DECOMPRESSIVE BIFRONTAL CRANIECTOMY IN THE TREATMENT OF SEVERE REFRACTORY POSTTRAUMATIC CEREBRAL EDEMA

OBJECTIVE: The management of malignant posttraumatic cerebral edema re mains a frustrating endeavor for the neurosurgeon and the intensivist Mortality and morbidity rates remain high despite refinements in medic al and pharmacological means of controlling elevated intracranial pres sure; therefore, a comparison of medical management versus decompressi ve craniectomy in the management of malignant posttraumatic cerebral e dema was undertaken. METHODS: At the University of Virginia Health Sci ences Center, 35 bifrontal decompressive craniectomies were performed on patients suffering from malignant posttraumatic cerebral edema. A c ontrol population was formed of patients whose data was accrued in the Traumatic Coma Data Bank. Patients who had undergone surgery were mat ched with one to four control patients based on sex, age, preoperative Glasgow Coma Scale scores, and maximum preoperative intracranial pres sure (ICP). RESULTS: The overall rate of good recovery and moderate di sability for the patients who underwent craniectomies was 37% (13 of 3 5 patients), whereas the mortality rate was 23% (8 of 35 patients). Pe diatric patients had a higher rate of favorable outcome (44%, 8 of 18 patients) than did adult patients. Postoperative ICP was lower than pr eoperative ICP in patients who underwent decompression (P = 0.0003). P ostoperative ICP was lower in patients who underwent surgery than late measurements of ICP in the matched control population. A statisticall y significant increased rate of favorable outcomes was seen in the pat ients who underwent surgery compared to the matched control patients ( 15.4%) (P = 0.014). All patients who exhibited sustained ICP values ab ove 40 torr and those who underwent surgery more than 48 hours after t he time of injury did poorly. Evaluation of the 20 patients who did no t fit into either of those categories revealed a 60% rate of favorable outcome and a statistical advantage over control patients (P = 0.0001 ). CONCLUSION: Decompressive bifrontal craniectomy provides a statisti cal advantage over medical treatment of intractable posttraumatic cere bral hypertension and should be considered in the management of malign ant posttraumatic cerebral swelling. If the operation can be accomplis hed before the ICP value exceeds 40 torr for a sustained period and wi thin 48 hours of the time of injury, the potential to influence outcom e is greatest.