Role of the “In-Window” Craniectomy in the Management of Serious Head Trauma: 12 Case Series, Technical Note, Literature Review, and Comparison With Other Surgical Managements

BACKGROUND AND OBJECTIVES: Decompressive bone flap remains the standard surgical for refractory intracranial hypertension in connection with serious head trauma. However, this surgical procedure is not free from risk in itself (infectious, hydraulic troubles) and the cranioplasty procedure, which will be performed remotely. In certain cases, an alternative “hinge” or “semifloating” bone flap technique can be discussed. METHODS: We aimed to present 12 cases of “semifloating” bone flaps made between January 2022 and September 2025 in our institution, describing our surgical technique (and alternatives published in the literature), the outcomes, and the possible complications. We also provide key points identified after a literature review of this procedure. RESULTS: In our short series, 2 of the 12 semifloating craniectomies were insufficient to control intracranial pressure and required a decompressive bone flap at J1. None of our patients presented with a cerebrospinal fluid-related complication; none presented with an infectious complication or autologous bone resorption; moreover, all the craniectomies returned to their physiological position in the following weeks. No major technical difficulties were encountered, and the procedure was associated with a short operative time. CONCLUSION: Given the possibility of controlling intracranial hypertension in most cases, the lower number of complications caused, and the possibility of avoiding one (or even more) invasive surgery(ies) with a high risk, particularly infection, hinge craniectomy should be considered but only in carefully selected traumatic brain injury patients with focal mass lesions and should not be extrapolated to cases of diffuse malignant cerebral edema.