Decompressive craniectomy for the management of patients with refractory hypertension: should it be reconsidered?
BACKGROUND
The management of refractory post-traumatic cerebral oedema remains a frustrating endeavor for the neurosurgeon and the intensivist. Mortality and morbidity rates remain high, despite refinements in medical and pharmacological means of controlling intracranial hypertension.


METHODS
In this retrospective study we have evaluated the efficacy of decompressive craniectomy as a last resort therapy, from the data of nine patients with severe brain injury and delayed cerebral oedema (diffuse injury type III), treated between January 1997 and September 1999. The following parameters were considered: age, Glascow Coma Scale, injury severity, intracranial pressure, CT findings, pupil reaction/posturing. Follow-up period was over at least 2 years and outcome measured on the GOS.


RESULTS
Patients have been operated on post-trauma median day 3, mean age 26+/-9, GCS 7+/-3.7, mean APACHE II 16+/-6.4, mean ISS 27.8+/-16.1, mean preoperative ICP 37.7+/-10.0, mean postoperative ICP 18.1+/-16.01. Seven patients have been operated by a frontotemporoparietal approach (six of them bilateral, one unilateral) and two patients have been operated on by a bilateral subtemporal approach. Mortality rates 22%, severe disability 11%, good recovery 66%.


CONCLUSIONS
Patients with STBI, developing delayed intracranial hypertension caused by diffuse cerebral oedema, definitely benefit from craniectomy when current medical treatment has failed. The encouraging results of outcome in this and more recent studies, indicate the need for a multi-institutional randomized prospective study evaluating early indicators of raised ICP, timing, efficacy of treatment, operative technique and complications of decompressive craniectomy.
Neurosurgical Department, Aristotle's University of Thessaloniki, AHEPA Hospital, Thessaloniki, Hellas, Greece.
V
V
Kontopoulos
N
N
Foroglou
J
J
Patsalas
J
J
Magras
G
G
Foroglou
M
M
Yiannakou-Pephtoulidou
E
E
Sofianos
H
H
Anastassiou
G
G
Tsaoussi
D000293:Adolescent; D000328:Adult; D001929:Brain Edema / Q000209:etiology / Q000601:surgery*; D001930:Brain Injuries / Q000150:complications; D019299:Decompression, Surgical / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology / Q000601:surgery*; D008297:Male; D019635:Neurosurgical Procedures / Q000379:methods*; D012189:Retrospective Studies; D012886:Skull / Q000601:surgery*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome