Modified Expansion-Floating Craniotomy for Refractory Intracranial Hypertension: A Technical Review and Case Series

Decompressive craniectomy (DC) relieves refractory intracranial hypertension but produces a cranial defect that mandates secondary cranioplasty and carries substantial morbidity. Bone-flap-preserving alternatives exist but are constrained by limited decompressive volume or the need for a second repositioning operation. We describe a modified expansion-floating craniotomy (EFC) and report its preliminary feasibility and safety.

We retrospectively reviewed 9 consecutive patients with refractory intracranial hypertension treated with a modified EFC between April 2025 and May 2026. The technique adds active elevation of the all bone-flap to achieve more uniform decompression and uses a quick-release (Highwayman's) knot to permit later bedside release and graduated repositioning of the flap without a second operation. Demographics, radiological parameters, complications, and outcomes were recorded.

The cohort comprised 2 patients with traumatic brain injury, 1 with aneurysmal subarachnoid hemorrhage, 1 with spontaneous supratentorial intracerebral hemorrhage, and 5 with large-area cerebral infarctions. All bone flaps were elevated without cortical compression, and postoperative midline shift was reduced in every patient. One patient developed malignant post-traumatic infarction, declined further treatment, and died. Among the 8 survivors, bedside flap repositioning was achieved in all, obviating cranioplasty, with no instrumentation failure, wound dehiscence, or surgical-site infection.

The modified EFC is a feasible, bone-preserving technique that provides uniform early decompression and permits non-surgical, bedside bone flap repositioning in appropriately selected patients. These are preliminary observations; larger controlled studies with systematic intracranial pressure monitoring are required for validation.