TECH N IQ U E APPLICATIONS

Decompressive Bifrontal Craniectomy in the Treatment of

Severe Refractory Posttraumatic Cerebral Edema

Richard S. Polin, M .D ., Mark E. Shaffrey, M .D .,

Christopher A. Bogaev, M .D ., Nancy Tisdale, R .N .,
Teresa Germanson, Ph.D ., Ben Bocchicchio, M .S.,
John A. Jane, M .D ., Ph.D.
Department of Neurosurgery, U niversity of V irginia Health Sciences Center,
C harlottesville, Virginia

O B JEC T IV E : The management of malignant posttraum atic cerebral edem a rem ains a frustrating endeavor for the
neurosurgeon and the intensivist. M ortality and m orbidity rates remain high despite refinem ents in m edical and
pharm acological means of controlling elevated intracranial pressure; therefore, a com parison of m edical man
agement versus decom pressive craniectom y in the management of malignant posttraum atic cerebral edema was
undertaken.
M ET H O D S : At the University of Virginia Health Sciences Center, 35 bifrontal decom pressive craniecto m ies were
performed on patients suffering from malignant posttraum atic cerebral edem a. A control population w as formed
of patients whose data was accrued in the Traum atic Com a Data Bank. Patients who had undergone surgery were
matched with one to four control patients based on sex, age, preoperative G lasgow Com a Scale scores, and
maximum preoperative intracranial pressure (ICP).
R ESU LTS: The overall rate of good recovery and moderate disability for the patients w ho underw ent craniectomies
was 3 7 % (13 of 35 patients), w hereas the m ortality rate was 2 3 % (8 of 35 patients). Pediatric patients had a
higher rate of favorable outcom e (4 4 % , 8 of 18 patients) than did adult patients. Postoperative IC P w as lower
than preoperative ICP in patients who underwent decom pression (P = 0 .0 00 3 ). Postoperative IC P w as lower in
patients who underwent surgery than late m easurem ents of ICP in the m atched control population. A statistically
significant increased rate of favorable outcom es was seen in the patients w ho underwent surgery com pared to the
matched control patients (1 5 .4 % ) (P = 0.014). All patients who exhibited sustained IC P values above 40 torr and
those w ho underwent surgery more than 48 hours after the time of injury did poorly. Evaluation of the 20 patients
who did not fit into either of those categories revealed a 6 0 % rate of favorable outcom e and a statistical
advantage over control patients (P = 0.0001).
C O N C L U S IO N : Decom pressive bifrontal craniectom y provides a statistical advantage over m edical treatm ent of
intractable posttraumatic cerebral hypertension and should be considered in the m anagement of malignant
posttraumatic cerebral swelling. If the operation can be accom plished before the ICP value exceeds 40 torr for
a sustained period and within 48 hours of the time of injury, the potential to influence outcom e is greatest.
(Neurosurgery 4 1 :8 4 - 9 4 , 1 9 9 7 )
Keywords: Brain edema, Brain trauma, Intracranial pressure, Traumatic Coma Data Bank

hen routine measures fail to alleviate cerebral

W
swelling associated with traumatic brain injury in
the absence of a mass lesion, management options
are few. The patients will most often either die or survive in
an extremely disabled state. Despite our advances in under­
standing, monitoring, and treating cerebral hypertension, the
outcomes for patients with severe, diffuse posttraumatic ce­
rebral edema remain poor. In the Traumatic Coma Data Bank
(TCDB), patients who suffered diffuse injury characterized by
compressed cisterns, less than 5 mm of midline shift, and no ■
mass lesion larger than 25 cc (Diffuse Injury III) demonstrated
only a 16.4% incidence of good outcome or moderate disabil- 1

Neurosurgery, Vol. 41, No. 1, july 1997

 D eco m p ressive C ra n iecto m y in Traum a

ity at hospital discharge (17) (Table 1). Furthermore, the mor­ value below 20 torr and is typically administered initially in a
tality rate in this group was 34%. The most powerful predic­ 1 g/kg of body weight bolus and then smaller doses as
tors of mortality in these patients were the highest intracranial required to maintain an ICP value below 20 torr. In this series,
pressure (ICP) values w ithin 72 hours of injury and post­ hypothermia was not used and only one patient received
resuscitation pupillary examination. preoperative barbiturate therapy.
Most strategies for managing these patients rely on reduc­
ing primary damage from the ischemic insult (hypothermia, O perative indications
free-radical scavengers), lowering ICP to minimize collateral
A bifrontal decompressive craniectomy was performed
damage (hyperventilation, head elevation, ventriculostomy),
when ICP remained elevated despite the aforementioned
or both (potentially mannitol, barbiturates). Because ICP ele­
therapies and when a CT scan demonstrated diffuse edema
vation is a major predictor of mortality in these patients, it
without a mass lesion. In rare instances, the operation was
seems logical that maximum effort toward preventing intra­
performed late in a patient's course after maximum cerebral
cranial hypertension is warranted. At the University of Virginia
swelling had subsided, but the clinical examination remained
Health Sciences Center, 35 bifrontal craniectomies for the treat­
poor as a heroic measure or immediately at presentation
ment of severe refractory posttraumatic cerebral edema have
based on a CT scan appearance and clinical syndrome sug­
been performed. It was hypothesized that bifrontal craniecto­
gesting imminent herniation (three patients). Each of five
mies, with a slight modification from the technique presented by
patients underwent a decompressive craniectomy combined
Kjellberg and Prieto (16), would positively influence both sur­
with resection of a large mass lesion, but these patients were
vival and the overall outcomes for these patients. Although
excluded from further analysis.
many authors have anecdotally reported limited degrees of
success with this approach, there has been no case-controlled
examination of the procedure. By m atching patients who Patient selection
underwent surgery in a case-controlled manner with patients Between January 1984 and September 1993, 35 patients
with the same intracranial diagnoses but no surgical interven­ underwent bifrontal decompressive craniectomies primarily
tion from the TCDB, we determined whether surgery impacted for malignant cerebral edema as indicated by elevated ICP or
the rate of favorable outcome in this patient population. a typical appearance on CT scans of loss of the normal gyral
pattern and compression of the basal cisterns (Fig. 1 ,A and B).
An additional five patients underwent bifrontal craniectomies
PATIENTS AND M ETH O D S
concurrent with evacuation of traumatic mass lesions. These
Standard clinical management five were excluded from the analysis. Also excluded was a
patient who presented at the emergency room with a GCS
All patients with presumed head injuries at the University
of Virginia Hospital are treated by the neurosurgical service.
Standard management includes completion of a computed
tomographic (CT) scan as rapidly as possible at presentation
to the emergency room and placement of an ICP monitor in all
patients with a Glasgow Coma Scale (GCS) score of 10 or less
or in individuals whose examinations are blunted by neuro­
muscular blockade or heavy sedation. Standard therapy for
elevated ICP includes mild hyperventilation to a P C 0 2 of 30
to 35 torr and elevation of the head of the bed. Mannitol is
administered when these measures fail to maintain an ICP

TABLE 1. Glasgow Outcom e Scores of Patients with Diffuse

-1' Injury IIU

GOS No. of Patients (%)

FIG U R E 1. CT scans obtained at admission of a 17-year-old
Good recovery 5 (3.3) boy with a G C S score of 5T (A) and a 30-year-old man with
Moderate disability 20 (13.1) a G C S score of 6T (B ) after motor vehicle accidents. There is
Severe disability 41 (26.8) evidence of diffuse cerebral edema demonstrated by poor
Vegetative 35 (22.9) grey-white matter differentiation, loss of the normal gyral
Dead 52 (34.0) pattern, and compression of the basal cisterns in the absence
Data obtained from the Traumatic Coma Data Bank. Diffuse Injury of lesions causing significant mass effect. There is some trau­
ls defined as compression of cisterns. GOS, Glasgow outcome score. matic subarachnoid hemorrhage in the first patient (A).

N eu rosurgery, Vol. 41, No. 1, July 1997 85

86 Polin et al.
score of 2T after an automobile accident and who displayed
bilaterally fixed and dilated pupils. The patient was taken
emergently to the operating room, where the typical removal
of bone (as described below) was performed. When opening
the dura, the operating surgeons observed evidence of an
absence of cortical blood flow bilaterally and the procedure
was terminated before completion.
Of 26 patients in whom vital signs were reviewed, preop­
erative systemic hypotension (systolic blood pressure less
than 100 mm Hg) was observed in six patients. In all of the
patients, the neurological injury was the major source of
morbidity and mortality. Only one patient experienced an
extended hospital stay because of systemic illness; this patient
developed posttraumatic pancreatitis, which necessitated pro­
longed hospitalization for hyperalimentation.
For the 92 control patients, limited data on systemic com­
plications were available from the TCDB. Seven patients suf­
fered cardiac arrests, and 31 were noted to be hypotensive at
some point. Shock was noted to be life-threatening in 14
individuals. Only five patients were noted to have systemic
(gastrointestinal, hepatosplenic, renal, or peripheral vascular)
injury that was life-threatening. Mannitol or furosamide was
administered in the early evaluation and treatment or the
1st day in the intensive care unit for 45 of 86 patients (52%),
and barbiturates were administered to an additional three
patients.
O perative technique
Decompressive bifrontal craniectomies were performed
with the patients in the supine position with a mild degree of
reverse Trendelenburg positioning. A bicoronal skin incision
was made, and the temporalis muscles were reflected inferi-
orly. Bitemporal burr holes were created, and bilateral large
subtemporal decompressions were performed. Subsequently,
a large bifrontal craniectomy was created, extending posteri­
orly into the parietal bones approximately 3 to 5 cm posterior
to the coronal sutures. Burr holes were located at either side of
the sagittal sinus at the posterior extent, bilaterally at the
keyhole, and bilaterally at the root of the zygoma. The final
bone cut was made anteriorly over the sagittal sinus after
stripping the dura from the underlying sinus. After bleeding
was controlled, bilateral fishmouth dural incisions were
made, extending medially to the sagittal sinus. The sagittal
sinus was then ligated and divided anteriorly between two
2-0 Nurolon sutures. This allowed a further vector of anterior
expansion. After hemostasis was obtained and both hemi­
spheres were inspected for subdural hematoma, dural expan­
sion grafts were affixed in a watertight fashion to the dural
openings so that all pressure was released from the underly­
ing brain (Fig. 2). An ICP monitor was placed before closing
on the nondominant hemisphere posterior to the bone defect.
Postoperatively, head elevation and mild hypocapnia were
maintained but more aggressive measures for ICP control
were not necessary. Typically, the bone flap was replaced
between 3 and 6 months after the original surgery. The flap
was maintained in a wet gauze at - 4 ° C until reinsertion.
Neurosurgery, Vol. 41, No. 7, July 1997
F IG U R E 2. Illustration of the
wide bifrontal craniotomy,
fishmouth dural incisions,
and dural expansion graft
that characterize the
bifrontal craniectomy.
Data collection
Patient flow sheets were retrospectively reviewed to deter­
mine the presenting GCS scores and results of the neurolog­
ical examinations. Intubated patients were assigned an im­
plied verbal score of 1. Hourly ICP values, systolic pressure,
and mean blood pressure, both pre- and postoperatively,
were recorded, as were therapeutic maneuvers designed to
reduce ICP. A Glasgow outcome score (GOS) was recorded as
the outcome at the time of hospital discharge, which included
acute inpatient care on the rehabilitation service at the Health
Science Center when applicable.
Patients from the TCDB with the diagnosis of diffuse injury
without significant mass lesion or midline shift were eligible
as control group patients. Anyone with a surgical decompres­
sion or a penetrating injury was excluded. Patients undergo­
ing surgery and control patients were matched by sex, age,
and best presenting GCS score. The highest sustained preop­
erative ICP values of the patients undergoing decompression
were matched with the maximum sustained ICP values of the
control patients within the first 48 hours of presentation. This
factor was not used for patients who underwent decompres­
sion emergently without ICP monitoring. In m atching control
patients to patients undergoing surgery, sex was always iden­
tical and age could vary by 1 year for children 10 years of age
and younger, by 2 years for patients from 11 to 18 years of age,
and up to 4 years for older patients. The admission GCS
scores of the patients were also maintained within 1 point of
those of the control patients. Maximum preoperative ICF
values were then used as a final discriminator. Each matched
control patient was included only once, and only patients who
had never undergone evacuation of a mass lesion were eligi­
ble as matches. The control patients were chosen by two
blinded observers working independently and then pooling
responses to include patients selected by both. The observers
were blinded to patient names and outcomes. A total of 92
control patients were accrued for the 35 patients undergoing
surgery (2.63 control patients/patient undergoing surgery)
The demographic data of the patients undergoing decompres­
sion and the TCDB control patients are listed in Table 2.
The highest sustained ICP values during the 24 hours after
surgery were recorded for the group who underwent decom­
pression. As a comparison, the maximum sustained hourly
ICP values of the control patients that were obtained 48 to 72
hours after injury were recorded. The mean 48- to 72-hour ICF

TABLE 2. Comparison of Baseline Characteristics of Patients
Undergoing Decompressive Craniectom ies versus those of
the Traumatic Coma Data Bank Control Group
Craniectomy Group Control Group
Age'1 18.7 ± 12.6 19.1 ± 9.42 lowed a bimodal distribution, with peaks at GCS scores of 4
Admission G C S 5.6 2 ± 2.11 5.6 8 ± 1.65 (12 patients) and 7 (9 patients) (Fig. 3). The mean GCS score at
score
Maximum IC P ‘ 3 4 .9 torr ± 14.9 33.2 torr ± 1 5.6 score higher than 7 had all deteriorated substantially at the
'Age, two-tailed t test, P = 0.784.
'’ GCS, Glasgow Coma Scale, two-tailed t test, P = 0.781.
c ICP, intracranial pressure, two-tailed t test, P = 0.346.
values were averaged within each control group before data
analysis.
A GOS of good recovery or moderate disability was con-
°R sidered to be a favorable outcome. All other outcomes were
111 considered to be unfavorable.
•sun
ei Statistical analysis
ed'
e(j Statistical analysis was performed by comparing the group
Ui), of 35 patients undergoing surgery to a weighted composite of
eal 35 control patients. The controls for each patient were aver­
aged and reported as a single entity to avoid patients with
njj, more matched controls from dominating the analysis. Age,
jgj^ GCS score, and maximum ICP value were treated as contin-
pr uous variables. For instance, the composite control for a pa-
er tient with three controls (ages 14, 15, and 16 yr; GCS scores of
. 4,5, and 5; maximum ICP values of 31, 33, and 34 torr) would
re be a 15-year-old with a GCS score of 4.67 and an ICP value of
>SSM 32.67 torr. Pediatric patients were defined as patients who
0PI were 17 years of age or younger. To compare the array of ICP
p values of the decompression group before and after surgery
rt and to compare postoperative ICP values of this group to the
Ij 48- to 72-hour ICP values of the control group, a Student's t diabetes insipidus, was most likely related to traumatic dien­
jjt test and a Kruskal-Wallis analysis were performed.
A conditional logistic regression analysis was performed
ifa cornparing the 92 control patients with the 35 patients under-
(v going surgery to determine whether an influence on favorable
pint outcome was present independent of the prognostic factors on
3 which patient matching was based. The statistical method of
tche us'n§ a multiple control patient to patient undergoing surgery
swk strategy was based on the analysis presented by Breslow and
elif ^ conditional logistic regression for matched sets.
, According to the authors, a 4:1 control to subject ratio is
X,lir °Pbmal, although any ratio between 1:1 and 4:1 is feasible. A
ojve A2was generated. A P value of less than or equal to 0.05
p was considered statistically significant. For univariate analy-
•goif S*S/ ^ yalues were generated with Fisher's exact test substi-
geP tutec* when at least one cell in the comparison group had a
ipre Va*ue ^ or smaller.
\
s aft RESULTS
ecof n
l0ur emo8raphics and baseline characteristics
Ito Twenty-four male and 11 female patients underwent the
jr I1 operation that was modified from the method presented by
N eu rosurg ery, Vol. 41, No. 1, luly 1997
D ecom p ressive C ra n iecto m y in Traum a 87
Kjellberg and Prieto (16). The average patient age was 18.7
years. Thirty-one of the 35 patients had suffered motor vehicle
accidents, whereas the remainder were victims of assault. In
no patient was there a non-neurosurgical injury requiring
thoracotomy or laparotomy. The admission GCS scores fol­
admission was 5.62. Three patients who presented with a GCS
time of surgery. No patient had a GCS score higher than 7 at
the time of surgery. The maximum sustained preoperative
ICP values were greater than 20 torr in all except two patients.
The distribution of preoperative ICP values is provided in
Figure 4.
A comparison was made between the patients who had
undergone a decompressive craniectomy and their matched
controls. The average age of the surgical series was 18.7 years,
compared to 19.1 for the weighted controls. The average
preoperative GCS score was 5.62 for the patients undergoing
surgery and 5.68 for the control patients. The average m axi­
mum ICP value before surgery of patients undergoing crani­
ectomies was 34.9 torr. The average maximum ICP value
during the first 48 hours after hospital admission was 33.2 torr
in the weighted controls.
O perative and postoperative com plications
Operative complications occurred in six patients. One pa­
tient developed a frontal lobe hematoma, which necessitated
evacuation. Two patients developed skim subdural hemato­
mas that were not considered symptomatic. One patient de­
veloped cerebrospinal fluid otorrhea, which resolved with
lumbar drainage that was most likely related to traumatic
cranial base injury. One individual developed meningitis that
resolved with antibiotics. The sixth complication, a case of
cephalic injury.
Ten patients developed shunt-dependent hydrocephalus
during their postoperative course; another two suffered bone
flap resorption after cranioplasty, which necessitated acrylic
cranioplasty. One patient, despite lower ICP, had late dilation
of his right pupil; a subsequent CT scan showed progression
of a small right temporal lobe contusion. This patient under-
3 4 5 6 7 8 >8
G C S S co re
FIG U RE 3. Postresuscitation G C S scores of patients undergo­
ing decompressive craniectomies.
88 Polin et al.
M a x im u m S u sta in e d P re -o p e ra tiv e ICP (torr)
FIG URE 4. Maximum sustained preoperative ICP values of
patients who underwent decompressive craniectomies.
went a small right-sided temporal lobectomy several days
after the bifrontal craniectomy.
Control of intracranial pressure
One goal of the analysis was to demonstrate the effect of
decompressive craniectomy on ICP. Preoperative ICP values
were similar between the two groups (34.9 torr in the patients
undergoing craniectomies versus 33.2 torr in the matched
control patients) (highest sustained ICP value within the first
48 h of presentation). The maximum sustained preoperative
ICP value of each patient was compared with the maximum
sustained ICP value obtained during the 24 hours after sur­
gery for the 26 patients for whom both values were available.
The mean ICP value was reduced from 32.1 torr preopera-
tively to 21.3 torr postoperatively. A paired t test revealed a
statistically significant change in ICP in the patients who
underwent decompression after surgery (P = 0.0001).
The postoperative ICP values of the patients who under­
went decompression were compared in a similar fashion to
the maximum ICP values of the weighted control patients
obtained from 48 to 72 hours after injury. Twenty-nine pa­
tients had postoperative ICP measured. The mean postoper­
ative ICP value of these patients was 21.6 torr, compared to
29.4 torr obtained between 48 and 72 hours after injury for the
control patients. The paired t test again demonstrated a sta­
tistically significant reduction in ICP (P = 0.026).
O utcom e
Patient outcome was assessed at discharge from the Uni­
versity of Virginia Health Sciences Center. The average hos­
pital time, excluding fatal cases, was 63.22 ± 46.1 days (range,
10-220 d). Four patients were discharged with good recover­
ies (return to school or work), 9 had moderate disabilities, 11
showed severe disabilities, 3 were vegetative, and 8 died
before discharge (Table 3). The overall rate of unfavorable
outcome was 62.9%, whereas the mortality rate was 22.9%.
The GCS score had a strong relationship to outcome. Only one
patient who presented with a GCS score of 3 or 4 had a
favorable outcome, compared to two-thirds of patients pre­
senting with a GCS score of 6 or greater (P = 0.0003).
Patients undergoing surgery within 48 hours of admission
had favorable outcomes in 13 of 28 cases (46%), compared to
N eu rosurgery, Vol. 41, No. 1, July 1997
TABLE 3. Discharge Glasgow Outcom e Scores of Patients
Undergoing Decompressive Craniectom ies versus 3-Month
Glasgow Outcom e Scores of Traum atic Coma Data
Bank Control
No. of Patients No. of TCDB
GOS Undergoing Control
Craniectomies (%) Patients (%)
Good recovery 4 (11.4) 7 (7.6)
M oderate disability 9 (25.7) 8 (8.8)
Severe disability 11 (31.4) 32 (35.2)
Vegetative 3 (8.6) 17 (18.7)
Dead 8 (22.9) 28 (30.8)
a G O S , Glasgow outcome score; T C D B , Traum atic Com a Data Bank,
no favorable outcomes in seven patients who were operated
on after 48 hours (P = 0.022). Most patients were discharged
to either a rehabilitation institute, another acute care hospital
or home. Only 3 of the 27 survivors (11%) were discharged to
a chronic care facility.
Several factors were identified retrospectively as being pos­
sible discriminators of favorable and unfavorable outcomes
Patients were assessed for the presence of preoperative co­
agulopathy to analyze the effect of prolonged coagulation
parameters on outcome. Eighteen patients showed elevation
of either the prothrombin time or the activated partial throm­
boplastin time before surgery, and 17 had normal studies. The
difference in the rate of favorable outcome (33 versus 41%)
and mortality (28 versus 18%) between the two groups was
not significant.
However, patients who attained ICP values greater than 40
torr for a sustained period not associated with agitation or
poor pain control and those patients not operated on within
the first 48 hours of presentation to the em ergency room had
poor outcomes. Only 1 of 15 (6.7%) patients meeting these two
criteria had a favorable outcome, compared to 12 of 20 (60%)
favorable outcomes if neither criteria was met (P — 0.0004)
Each of eight patients had an ICP value greater than 40 ton
whereas seven had surgery delayed past the 2nd day.
Pediatric patients had better results with surgery than did
adult patients, with favorable outcomes in 8 of 18 (44%)
pediatric patients, compared to 5 of 17 (29%) adult patients
For the pediatric subset, the rate of favorable outcome was
statistically significantly higher than for their matched con­
trols (P = 0.025).
In a conditional logistic regression analysis comparing all
92 control patients to the patients undergoing craniectomies,a
significant influence of the operation on favorable outcome
was seen (Wald y2 = 6.097, P = 0.014). Medical management
alone carried a 3.86 times greater risk of unfavorable outcome
than did decompressive craniectomy. This advantage was
maintained in the subset of patients who were operated or
within 48 hours and who did not have maximum ICP values
that exceeded 40 torr (Table 4). The pediatric patients had
favorable outcomes in 8 of 18 cases compared to 9 of 41
control patients (P = 0.079). However, if only patients with
the aforementioned restrictions are considered, the advantage

TABLE 4. Favorable Outcom e and Decompressive
Craniectomy: Overall Results and Subset Analyses'*
Patients
Matched
Undergoing
Sample Control P Valueb
craniectomies
Patients (%)
(%)
All patients 35 (37) 92 (16) 0.014
Optimal subsetc 20 (60) 58 (18) 0.0001
Pediatric (age < 1 8 yr) 18 (44) 41 (22) 0.079
Pediatric and optimal 10 (80) 25 (24) 0.002
J Favorable outcome rates w ere used for patients undergoing de­
compressive craniectomies and for control patients.
b Conditional logistic regression with stratification by matching.
c Surgery performed within 48 hours of injury and no sustained
intracranial pressure greater than 40 torr.
over control patients is statistically significant both for all
patients (P = 0.001) and for pediatric patients (P = 0.002).
DISCUSSION
Clinical studies for posttraum atic brain edema
As indicated by the 16.4% rate of favorable outcome (good
outcome or moderate disability) for patients with severe ce­
rebral edema revealed by CT scans from the TCDB (Table I)
(16), recovery to independent activity in these patients is rare.
Patients with this radiographic diagnosis and intractably ele­
vated ICP were considered in this study. No single therapeu­
tic maneuver, either pharm acological or surgical, has been
shown to significantly im prove the prognosis for these pa­
tients. Criticism of each new approach has centered on two
points: first, one must prove that patients exposed to the
treatment and who recover well would not have done so
without the treatment; second, one must show that the impact
of the intervention is not simply to take patients who would
have died and allow them to live with severe disability or in
a vegetative state. For these reasons, any novel intervention
must be examined in a study that incorporates a carefully
chosen control population. We have undertaken such an anal­
ysis of 35 patients undergoing decompressive bifrontal crani­
ectomies (modified from the method presented by Kjellberg
and Prieto [16]) at the University of Virginia Health Sciences
Center between January 1984 and Septem ber 1993.
The rationale for decompression has intuitive merit. Al­
though decompression does not reverse the primary brain
injury associated with traumatic injury, it can ameliorate sec­
ondary damage caused by elevation of ICP. For this reason,
surgery should be undertaken within 48 hours of injury,
before the period of maximal cerebral swelling. In this study,
decompression significantly reduced ICP in the patients who
underwent surgery (P = 0.0001). Furthermore, postoperative
iCP values of the patients who underwent craniectomies were
lower than those of the control patients obtained 48 to 72
hours after injury (P = 0.026). This time limit was chosen for
the control patients, because most patients were operated on
within 48 hours; therefore, 24 hours after surgery most readily
compares with postinjury Day 3 in the control group. Decom­
N eu rosurgery, Vol. 41, No. 1, July 1997
D eco m p ressive C ra n ie cto m y in Traum a 89
pression may allow the edematous brain an alternative to
transtentorial and tonsillar herniation. Theoretically, by cre­
ating a vector of expansion in a frontal direction, the possi­
bility of upward herniation, as seen in the large parietal
decompressive craniectomies performed by Clark et al. (5),
would be minimized. The procedure is simple and allows
inspection of both cerebral hemispheres for extra-axial mass
lesions and access to frontal or anterotemporal intracranial
pathological abnormalities.
Literature review
The concept of wide bone removal for treatm ent of intra­
cranial hypertension has existed since the dawn of neurosur­
gery. Harvey Cushing performed a subtem poral decompres­
sion for relief of elevated ICP related to neoplastic growth as
early as 1905 (7) and later reported the application of this
operation to wartime trauma (8). Surgeons at many centers
have performed hemicraniectomies after removal of hem i­
spheric traumatic brain lesions (10, 21). In 1968, Clark et al. (5)
reported two cases of posttraum atic cerebral hypertension
that they had treated using "circum ferential craniotom ies,"
resulting in a 100% mortality rate. Kerr (15) presented a single
case of an extensive bifrontal craniectomy for trauma in a
patient who initially showed clinical im provement but subse­
quently deteriorated and died.
In 1971, Kjellberg and Prieto (16) reported the results of 73
patients undergoing extensive bifrontal craniectomies and li­
gation of the sagittal sinus for posttraumatic injury. Overall,
only 18% of the patients survived, including 11 of 50 (22%)
with nonpenetrating head trauma. The vast majority dem on­
strated dilated pupils and decerebrate motor response. This
craniectomy was similar to a procedure that M iyazaki (18)
and Miyazaki et al. (19) had presented. Venes and Collins (23)
published a series of 13 patients who underwent craniecto­
mies that were performed using the method described by
Kjellberg and Prieto (16). They documented only one survivor
with a favorable outcome. Da Silva et al. (9) and Pereira et al.
(20) also reported anecdotal series, documenting their expe­
rience with external bifrontal decompression for trauma.
Pereira et al. (20) operated on 12 patients with refractory
cerebral edema and noted excellent results in 5 (41.7%).
In 1980, Gerl and Tavan (14) reported a series of 30 patients
undergoing extensive dual hemispheric craniectomies for
trauma. This series had a 70% mortality rate and a 20% rate of
"full restitution." There was an average 3.2-day interval be­
tween injury and operation. Gaab et al. (13) undertook a
prospective investigation of decompressive craniectomy, ex­
cluding patients older than 40 years and those with mass
lesions. Of 37 patients treated, 19 underwent bifrontal crani­
ectomies and 18 underwent hemicraniectomies. Unfortu­
nately, their results were not broken down by type of opera­
tion; however, only 5 of 37 patients died and 14 of 37
demonstrated "full rehabilitation." These investigators
stressed the need for early intervention and claimed that full
recovery occurred in all patients with preoperative GCS
scores greater than 5 if prompt surgery was performed. Fisher
and Ojemann (11) reported anecdotally favorable recoveries
 Polin et al.
after bifrontal craniectomies for patients with malignant cere­
bral edema after subarachnoid hemorrhage.
Although these authors have introduced into the literature
a considerable volume of anecdotal experience with the bi­
frontal decompressive craniectomy, the criticism of the rele­
vance of this work in guiding clinical decisions is apparent.
The outcome scales provided are more simplistic and perhaps
more subjective than the GOS. There is no control group
matched by age, sex, GCS score, or ICP to demonstrate a poten­
tial beneficial effect. There is no mention of postoperative ICP.
For these reasons, although improved results have been seen in
the most recent studies, no conclusive evidence showing a ben­
efit of decompressive craniectomy has been produced.
Laboratory investigation
Part of the controversy surrounding the application of de­
compression for trauma stems from the mixed results of crani­
ectomy in experimental models of head injury. Cooper et al.
(6) created cold-induced lesions in dogs and observed that
craniectomized animals had lower ICP but significantly
higher volumes of brain edema. They postulated that lower
interstitial pressure caused a larger fluid egress into the brain
underlying the bone defect. Gaab et al. (12) created cold-
induced lesions in cats and observed that craniectomy alone
produced more local damage than craniectomy plus removal
of contused brain. However, Rinaldi et al. (22) observed that
in rabbits with cold-induced lesions, craniectomy lowered
ICP, normalized cerebral blood flow, and caused no addi­
tional breakdown in the blood-brain barrier as determined by
Evans blue extravasation.
Burkert and Paver (2) showed that the size of a of craniec­
tomy radius needed to be two-thirds that of the head radius to
create a reduction in ICP values of at least 20 to 30 torr in an
experimental model. Burkert and Plaumann (3) reported the
ability to reduce ICP in an experimental canine model of brain
trauma and presented the results of 19 patients treated with
bilateral frontotemporal parietal craniectomies.
Control population
To consider decompressive craniectomy a logical proce­
dure to ameliorate the effects of cerebral hypertension, one
must first prove that the operation actually leads to a reduc­
tion of ICP in the patient group compared to the control
group. Subsequently, one must show an improvement in
outcome compared to a matched control population. In the
absence of a prospective, randomized trial, historical controls
must be used. In this study, the TCDB has been used as a
source of control patients for several reasons: 1) most of our
patients were accrued during or within 3 years of the dates of
the TCDB, negating any effect of improved management of
the head-injured patient over time between the series; 2) the
TCDB was meticulously constructed so that information
about daily ICP, GCS score, and level of therapeutic intensity
was recorded in the master data bank; 3) the TCDB was
constructed from major neurosurgical centers with an institu­
tional committment to neurotrauma, including the University
N eu rosurgery , Vol. 41, No. 1, July 1997
of Virginia Health Sciences Center, so that all patients \vert
managed with a similar standard of care. Although the med
ical care provided may not represent the most aggressivt
nonsurgical treatm ent currently available, one can assumt
that the centers involved provided a standard that is reason
able for leading neurotrauma centers.
The control patients were essentially equivalent to the op
erative patients in terms of age, admission GCS score, and
maximum ICP. Each patient in the craniectom y group was
treated with hyperventilation. An attempt was made to lower
ICP chemically, with mannitol or diuretics, in all patients
except those who underwent im m ediate surgery. Each pa
tient, at admission to the intensive care unit, was experiencing
some form of sedation or paralysis. Only one patient had a
trial of barbiturate coma. None received tirilazad or any other
study drug or experimental protocol. Sim ilarly, the TCDB
patients were universally treated with aggressive manage­
ment of elevated ICP. As a whole, the patients undergoing
craniectomies patients suffered relatively isolated closed head
injuries. There was no life-threatening abdominal or chest
trauma. In the TCDB patients, 5 of 92 had life-threatening
systemic complications. Severe hypotension was seen in a
slightly higher (15 versus 14%) percentage of TCDB patients
although the absolute severity of hypotension is difficult to
deduce in this retrospective review. The rate of mannitol
administration (52%) in controls is slightly lower than ex
pected but may represent data collection, which includes onh
the first 24 hours after injury or potentially the reliance on
ventricular drainage rather than osmotic diuresis as a primary
method to reduce ICP. Thirty-six patients underwent ventric
ulostomies, including 17 who did not receive mannitol. Over
all, only 18 of 92 (19.6%) control patients were known not to
have received mannitol, furosamide, barbiturate, or a ventric
ulostomy. Although we cannot exclude the critique that the
control patients may have been treated less aggressively than
the craniectomy patients, we again em phasize that the centers
involved in the TCDB are leaders in neurotrauma research
and care is expected to have been managed according to an
aggressive standard.
Another consideration was the difference in end points for
analysis. For TCDB patients, the 6-month GOS was used
compared to the discharge GOS for the patients who under
went craniectomies. The mean length of hospitalization in the
surgical population was 62 days, excluding fatalities. There­
fore, the control patients had longer average follow-up peri
ods. Because GOS tends to improve over time (4), this may
have introduced a bias favoring the control population. The few
patients in the operative population who remained hospitalized
to nearly the 6-month point were universally the most impaired
survivors, none of whom gained favorable outcomes.
Indications for operation
The usefulness of any intervention for raised ICP is im
paired if the delay to operation is excessive, the ICP elevation
is too intense, or the primary mechanism of impairment is
brain stem shear and not ICP-related. As our criteria for the
bifrontal craniectomy have evolved over time, there are sowt’
 D ecom p ressive C ra n iecto m y in Traum a 91

patients early in the series for whom this procedure may have SU M M A R Y
been overly heroic. In particular, one victim of child abuse
A retrospective analysis of 35 patients undergoing de­
and several pedestrians struck by motor vehicles were oper­
com pressive craniectom ies via a m odified m ethod of that
ated on more than 96 hours after the time of presentation. The
presented by Kjellberg and Prieto (16) was performed. O per­
outcomes in these patients were universally poor.
ative complications were few. ICP reduction achieved by
To demonstrate the efficacy of this operation within appro­
performing surgery was statistically significant (P = 0.0001).
priate clinical guidelines, criteria for the procedure were cre­
Thirteen patients had favorable outcom es, and 22 had un­
ated. These standards dictate that surgery should be under­
favorable outcom es. For the subset of patients w ho under­
taken within 48 hours and that ICP elevation should not
w ent surgery w ithin 48 hours and who never sustained ICP
exceed 40 torr. This is based on the common sense principle
values greater than 40 torr, favorable outcom es w ere ob­
that patients cannot recover from certain injuries and that
served in 12 of 20 patients, com pared to 18% favorable
some intervention is too late. We argue that once the ICP
outcom es in control patients. These criteria are intended to
reaches a sustained level above 40 torr, the chance for inter­
screen for patients who have herniated from m alignant
vention before permanent neurological devastation has
edema before decom pression or w ho have passed the point
passed. Similarly, if the patient is not operated on promptly,
at which recovery is possible.
sustained damage from elevated ICP can preclude recovery.
Each patient was matched with one to four patients from
Most of our failures within the entire population consisted
the TCDB with a diagnosis of diffuse edema and without
of heroic attempts to help patients recover from injuries
presence of mass lesions. W eighted composites consisting of
from which they likely could not recover. Two additional
the average of the control patients were constructed for each
failures included the patients without severe ICP elevation
patient. Comparing the 35 patients with their 35 composite
whose poor neurological states were likely secondary to dif­
control patients, there was essential equivalence in average
fuse axonal injury. They underwent the procedure based on
age, GCS score, and ICP. Using a conditional logistic regres­
their age and their CT scans, which demonstrated diffuse
sion analysis, the patients who underwent craniectomies had
cerebral edema. It has been discovered that although aggressive
an increased incidence of favorable outcome (P = 0.014). The
craniectomy for refractory cerebral edema is superior to medical
subgroup of patients with the aforementioned favorable clin­
management of elevated ICP, it is not universally successful, and
ical characteristics had significantly more favorable outcomes
our patient selection criteria have changed accordingly. The
as well (P = 0.001). Pediatric patients showed a greater sta­
presenting GCS score provides a relative contraindication. We
tistical advantage over their matched control pediatric pa­
j, do not recommend operating on patients with a GCS score of 3,
tients (P = 0.079) than did adult patients. Pediatric patients
v, but patients otherwise meeting the criteria for surgery with GCS
with favorable clinical characteristics had a statistically signif­
,t scores of 4 or 5 should be considered.
icant advantage over control patients (P = 0.002).
ft The malignant edema predicted in several experimental
The role of decompressive craniectomy in brain trauma
t models was not observed. This may relate to the inherent
remains controversial. Although retrospective studies cannot
b difference between a cold-induced and a traumatic brain le-
substitute for clinical trials, the careful construction of a con­
itf sion. Most patients have a small area of encephalomalacia in
trol population that matches the patients in terms of sex, age,
ait noneloquent cortex adjacent to the frontal pole (Fig. 5).
ICP, and GCS score allows a valid matched analysis. Because
3i
of the limited number of centers currently performing this type
FIG U R E 5. CT scan obtained of operation, no prospective trial has been possible. Potentially,
1 month after injury of the the advantage shown in this study and the experience with
sa
d(
same patient as in Figure 1B. patient selection may help guide the formulation of prospective
id The patient presented with a studies. This series of 35 patients who underwent decompressive
iei G C S score of 6T (E2 M4VT) craniectomies for diffuse malignant brain edema showed a clear
pa and an ICP value of 30 torr, advantage of surgery over medical therapy alone. Using the
despite hyperventilation and criteria for intervention, which we have developed over time, the
ini
'fi mannitol therapy. He was potential clinical benefit is enhanced.
taken to the operating room,
IK
tin
where a decompressive
bifrontal craniectomy was
performed. The patient was A CKN O W LED G M EN TS
discharged to rehabilitation We thank Lou Pobereskin and Elizabeth Fisher for technical
after 43 days in the hospital following commands and and editorial assistance.
verbalizing, able to eat and walk without assistance, but still
confused (moderate disability). The frontal lobes are Received, April 12, 1996.
it*
sorrounded by small fluid collections without significant Accepted, February 5, 1997.
nt
mass effect. There is a small area of encephalomalacia at the Rep rin t requests: Richard S. Polin M .D., University of Virginia
rd
medial tip of the right frontal lobe. Health Sciences Center, Box 212, Charlottesville, VA 22908.
;of

N eu rosurgery, Vol. 41, No. 1, July 1997

92 Polin et al.
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7. Cushing H: The establishment of cerebral hernia as a decompres­
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11. Fisher CM, Ojemann RG: Bilateral decompressive craniectomy for
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12. Gaab M, Knoblich OE, Fuhrmeister U, Pflughaupt KW, Dietrich
K: Comparison of the effects of surgical decompression and re­
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Childs Brain 5:484-498, 1979.
13. Gaab MR, Rittierodt M, Lorenz M, Heissler HE: Traumatic brain
swelling and operative decompression: A prospective investiga­
tion. Acta Neurochir Suppl (Wien) 51:326-328, 1990.
14. Gerl A, Tavan S: Bilateral craniectomy in the treatment of severe
traumatic brain edema [in German], Zentralbl N eurochir 41:125-
138, 1980.
15. Kerr FW: Radical decompression and dural grafting in severe
cerebral edema. M ayo Clin Proc 43:852-864, 1968.
16. Kjellberg RN, Prieto A Jr: Bifrontal decompressive craniotomy for
massive cerebral edema. J Neurosurg 34:488-493, 1971.
17. Marshall LF, Marshall SB, Klauber MR, van Buham, Clark M,
Eisenberg HM, Jane JA, Luerssen TG, Marmarou A, Foulkes MA:
A new classification of head injury based on computerized to­
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18. Miyazaki Y : Bifrontal external decompression for traumatic brain
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19. Miyazaki Y, Hirai H, Hachisu Y, Takada I: Bifrontal external
decompression for traumatic brain edema [in Japanese]. Shujutsu
20:845-852, 1966.
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20. Pereira WC, Neves VJ, Rodrigues Y: Bifrontal decompressive cram
otomv as the treatment for severe cerebral edema [in Portuguese
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21. Ransohoff J, Benjamin MV, Gage EL Jr, Epstein F: 1 lemicranie,
tomy in the m anagement of acute subdural hematoma. J Neuro
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22. Rinaldi A, Mangiola A, Anile C, Maira G, Amante P, FerraresiA
Hemodynam ic effects of decom pressive craniectomy in cold
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1990.
23. Venes JL, Collins WF: Bifrontal decom pressive craniectomy in th
management of head trauma. J N eurosurg 42:429^133, 1975.
CO M M EN TS
Polin et al. report their sizable experience in the use of decom
pressive bifrontal craniectomy for the treatment of posttraumati
refractory intracranial hypertension. In this carefully selectee
series, the results are impressive and, along with the report-
from Gaab et al. (1, 2) and other European groups, should leac
to a reevaluation of this procedure in carefully selected patient
It is important to em phasize that the patient population wa
young and that the medical therapy that failed would be con
sidered by many to be less aggressive than that performed in
many head injurv centers. For example, ventricular drainage in
general was not used and only one patient received high dose-
of hypnotic psychotherapeutic drugs. Because of the availabilih
of newer agents, such as propofol, it is likely that some of these
patients could have been treated for intracranial hypertension
with nonsurgical therapy. Nevertheless, there is a group of pa
tients, often young, for whom control of intracranial pressure I
(ICP) is very difficult despite the most aggressive medical treat­
ment and for whom surgery may be life-saving. In theory, a
randomized clinical trial is highly desirable, but the logistic
render such an endeavor almost impossible to accomplish. Thu I
the case control method that was used here, although not perfect
at least offers the reader a reasonable group with which to
compare medical therapy with bifrontal craniectomy.
One rather unusual observation in the study is the high
frequency of shunt-dependent hydrocephalus. In most largt
series of severe head injury, specifically in patients with diffuse
brain swelling, shunt-dependent hydrocephalus develops in
fewer than 10% of the patients. In this study, it developed in
more than one-third of the survivors (10 of 27 patients). Th
mechanism by which this developed is completely unclear, bu
this observation deserves further investigation.
As have other authors, these authors argue that for decom
pressive craniectomy to be effective, it must be performed earl
and before the situation is irreversible. What we need in th
future is a better definition and stringent criteria for regarding
medical therapy as having failed, so that surgery candidates car
be more accurately targeted. I think that if the ICP value in'
patient with diffuse brain swelling remains greater than 25 tor
in the first 48 hours despite vigorous therapy, including th
administration of hypnotic psychotherapeutic drugs, and th
cerebral perfusion pressure cannot be kept above 70 mm Hf
decompressive craniectomy should be considered.
Law rence F. Marshal
San Diego, California

1. Gaab M, Knoblich OE, Fuhrm eister U, Pflughaupt KW, Dietrich
K: Comparison of the effects of surgical decom pression and re­
section of local edema in the therapy of experim ental brain trau­
ma: Investigation of ICP, EEG and cerebral metabolism in cats.
Childs Brain 5:484-498, 1979.
2. Gaab MR, Rittierodt M, Lorenz M, Heissler HE: Traum atic brain
swelling and operative decom pression: A prospective investiga­
tion. Acta Neurochir Suppl (W ien) 51:326-328, 1990.
Sometimes, simple solutions work best. Every neurosurgeon
knows that severe closed head injury often results in increased
ICP and a bad outcome. The intervention studied here has an
appealing rationale, to improve outcome by providing a radical
decompression that decreases ICP. There seems to be little doubt
that the operation was effective in reducing ICP. The authors
infer a significant improvement in outcomes as well; 37% of their
patients had favorable results, compared to approximately 15%
in a matched control group. This implies one additional favor­
able outcome for every five patients treated.
The methodology used, comparison to a matched historical
control group, is a marked im provement over prior studies
that used comparison to external, literature-based controls.
However, there are well-known problems with historical con­
trol groups, even when carefully matched (1-4). The compa­
rability of treated and control patients can be difficult to
assess because of intangible factors that defy explicit matching
strategies. For example, only three decompressive craniecto­
mies per year were performed at the study center, and the
mean age of the patients was only 18 years. This suggests that
this aggressive approach may have been used selectively for
younger patients. Although the controls were matched for
age, other less easily identified (and nonmatchable) prognos­
tic factors may have guided physicians in selection of patients
for surgery, biasing the study in favor of craniectomy. In the
absence of a prospective protocol, it is difficult to tell whether
some patients who were nominally eligible for craniectomy
according to the stated criteria did not undergo surgery be­
cause of physician or family choice. Another difficulty is that
the control patients were not matched for postresuscitation
pupillary examination, a major prognostic factor.
The comparability of treated and control groups also de­
pends on the intensity of the medical management of ICP,
eg., the use of barbiturates. Although there is no conclusive
evidence that barbiturates affect outcome in postraumatic
coma, they do have an effect on ICP. Potentially, the control
patients could have had more serious brain injuries than the
patients they were matched to and yet could have had similar
ICP values because of barbiturate treatment. This would bias the
results in favor of craniectomy. Other medical treatments for
elevated ICP may not have been used equally in the treated and
control groups; the biases resulting from such imbalances cannot
be readily predicted or adjusted for post hoc.
This is a provocative and thoroughly analyzed report of a
treatment that may deserve wider use, although the favorable
outcome rate was still poor (7%) for patients with a preoper­
ative GCS score of 3 or 4. The general applicability of the
authors' results to a broader population of patients would be
N eu rosurgery, Vol. 41, No. I, July 199/
D eco m p ressive C ra n iecto m y in Traum a 93
more strongly supported by a prospective trial of craniectom y
versus more aggressive medical modalities, such as hypother­
mia or barbiturates, with the potential for crossover to crani­
ectomy if medical management fails.
Fred G. Barker II
R obert G. O jem ann
Boston, M assachusetts
1. Bailar JC III, Louis TA, Lavori PW, Polansky M: Studies without
internal controls, in Bailar JC III, M osteller F (eds): M edical Uses o f
Statistics. Boston, NEJM Books, 1992, ed 2, pp 105-123.
2. Diehl LF, Perry DJ: A com parison of randomized concurrent
control groups with matched historical control groups: Are his­
torical controls valid? J C lin O ncol 4:1114-1120, 1986.
3. M iller JN , Colditz GA, M osteller F: How study design affects
outcomes in com parisons of therapy: II— Surgical. Stat Med
8:455-466, 1989.
4. Sacks H, Chalm ers TC, Smith H Jr: Randomized versus historical
controls for clinical trials. Am J Med 72:233-240, 1982.
In this article, Polin et al. provide reasonably convincing
evidence that bifrontal decom pressive craniectomies can help
improve outcomes for a selected group of patients with dif­
fuse brain swelling. This study is im portant for two reasons:
1) it validates the use of an operation that has anecdotally and
variably peppered the neurosurgical literature for many
years, and 2) it is a good example of the use of case-controlled
study design to look at issues that would be practically or
financially difficult to subject to a prospective randomized
clinical trial.
As do all good studies, this one raises issues that remain
unanswered. 1) At the University of Virginia Hospital, sub­
arachnoid bolts have been preferentially used long after they
were virtually abandoned in favor of ventriculostomies by the
group in Richmond that designed them. I wonder whether
better ICP controls with ventricular drainage would have
reduced the number of patients who would have required
decompressive surgery. 2) Because early intervention seems
to optimize outcome, I wonder whether performing a decom ­
pression and removing the bone flap at the initial operation
would be advisable for patients who seem to be at significant
risk for brain swelling. Would the added time, potential mor­
bidity, cosmetic disfigurement, and cost (including a subse­
quent operation for replacement of the flap) be justified?
Nevertheless, this study suggests that bifrontal decompres­
sion should be considered for patients who are likely to
recover (patients with GCS scores greater than 3) from severe
head injuries and whose brain swelling is refractory to max­
imal medical therapy.
Raj K. Narayan
Philadelphia, Pennsylvania
This article reviews some of the ancient and modern studies
of extensive craniectomy for brain injury. Surgeons, both past
and current, have intuitively studied the use of extensive
craniectomy in this population of patients for whom medical
modalities and cerebrospinal fluid drainage have produced
poor results. Unfortunately, the present article by Polin et al.
94 Polin et al.

does not prove or disprove the value of craniectomy in exten­
sive head injury, and we are still left at the intuition stage. The
case control method does not provide a definitive answer. I
have several criticisms of the way these authors performed
the “matches." I am not convinced that comparable cases have
been matched in this study, even though a serious attempt
was made. There are too many variables in these trauma
populations to be assured that comparable cases have been
selected, and the validity of the results must therefore be
seriously questioned. However, the article serves an impor­
tant purpose, which is to encourage organized neurosurgery
to consider this therapeutic strategy.
Charles H. Tator
Toronto, Ontario, Canada
This study of the outcomes of patients treated with bifron­
tal craniectomies for elevations of ICP refractory to medical
management is another addition to the considerable literature
on the subject. Although some authorities have observed ben­
efits from craniectomies performed using a variety of tech­
niques, most have not. In a retrospective analysis examining
the effects of hemicraniectomy in a series of patients with
acute subdural hematoma who were decerebrate or flaccid at
the time of presentation, more than 90% of the patients had
unsatisfactory outcomes (1). The futility of craniectomy for
this group of patients contradicted the beneficial effects of this
procedure reported by some of the same authors at the same
institution several years previously (2). The differing results
of these two studies emphasizes the dangers in drawing con­
clusions from studies that are not performed prospectively
with randomized matched controls. Other studies in the lit­
erature suffer from failure to measure ICP values or to objec­
tively evaluate outcomes.
In this study, Polin et al. treated a very restricted group of
patients. They excluded patients with intracranial hematomas
and considered only those with elevations of ICP that re­
mained uncontrolled by medical therapy. O f the patients
studied, they observed, with one exception, that those with a
GCS score of 3 or 4 did not recover.
Should one conclude that bifrontal craniectom y is an ap­
propriate management strategy for patients with posttrau-
matic cerebral edema with GCS scores of 5 or greater and
elevated ICP refractory to medical management who do not
have intracranial hematomas? At this time, I answer this
question with an em phatic no. Although Polin et al. used
"control patients" from the Traumatic Coma Data Bank in an
imaginative way, this is not a substitute for a randomized
prospective study. The head injury literature is replete with
therapies that seemed promising but were not proved to be
efficacious after more rigorous examination. It is thus impor­
tant that this study be repeated (probably in a cooperative
venture) in a prospective fashion with randomized controls.
Paul R. Cooper
New York, New York
1. Cooper PR, Rovit R, Ransohoff J: H em icraniectom y in the treat­
ment of acute subdural hematoma: A re-appraisal. Surg Neurol
5:25-28, 1975.
2. Ransohoff J, Benjamin MV, Gage EL Jr, Epstein F: Hemicraniec­
tomy in the m anagement of acute subdural hematoma. J Neuro­
surg 34:70-76, 1971.

A N N O U N CEM EN T

1997 Annual Meeting

Congress of N eurological Surgeons

Earnest N. Morial Convention Center

New Orleans, Louisiana
September 27 through October 2

Mitchel S. Berger, Meeting Chairman

Mark N. Hadley, Program Chairman
Frank Culicchia, Local Arrangements Chairman

Neurosurgery, Vol. 41, No. 1, july 1997