The value of decompressive craniectomy as a method of treatment for massive brain edema or cerebral contusions associated with acute subdural hematoma remains controversial. In this report, the results of further experience with decompressive hemicraniectomy were described and operative indications were discussed.
The present series consisted of 31 consecutive patients with acute subdural hematoma undergoing decompressive hemicraniectomy (24 males and 7 females) whose age ranged from five to 82 years, averaging 45.7 years. They included six patients with postoperative barbiturate therapy with a mean age of 41.2 years. Glasgow Coma Scale (GCS) scores obtained before surgery were 8 or less in all patients. Intracranial pressure (ICP) was measured in the extradural space on the operated side and was monitored for 48 to 72 hours after the operation. In cases with a combination of barbiturates and surgery, 2-3 mg/kg/hour of thiopental was administered after the operation when postoperative ICP rose above 35 mmHg within several hours. The barbiturate therapy was continued for 48 to 72 hours under mechanical ventilation.
The final outcome of the present series demonstrated a 32.2% favorable outcome (good recovery and moderate disability), a 13.0% unfavorable outcome (severe disability and vegetative state) and a 54.8% mortality rate. Careful evaluation of the results, however, revealed that 80% of the less serious patients with GCS scores of 6 to 8 before the operation had a favorable outcome. On the other hand, a mortality rate of 81% was found in the more serious patients with GCS scores of 3 to 5. Preoperative ICP was higher than 40 mmHg in all patients and postoperative ICP was controlled at around 50 mmHg or below except for cases of diffuse brain swelling. In 36.4% of the patients with sustained high ICP around 50 mmHg for days after the operation, the outcome was favorable. Postoperative use of barbiturates was effective in lowering ICP by 10 to 15 mmHg and was not associated with any complications. These results indicated that limiting the operative indications according to preoperative GCS scores and use of barbiturate therapy could improve the outcome of acute subdural hematomas.