gms | German Medical Science

Objective: The increase of treatment-refractory pressure following severe closed head injury with no evidence of operable hemorrhages still presents an insoluble problem in the management of these patients.

Methods: In a prospective study since 1977 until now 86 patients with traumatic brain injury underwent decompressive craniectomy. The clinical status of the patients, CAT scans and ICP values were documented prospectively in a standard protocol. Primary brain or brain stem injury with fully developed bulbar brain syndrome were contraindications to decompressive craniectomy. A positive indication for decompression was given in the case of progressive therapy-resistant intracranial hypertension in correlation with clinical and electrophysiological parameters and with findings on CAT scan. In all cases, a wide fronto-temporo-parietal craniectomy was followed by a dura enlargement covered with temporal muscle fascia.

Results: The outcome was surprisingly good. 49 patients (57%) attained social rehabilitation.Twelve patients (14%) survived with a severe permanent neurological deficit. Eight patients (9%) survived, but remained in a persistent vegetative state, and 12 patients (14%) died. Five patients (6%) did not have a follow-up examination. The GCS on the first day posttrauma and the mean ICP turned out to be the best predictors for a good prognosis.

Conclusions: Surgical decompression should be routinely performed when indicated before irreversible ischemic brain damage occurs.