Bifrontal decompressive craniotomy (BDC) was initially described by Miyazaki in 1966 1) and was popularized by Kjellberg and Prieto in 1971 who performed on 50 patients with TBI. Kjellberg and Prieto did not think that this procedure was simply prolonging the life of patients with irreversible damage, but with proper indication could result in reasonable outcomes. They deplored its application in patients with modest injury and noticed that younger survivors, even if they had a decerebrate state at presentation, had the better potential for good neurological recovery than the adults. They suggested “the following indications as a guide to the decision to use this procedure: 1. Coma: totally unresponsive or responsive only to deep pain 2. Unilaterally or bilaterally dilated and fixed pupils 3. Apnea 4. Decerebrate posturing…at least two of the indications above should be present.” 2).
In 2001 in an observational study, Whitfield et al. reported the clinical outcome and physiological effects of the procedure in a series of 26 patients with refractory intracranial hypertension and provided pathophysiological evidence that bifrontal decompressive craniectomy significantly reduces posttraumatic intracranial hypertension and improves pressure dynamics 3).
Bifrontal decompressive craniectomy is not recommended to improve outcomes as measured by the Glasgow Outcome Scale–Extended (GOS-E) score at 6 months post-injury in severe TBI patients with diffuse injury (without mass lesions), and with ICP elevation to values >20 mm Hg for more than 15 minutes within a 1-hour period that are refractory to first-tier therapies. However, this procedure has been demonstrated to reduce ICP and to minimize days in the intensive care unit (ICU).
A 17-year-old girl underwent emergency bifrontal decompressive craniectomy for severely raised intracranial pressure with brainstem compression, having developed acute disseminated encephalomyelitis (ADEM) following Epstein-Barr virus infection.
Bourke et al discussed the current evidence for craniectomy in both ADEM and infective encephalitis and propose an approach to management 4).