Bilateral Decompressive Craniectomy for Patients with Malignant Diffuse Brain Swelling after Severe Traumatic Brain Injury: A 37-Case Study

In this study we retrospectively analyzed the outcome of bilateral decompressive craniectomy (BDC) for 37 patients with bilateral malignant diffuse brain swelling following severe traumatic brain injury (TBI). Our 37 patients (Glasgow Coma Scale [GCS] score <= 8) were retrospectively analyzed from September 2005 through September 2008. All patients underwent bilateral frontotemporoparietal decompressive craniectomy followed by duraplasty. The intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were measured before and after BDC, and Glasgow Outcome Scale (GOS) scores were measured after >6 months of follow-up. The mean ICP was 37.7 +/- 6.4mm Hg, and the mean CPP was 57.6 +/- 7.5mm Hg before BDC. The ICP significantly decreased to 27.4 +/- 7.2mm Hg (p<0.05) after bone removal, and the CPP significantly increased to 63.3 +/- 8.4mm Hg (p<0.05). The ICP had a larger decrease, to 11.2 +/- 7.1mm Hg (p<0.05), after opening and enlargement of the dura mater (p<0.05) compared to the levels seen after bone removal, and CPP significantly increased to 77.8 +/- 8.3mm Hg (p<0.05). After surgery, the ICP was elevated, but remained lower than the initial ICP (p<0.05), and was easily controlled by routine medical treatment in the ensuing days, and the CPP remained above the optimal threshold of 70mm Hg. The mean follow-up time was 9.4 +/- 3.2 months. In total, 20 patients (54.1%) had favorable outcomes, including 12 patients (32.5%; GOS 4) with moderate deficits, and 8 patients (21.6%; GOS 5) showed good recovery and social reintegration. Also, 17 patients (45.9%) had unfavorable outcomes, including 7 patients (18.9%; GOS 1) who died, 4 patients (10.8%; GOS 2) remained in a vegetative state, and 6 patients (16.2%; GOS 3) had severe deficits. The most common complication was hydrocephalus (7 patients, 18.9%). Our data show that BDC offers immediate reductions in intracranial hypertension, and perhaps contributes to satisfactory outcomes in patients with bilateral diffuse brain swelling following severe TBI.