i usually place the loose flap over a duroplasty. if the bone edges have been cut bevelled then there is usually no problem of the flap sinking back.

thanks sunil

Any reference study relating to this kind of experience.

I was  once referred a patient who had had a decompressive craniectomy in another unit. I don't recall whether the flap was replaced at the original surgery or later, but she experienced classical low pressure headache when upright, that was relieved by recumbency. On examination in the upright position the flap was well recessed, At surgery, we fixed it at the correct position with bioplates and the symptoms were completely relieved. I learned from German colleagues that fixing bioplates just to the flap but not to the surrounding bone at emergency craniotomy allows it to ride in the acute phase, and not to sink in after resolution of the oedema etc.

 DHC IS A LAST RESORT FOR  SURGICAL MANAGEMENT OF TRAUMATIC MALIGNANT CEREBRAL EDEMA, BUT  IT IS NOT WITHOUT COMPLICATIONS. IN A LONG RUN, IT PREDISPOSES TO SINKING FLAP SYNDROME AND PROGRESSIVE HYDROCEPHALUS.SO IT IS ADVOCATED TO PERFORM CRANIOPLASTY AS EARLY AS POSSIBLE, ONCE THE MALIGNANT BRAIN EDEMA IS CONTROLLED.

Yes Sunil, the concept of DHC and its complication is an interesting discussion. However the point under discussion here is loose cranial flap with out cranioplasty. Can you comment about that please.

Thanks anyway.

There has been a recent study on performing  window technique while replacing bone flap back in suspected cases of malignant traumatic cerebral odema....We half the bone flap in middle then replace and fix its corners with the parent bone.