Document Detail

Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema.
MedLine Citation:
PMID:  9218299     Owner:  NLM     Status:  MEDLINE    
OBJECTIVE: The management of malignant posttraumatic cerebral edema 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 elevated intracranial pressure; therefore, a comparison of medical management versus decompressive craniectomy in the management of malignant posttraumatic cerebral edema was undertaken. METHODS: At the University of Virginia Health Sciences Center, 35 bifrontal decompressive craniectomies were performed on patients suffering from malignant posttraumatic cerebral edema. A control population was formed of patients whose data was accrued in the Traumatic Coma Data Bank. Patients who had undergone surgery were matched with one to four control patients based on sex, age, preoperative Glasgow Coma Scale scores, and maximum preoperative intracranial pressure (ICP). RESULTS: The overall rate of good recovery and moderate disability for the patients who underwent craniectomies was 37% (13 of 35 patients), whereas the mortality rate was 23% (8 of 35 patients). Pediatric patients had a higher rate of favorable outcome (44%, 8 of 18 patients) than did adult patients. Postoperative ICP was lower than preoperative ICP in patients who underwent decompression (P = 0.0003). Postoperative ICP was lower in patients who underwent surgery than late measurements of ICP in the matched control population. A statistically significant increased rate of favorable outcomes was seen in the patients who underwent surgery compared to the matched control patients (15.4%) (P = 0.014). All patients who exhibited sustained ICP values above 40 torr and those who 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 60% rate of favorable outcome and a statistical advantage over control patients (P = 0.0001). CONCLUSION: Decompressive bifrontal craniectomy provides a statistical advantage over medical treatment of intractable posttraumatic cerebral hypertension and should be considered in the management of malignant posttraumatic cerebral swelling. If the operation can be accomplished before the ICP value exceeds 40 torr for a sustained period and within 48 hours of the time of injury, the potential to influence outcome is greatest.
R S Polin; M E Shaffrey; C A Bogaev; N Tisdale; T Germanson; B Bocchicchio; J A Jane
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Neurosurgery     Volume:  41     ISSN:  0148-396X     ISO Abbreviation:  Neurosurgery     Publication Date:  1997 Jul 
Date Detail:
Created Date:  1997-08-19     Completed Date:  1997-08-19     Revised Date:  2004-11-17    
Medline Journal Info:
Nlm Unique ID:  7802914     Medline TA:  Neurosurgery     Country:  UNITED STATES    
Other Details:
Languages:  eng     Pagination:  84-92; discussion 92-4     Citation Subset:  IM    
Department of Neurosurgery, University of Virginia Health Sciences Center, Charlottesville, USA.
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MeSH Terms
Brain Edema / etiology,  mortality,  radiography,  surgery*
Brain Injuries / complications,  mortality,  radiography,  surgery*
Case-Control Studies
Craniotomy / methods*
Decompression, Surgical / methods*
Disability Evaluation
Glasgow Coma Scale
Intracranial Pressure / physiology
Survival Rate
Treatment Outcome

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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