Surgical decompression for traumatic brain swelling: indications and results

Object. Decompressive craniectomy has been performed since 1977 in patients with traumatic brain injury. The authors assess the efficacy of this treat ment and the indications for its use. Methods. The clinical status of the 57 patients, their computerized tomogra phy (CT) scans, and intracranial pressure (ICP) levels were documented pros pectively in a standard protocol. At the beginning of the study, all patien ts older than 30 years were excluded. As of 1989 patients older than 40 yea rs were excluded until 1991; since that time patients older than 50 years h ave been excluded. Primary brain or brainstem injury with fully developed b ulbar brain syndrome, loss of auditory evoked potentials (AEPs), and/or osc illation flow in a transcranial Doppler ultrasound examination were contrai ndications to decompressive craniectomy. A positive indication for decompre ssion was given in the case of progressive therapy-resistant intracranial h ypertension in correlation with clinical (Glasgow Coma Scale [GCS] score, d ecerebrate posturing, dilating of pupils) and electrophysiological (electro encephalography, somatosensory evoked potentials, and AEPs) parameters and with findings on CT scans. Unilateral decompressive craniectomy was perform ed in 31 patients and bilateral craniectomy in 26 patients. In all cases, a wide frontotemporoparietal craniectomy was followed by a dura enlargement covered with temporal muscle fascia. The outcomes of the treatment were surprisingly good. Only 11 patients (19% ) died, three of whom died of acute respiratory disease syndrome. Five pati ents (9%) survived, but remained in a persistent vegetative state; six pati ents (11%) survived with a severe permanent neurological deficit, and 33 pa tients (58%) attained social rehabilitation. Two patients (3.5%) did not ha ve a follow-up examination. The GCS score on the 1st day posttrauma and the mean ICP turned out to be the best predictors for a good prognosis. The re sults demonstrate the importance of decompressive craniectomy in the treatm ent of traumatic brain swelling. Conclusions. Surgical decompression should be routinely performed when indi cated before irreversible ischemic brain damage occurs.