Role of subtemporal decompression in severe closed head injury

There is general agreement that aggressive management and monitoring of the patient with closed head injury with control of intracranial pressure (ICP) will improve patient survival and eventual outcome. Conversely, there is little agreement on the value of surgical craniectomy for increasing intracranial volume and subsequently decreasing ICP in these same patients. This study examines 115 patients with severe closed head injuries (Glasgow Coma Score 8 or less) seen at the North Carolina Baptist Hospital between July 1, 1983, and April 1, 1987. All 115 patients were started on a regimen of head elevation, fluid restriction, chemoparalysis, and hyperventilation at PCO2 25-30 torr. Fifty-seven patients failed to respond to that therapy and were given mannitol. Twenty-seven of these still failed to respond; 24 were placed in a pentobarbital coma therapy group and 3 underwent subtemporal decompression. Of the 24 patients in pentobarbital coma, 17 failed to respond, 7 of whom underwent subtemporal decompression and 10 of whom were not operated on. Of all 10 patients undergoing subtemporal decompression, 7 (70%) responded with an average reduction in ICP of 34% (+/- 19.5% SD). Of the 10, 4 died (40%), in contrast with a mortality of 82.4% among patients in pentobarbital coma without subtemporal decompression. These data strongly suggest that subtemporal decompression can be beneficial in patients with medically intractable elevations of ICP.