The Failure of Circumferential Craniotomy in Acute Traumatic Cerebral Swelling

M ANY attempts have been made to control traumatic cerebral swelling. Hypothermia, 7 intravenous hypertonic solutions, -~ steroids, 6 and surgical decompression s have been, or are being, employed. Some moderate success has been obtained with each of them. Surgical decompression of the massively swollen brain has included subtemporal decompression, temporal or frontal lobe resection, and splitting of the tentorium. ~ They have all been tried but, by and large, have been abandoned due to several factors. They may be technically difficult or fail to provide adequate room. Occasionally, bony decompression may actually increase edema. If, for instance, the brain becomes incarcerated outside the skull, its venous drainage may be obstructed at the cranial edge with enhancement of the edema2 Subtemporal decompression is not too successful for these reasons. Or, as with temporal lobectomy, the procedure itself may increase the neurological deficit, if the patient survives. The chief problem with surgical decompression, however, is inability to provide adequate room for severe cerebral swelling. Since this swelling is hemispheric, not lobar, an attempt to enlarge the entire cranial cavity in an upward and outward dimension seemed logical. This report deals with our experience in attempting a radical surgical decompression. The reason for reporting this experience is to warn others from doing similar surgery. More important, it is to point out the fallacy of considering the skull as a single box. Surgical decompression may ultimately prove useful in control of cerebral swelling. If so, the procedure must be designed to open all dural compartments within the skull, as well as the skull itself. The background for circumferential crani-