Bifrontal decompressive craniectomy is a life-saving procedure for patients with nontraumatic refractory brain edema

Despite advances in understanding, monitoring, and treatment, the outcome of patients with refractory brain oedema (RBE) remains poor. The concept of wide bone removal for treatment of RBE has been recognized since the nineteenth century. Bifrontal decompressive craniectomy (BDC) is performed as last resort treatment for patients with posttraumatic RBE. In this series the author treated 5 adult patients with non traumatic RBE using BDC. This is a retrospective review of all patients who developed RBE and herniation syndrome, all of them deteriorated to GCS 4-5/15 and had their pupils were dilated and fixed and had surgery after trial of medical management (mannitol and hyperventilation). The primary pathology was aneurysmal SAH in 2 patients, CNS infection in 2 patients, and one large calcified olfactory groove meningioma. The follow-up ranged from 6 months to 7 years, mean 3.9; there were no complications related to bone flap, no mortality or vegetative patients, one patient (20%) had good outcome, 2 patients (40%) had moderate disability (independent), and 2 patients (40%) had severe disability (dependent). BDC is an effective method of surgical decompression in patients with RBE; the procedure should be performed quickly after clinical deterioration to prevent irreversible secondary brain damage. Although difficult to accomplish, a randomized clinical trial is necessary to define criteria for surgical interference in patients with nontraumatic RBE.