuram, Sumeet V Sasane, Anil Chandra, Bal K Ojha, Sunil K Singh, Chhitij Srivastava, Somil Jaiswal, Ankur Bajaj, and Manish Jaiswal.
• Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India. Electronic address: vanki.siddharth@gmail.com.
• World Neurosurg. 2020 Mar 1; 135: e393-e404.

ObjectivePrimary decompressive craniectomy (DC) is indicated to evacuate the hematoma and reduce intracranial pressure in traumatic brain injury (TBI). However, there are a myriad of complications because of absence of the bone flap. A novel technique, four-quadrant osteoplastic decompressive craniotomy (FoQOsD) retains the bone flap while achieving adequate cerebral decompression.MethodsA single-center randomized controlled trial of 115 patients with TBI needing decompressive surgery was conducted. Of these patients, 59 underwent DC and 56 underwent FoQOsD. The primary outcome determined was functional status at 6 months using the Glasgow Outcome Scale-Extended.ResultsNo significant differences were identified in baseline characteristics between both groups. Mean Glasgow Outcome Scale-Extended score was comparable at 6 months (4.28 in DC vs. 4.38 in FoQOsD; P = 0.856). Further, 22 of 58 patients in the DC group had died (38%) compared with 25 of 55 patients in the FoQOsD group (44.6%) (odds ratio [OR], 1.19; 95% confidence interval [CI], 0.6-2.36; P = 0.6) (1 patient lost to follow-up in each group). A favorable outcome was seen in 56.8% of patients in the DC group versus 54.4% of patients in the FoQOsD group (P = 0.74). Presence of intraventricular hemorrhage and subarachnoid hemorrhage (OR, 7.17; 95% CI, 1.364-37.7; P = 0.020), opposite side contusions (OR, 3.838; 95% CI, 1.614-9.131; P = 0.002) and anisocoria (OR, 3.235; 95% CI, 1.490-7.026; P = 0.003) preoperatively were individual factors that played a significant role in final outcome.ConclusionsFoQOsD is as efficacious as conventional DC with the added benefit of avoiding a second surgery. The procedure is associated with better cosmesis and fewer complications.Copyright © 2019 Elsevier Inc. All rights reserved.

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