Role of Subtemporal Decompression in Severe Closed Head Injury

Abstract

There is general agreement that aggressive management and monitoring of the patient with closed head injury with control of intracranial pressure (ICP) will improve patient survival and eventual outcome. Conversely, there is little agreement on the value of surgical craniectomy for increasing intracranial volume and subsequently decreasing ICP in these same patients. This study examines 115 patients with severe closed head injuries (Glasgow Coma Score 8 or less) seen at the North Carolina Baptist Hospital between July 1, 1983, and April 1, 1987. All 115 patients were started on a regimen of head elevation, fluid restriction, chemoparalysis, and hyperventilation at PCO2 25-30 torr. Fifty-seven patients failed to respond to that therapy and were given mannitol. Twenty-seven of these still failed to respond; 24 were placed in a pentobarbital coma therapy group and 3 underwent subtemporal decompression. Of the 24 patients in pentobarbital coma, 17 failed to respond, 7 of whom underwent subtemporal decompression and 10 of whom were not operated on. Of all 10 patients undergoing subtemporal decompression, 7 (70%) responded with an average reduction in ICP of 34% (+/- 19.5% SD). Of the 10, 4 died (40%), in contrast with a mortality of 82.4% among patients in pentobarbital coma without subtemporal decompression. These data strongly suggest that subtemporal decompression can be beneficial in patients with medically intractable elevations of ICP.

Unilateral decompressive craniectomy for children with severe brain injury. Report of seven cases and review of the relevant literature

“…The mortality rate in patients treated with barbiturate for raised ICP was extremely high and ranged from 58% to 82%. Gower et al [9] published a rate of 82% and Piek [18] a rate of 58% [18]. Under CPP/ICP monitoring, a widely used adjunctive therapy is controlled hyperventilation.…”

Management of Traumatic Brain Injury

“…It is estimated that 10-15% of patients admitted with STBI will ultimately manifest medically and surgically intractable elevated ICP with an associated mortality of 84-100% [65,84]. An obvious way to convert the closed box surrounding the brain into an open box is to open the skull by craniectomy, which has been performed for decades [17,23,38,57,61,91].…”

“…There is evidence that the operation does favorably influence ICP. In both animal and human studies, surgical decompression has been found to lower ICP by increasing intracranial volume [4,7,25,38,41,42,44,47,54,61,78,89]. Muench et al [81] found that the mean volume gained by surgical decompression ranged from 15.9 to 347.4 cm 3 with a median volume of 73.6 cm 3 .…”

“…There is considerable debate in terms of the nuances of the type and the extension of subtemporal decompression: • fronto-parieto-temporal unilateral [81] versus bilateral; • bifrontal with/without cutting through the superior sagittal sinus and the falx cerebri [57,89,118,122]; • subtemporal decompression [4,38]; • circumferential craniotomy [17]. Furthermore, the dura may be left intact, scarificated [90], sliced [79] or it may be augmented by a plasty [20].…”

Emergency decompressive craniectomy for trauma patients with Glasgow Coma Scale of 3 and bilateral fixed dilated pupils

“…A report published by Saul and Ducker [9] indicated an 84% death rate when ICP was greater than 25 mmHg despite maximum medical management. Decompressive craniectomy has been proven to reduce ICP that is resistant to maximum medical treatment, improve brain elasticity, improve cerebral perfusion pressure, increase brain tissue PO 2 , and reduce midline shift and brainstem compression, following severe TBI, by increasing intracranial volume [10][11][12][13][14][15][16][17][18][19][20][21][22].…”