Traumatic Brain Swelling and Operative Decompression: A Prospective Investigation
Since 1978, decompressive craniotomy was performed according to a standardized protocol. Exclusion criteria were age ≥ 40 years, deleterious primary brain damage, operable space occupying lesions, larger infarctions in CT scan or irreversible brain stem incarceration/ischaemic damage as shown by bulbar syndrome, loss in BAEP or oscillating flow in TCD. Indication was given by progressive intra-cranial hypertension not controllable by conservative methods, if ICP decompensation was correlated with clinical (GCS, extension spasms, mydriasis) and electrophysiological (EEG, SEP, CCT) deteriorations. 18 patients were decompressed by unilateral, 19 by bilateral craniotomy with large fronto-parieto-temporal bone flap and a dura enlargement by use of temporal muscle/fascia. 37 patients at an age of 18 ± 7 (4–34) years were operated 5 h–10 d after trauma. Recovery was surprisingly good: only 5 died, 2 due to an ARDS; 3 remained vegetative, all others achieved full social rehabilitation14 or remained moderately disabled12*. The best predictor of a favourable outcome was an initial posttraumatic GCS ≥ 7. These encouraging results suggest a routine use of operative decompression in younger patients with delayed posttraumatic decompensation before irreversible ischaemic damage occurs.
KeywordsIntracranial Hypertension Brain Damage Decompressive Craniectomy Bone Flap Large Hemispheric Infarction
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