Accepted Manuscript

Surgical treatment of traumatic bifrontal contusions: when and how?

Lu zhaofeng, Li bing, Qiao peng, Jiang jiyao

PII: S1878-8750(16)30406-5
DOI: 10.1016/j.wneu.2016.06.021
Reference: WNEU 4180

To appear in: World Neurosurgery

Received Date: 1 March 2016

Revised Date: 3 June 2016
Accepted Date: 6 June 2016

Please cite this article as: zhaofeng L, bing L, peng Q, jiyao J, Surgical treatment of traumatic bifrontal
contusions: when and how?, World Neurosurgery (2016), doi: 10.1016/j.wneu.2016.06.021.

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 ACCEPTED MANUSCRIPT

Surgical treatment of traumatic bifrontal

contusions: when and how?
Lu zhaofeng1, Li bing1, Qiao peng1, Jiang jiyao2

1. Department of Neurosurgery Intensive Care Unit, First Affiliated

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Hospital of Henan University of Science and Technology, Luoyang,

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China

2. Department of Neurosurgery, Renji Hospital Affiliated to

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Shanghai Jiao Tong University, Shanghai, China

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Correspondence to: Dr. Lu Zhaofeng, Department of Neurosurgery

Intensive Care Unit, First Affiliated Hospital of Henan University of

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Science and Technology, Jinghua Road 24, Luoyang, China. E-mail:

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zhaofenglu001@163.com
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Abstract
Objective The study aimed to investigate optimal surgical timing,

methods, and clinical efficacy of bifrontal decompression craniotomy

(BDC) on traumatic bifrontal contusions (TBC). Methods

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Retrospective analysis of 98 cases with TBC underwent BDC in 2510

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traumatic brain injury patients. The operation-timing score was used to

determine surgical timing. Results Ninety-eight cases (19%) underwent

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amended BDC. Initial GCS was 13-14 in 52 cases (61%). Initial CT scan

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showed hematoma volumes of 15.1±5.2 ml in 73 cases (74%).
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Preoperative hematoma (80.2±20.5ml, P ＜ 0.05) was significantly

enlarged. Fluctuation in surgery-timing curve is timing for surgery.

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Average operation time was 4.5±3.4 days after admission. Hematoma

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totally evacuated and GCS significantly increased(P＜0.05)in all cases.In

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the follow-up GOS, 79 (81%) patients recovered well. Conclusions

TBC progressed gradually and deteriorated rapidly; this should be strictly

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and dynamically observed, and patients should be operated on in a timely

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manner. The changing of operation-timing score is the gold standard for

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surgery. Amended BDC can significantly improve the prognosis of

patients.

Key words: Bifrontal contusions; Bifrontal decompressive craniotomy;

Timing of operation
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Introduction
Traumatic brain injury (TBI) constitutes a major health and

socioeconomic problem throughout the world. It is the leading cause of

mortality and disability among young individuals in high-income

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countries, and globally, the incidence of TBI is rising sharply, mainly due

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to increasing motor-vehicle use in low-income and middle-income

countries(12). Occipital impact leading to frontal contrecoup injury is

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common. The secondary brain injury (ischemia and hypoxia) deteriorates

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gradually. Multi-modal individual monitoring (e.g. intracranial pressure,
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and so on) as soon as possible is necessary(27) to determine individual

treatment. The application of sedative drugs, the mechanism of injury and

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other factors limits Glasgow Coma Score (GCS) application.

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Meanwhile, DC performed for the management of ICH alone is more

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controversial in light of the DECRA trial (DC in Diffuse TBI), which was

associated with more unfavorable outcomes. Studies showed that obvious

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brain contusions could be seen in CT scans of 70% of patients with

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severe brain injuries. CT scans based on GCS examination could be used

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as criterion in patients who need surgery. Combined evaluation of

multi-indicators (including injury mechanism, size of hematoma and

edema, neurological impairment, etc.) is still the most important

indication for therapy strategies(8). The Brain Trauma Foundation (BTF)

evidence-based guidelines have defined threshold values for volume and

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thickness of hematomas that require evacuation (class II and III evidence).

However, TBC have the characteristics of gradually progressing

hematoma/edema and rapid deterioration owing to central herniation,

even if conscious at the time of admission. The state of consciousness,

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dynamic and timely CT scan, and even ICP monitoring after admission

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should be closely observed and analyzed. In order to reduce mortality and

improve outcomes, timely identification of patients who need surgical

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intervention is extremely important. However, there are still controversies

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regarding TBC-timing and treatment method(19).
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We retrospectively analyzed the clinical features of 98 patients with TBC

in our department and the timing of operation, the operation method, and
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the prognosis.
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Materials and methods

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General data

Clinical data of 2510 patients with traumatic brain injury admitted to the
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surgical intensive care unit from January 2000 to June 2015 were
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collected. Ninety-eight patients with TBC underwent surgical treatment

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by neurosurgeons. Sixty-two cases were male, and 36 were female.

Average age was 44.5 years old, with the youngest patient being 13 years

old and the oldest being 76 years old. Causes of injury were as follows:

36 cases of falling from height, 20 cases of accidental injury, 78 cases of

injury caused by ground level falls. Injury mechanisms included: 82 cases

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contrecoup injury, 16 cases coup injury. Occipital bone fracture was

present in 70 cases, and forehead fracture was present in 12 cases.

Sixty-six cases presented occipital subcutaneous hematoma, and 11 cases

presented forehead subcutaneous hematoma. On admission, GCS score

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was 6-8 in 9 cases, 9-12 in 38 cases, and 13-14 in 51 cases.

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Exclusion criteria
Multiple serious injuries (injury to two or more organs, and underwent

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abdominal surgery or chest surgery); heart, lung, liver, kidney, or other

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organ function failure; pregnancy or lactation; admission or rescue after
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bilateral pupil scattering, ventilator application; patients with cerebral

rigidity; TBC combined with other types of hematoma; and admission

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GCS score less than 5.

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Clinical manifestation and imaging data

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After admission to ICU, clinical data were recorded by two

neurosurgeons. CCT (cranial CT) scans were performed every 4 to 6

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hours for 48 hours according to the patient's condition. Subsequent CT

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scans depended on clinical manifestations, such as aggravated disorder of

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consciousness, enlarged hematoma/edema (CT scan), midline structure

shift, ambient cisterns not clear, bilateral anterior horn of lateral ventricle

compressed and became small, the suprasellar cistern, quadrigeminal

cistern, or the third ventricle compressed or disappeared. The volume of

hematoma and edema was calculated by two radiologists using the

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Coniglobus formula (AxBxC/2).

Timing of operation
All patients with TBC were closely observed and measured by two

neurosurgeons. The change curve of the timing of operation score was

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drawn and recorded every 2 hours.

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The score is divided into 4 grades:

Ⅰ (1 point): There was no significant change in GCS score and/or no

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significant change in the volume of hematoma and edema;

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II (2 points): GCS score decreased to 9-12, and/or the volume of
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hematoma and edema increased significantly;

Ⅲ (3 points): GCS score decreased to 6-8, and/or the volume of

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hematoma and edema increased significantly;

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Ⅳ (4 points): GCS score decreased to below 6, and/or hematoma and

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edema volume increased significantly; bilateral mydriasis and the vital

signs were not stable.

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The score curve is divided into four categories; if it reaches the latter two,
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emergency BDC should be carried out immediately (Figure 4).Surgical

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methods
All patients with TBC that met the surgical criterion underwent a

modified bifrontal decompressive craniotomy. Patients were placed in the

supine position, with their heads fixed by a headstock system (Doro,

Germany) or head rest. The head of bed was elevated 15-20 degrees
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(reverse Trendelenburg position). A modified bifrontal coronal incision

was used, and the preferential craniotomy side was selected according to

hematoma and edema volume .(1) Skin incision: bicoronal skin incision

runs from 1.5 to 2 cm above the bilateral zygomatic arch, pretragal 0.5

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cm to 1.0 cm, walking within the hairline. Total length of incision was

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about 22.1 ± 3.1 cm. (2) Skin flap: skin was raised in one flap to the

forehead. The temporalis muscle was kept intact on both sides. Only the

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keyhole and temporal line were exposed totally. The periosteotomy ran

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respectively 0.5 cm apart from the midline and along the skin edge to
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each temporal line. (3) Burr holes: four burr holes in each side were

located along the exposed range of periosteum, with the first burr hole
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located in the keyhole. The medial margin of each bone flap was about
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0.5 cm from the midline, the lower margin was about 0.5 cm from the
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superior orbital, and the lateral margin located on temporal line. The

anterior skull base was fully exposed. Each bone flap was about 4 cm × 6
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cm, leaving a strip of midline bone bridge covering the superior sagittal
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sinus. (4) Dural incision and suture: dura mater was cut along the edge of
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the bone window in the direction of the superior sagittal sinus. The

periosteum was applicated to relaxation suture dura mater posthematoma

evacuation. The bone flap was removed for decompression. Biological

glue was used to temporal muscle flap-gelatin sponge-periosteum

consisted of sandwichlike structure to seal the opened frontal sinus

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(Figure2).

Post operative assessment and treatment

Changes in vital signs were observed by neurosurgeons every 2 hours.

Routine postoperative CCT scans were performed to detect the patient's

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intracranial condition. Whether or not tracheotomy was performed

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depended on the patient's condition of consciousness. All patients were

routinely conservatively treated with mannitol, furosemide, and

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antiepileptic drugs.

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Outcome
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Three months of patient follow-ups were recorded by two neurosurgeons

according to the Glasgow Outcome Score (GOS). Rating grade: (5) good
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recovery and return to normal life, despite the slight defect; (4) mild
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disability, but can live a life of independence; can work under protection;
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(3) severe disability awake, requires care in daily life; 2 patients survive

in a vegetative state, with only a minimal response (such as with the

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sleep/wake cycle) and eyes open; 1 patient died.

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Statistical Analysis
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Continuous variables were presented as mean or median and standard

deviation. We considered a confidence interval of 95%, and Student’s

t-test was used to make comparisons. P-value less than or equal to 0.05

was considered to be significant. Data analyses were performed in SPSS

Statistics 18.0.
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Results
Clinical data analysis
Among the 98 TBC cases, there were 62 male cases (63%) and 36 female

cases (37%). Thirty-six cases (37%) were caused by falling from height,

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20 cases (20%) were caused by traffic accident injury, and 42 cases (43%)

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were caused by ground level falls. Eighty-two cases (84%) showed

contrecoup injury, 16 cases (16%) showed coup injury. Occipital bone

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fracture was present in 70 cases (71%), frontal bone fracture in 12 cases

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(12%). There were 66 cases (67%) with occipital subcutaneous hematoma,
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and 11 cases (11%) with frontal subcutaneous hematoma. The GCS score

was 6-8 in 9 cases (9%), 9-12 in 38 cases (39%), and 13-14 in 51 cases
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(52%) on admission. After injury, coma occurred in 10 cases (10%),

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headache in 82 cases (84%), vomiting in 36 cases (37%), irritability in 45

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cases (46%), apathy in 11 cases (11%), and obvious mental symptoms,

such as hallucinations in 23 cases (23%). Hemorrhagic cerebrospinal

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fluid leakage was present in 18 patients (18%) and subarachnoid

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hemorrhage (SAH) in 52 patients (53%). Seizures occurred in 5 cases

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(5%). In 2 cases (2%), one pupil was dilated and eyelid was drooping on

admission. The first cranial CT scan immediately on admission showed

patchy and tiny contusions (spotted contusions) in 18 cases (18%), with a

hematoma volume of 15.1±5.2 ml in 73 cases (74%) and 30.2±5.1 ml in 8

cases (8%).Patients stayed in the intensive care unit for a period of

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12.3±3.2 days (Table 1，

，Figures 1 and 2).

Timing of operation
Average operation timing was 4.5±3.4 days after admission. Among these,

8 (8%) patients were operated on within 1 day of admission to ICU, 20

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patients (20%) within 2 days, 31 patients (32%) within 3 days, 32 patients

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(33%) within 4 days, 6 patients (6%) within 7 days, and 1 patient (1%)

within 10 days (Table 2).

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Assessment of Efficacy

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Dynamic CCT scan showed satisfactory removal of hematoma in 98
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patients (Figure 3). At 3 days after surgery, the GCS score was 13 in 92

cases (94%) (P < 0.05), 6 in 6 cases (6%), and 14 in 93 cases (93%) (P <
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0.05). The GCS score was 6 in 5 cases (5%) at 7 days post operation. Two
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patients had cerebrospinal fluid rhinorrhea and underwent repairing

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surgery 1 month later. At the 3-month follow-up, the GOS score was 5 in

79 cases (81%), 4 in 14 cases (14%), 3 in 2 cases (2%), and 2 in 1 (1%)

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case. Two (2%) patients died (Table 3).

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Discussion
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TBCs have unique features from contusions in other locations. Awake

TBCs often lead to rapid deterioration late in the clinical course, with the

characteristics of “talk and die”.

The TBC patients present with mild head injury (GCS13–15) and then

deteriorate and die abruptly from intracranial causes. This accounts for
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2.6% of overall TBC, and the annual incidence did not significantly alter
(6)
over the 10-year period . A combination of high GCS and benign

clinical course for several days made aggressive management of these

patients difficult to justify. For the first time, in this study, we examined

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when and how to treat this subgroup timely and appropriately. The

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primary finding of this paper is that the pathological process could be

controlled with timely BDC and that good recovery outcomes are

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possible.

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General clinical features
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Research showed that the causes of TBI have changed from traffic

accidents to falls or falling from heights with the aging and developing of
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society. Average age also increased from 25 to 48 years old. This study
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showed that 78 (80%) of patients with falling injury were an average age
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of 44.5 years old, which was similar to the previous study(12). In spite of

the relatively low risk of GCS 15 in patients with brain contusion, Smits
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et al found that 14% of GCS 14 patients with TBI had intracranial

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lesions(21). Patel et al unequivocally showed a 2.15 times increase in the

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odds of death (adjusted for case mix) for patients with severe head injury

treated in non-neurosurgical centers versus neurosurgical centers(16). In

our study, 98 patients (98/2510, 3.9%) were admitted to the surgical

intensive care unit and underwent operations. Santiago et al found a

statistically significant association between frontal traumatic intracerebral

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hemorrhage and impact sites located on the anterior area of the head. The

contrecoup represents a risk factor independently associated with

hemorrhagic progression(3). Forehead contrecoup injury is often

associated with fracture of the occipital bone. It was found that the

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incidence of skull fracture was 64% in patients with craniocerebral

injury(14). This study showed that 82 (84%) cases suffered contrecoup

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injury, with 16 (16%) cases of coup injury. Skull fracture is an important

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risk factor for brain injury, and it is closely related to the prognosis(20).

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Seventy (71%) cases presented with occipital bone fracture, and 12 (12%)
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cases presented with forehead fracture. The high incidence of fractures in

this group was due to the injury mechanism. We also had the experience
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of conservative treatment of frontal contusion with occipital bone fracture,

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which reminded us that much attention should be paid to frontal

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contusions with occipital fractures. Cerebrospinal fluid leakage was

found in 15% of frontal depression fractures, and the incidence of

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intracranial inflammation due to fracture was 15–30%. The cerebrospinal

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fluid leakage was 18% (18/98) in this group, which was similar to that of
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the former report. Postoperative cerebrospinal fluid leakage was repaired

in 2 patients (recovered well) 1 month after surgery. Scholsem et al

reported intracranial gas (70%) and SAH (82.5%) were more common in

TBI patients with skull fractures. It is believed that intracranial gas

accumulation is also an important cause of intracranial infection(24). Eight

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cases (8/12) of intracranial gas and no intracranial infection occurred in

this group. This might be associated with good environment and early

antibiotic treatment in the intensive care unit. Studies have shown that

SAH incidence was 42.5%. The incidence of SAH in this group was 53.1%

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(52/98), which may be not related to the initial overall GCS score. We

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believe the difference is caused by the mechanism of injury and that SAH

might be a risk factor for TBC.

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Bokhari et al showed GCS scores of 9-12 (92%), and 13 (8%) for cases of

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admission for bifrontal contusion(9). Our study showed a GCS score of
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6-8 in 9 cases (9%), 9-12 in 38 cases (39%), and 13-14 in 51 cases (52%).

Indeed, 8 patients who had lower GCS scores were operated on within 1
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day. Liang Gao showed GCS scores of 13-14 in 53 cases (42%), 9-12 in
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38 (30%) cases, and 3-8 in 36 (28%) TBC cases(7). We postulate that the
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difference is mainly due to rapid and timely transport, named trauma

green channel in the emergency department. The time from injury to

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admission was less than 2 hours. We believe that GCS scores combined
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with time of injury to admission is more appropriate for initial injury

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judgment.

Studies have indicated that the frontal pole, and medial and lateral frontal

lobe lesions correspond to a series of behavioral, will, and affective

syndromes, respectively, even pseudo-psychopathic syndromes(13).

Bifrontal contusions manifest common symptoms, such as coma in 9

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cases (9%), headache in 82 cases (84%), and vomiting in 36 cases (37%),

that are also found in other types of TBI; psychiatric symptoms, such as

irritability in 45 cases (46%), indifference in 11 cases (11%), and

hallucination and delusion in 23 cases (23%) in this group. These are all

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alleviated or disappear post operation.

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Wang et al. reported that the incidence of epilepsy in severe, moderate,

and mild brain injury was 19.9%, 10.3% and 6% (12), respectively(25).

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Seizures in 5 cases (5%) in this group, all occurred within 1 week after

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injury. This might be associated with low mechanism of injury and most
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are categorized as mild. TBI and prophylactic intravenous infusion of

sodium valproate are administered on admission.

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Two (2%) of our patients showed primary injuries of the oculomotor

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nerve, with ptosis and dilated pupils from traffic accidents, which were
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related to the fracture of the anterior skull base. This is similar to the

previously reported 1.2%. In our study, conservative treatment was

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implemented in these cases.

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TBCs occurred in up to 8.2% of all TBI. The occurrence of traumatic

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parenchymal mass lesions reached 13–35 % in TBI, representing as much

as 20% of all surgical intracranial lesions in published series(8). The first

CT scans on admission showed tiny and patchy injuries in 18 cases (18%),

hematoma volume of 15.1±5.2 ml in 73 cases (74%), and hematoma

volume of 30.2± 5.1 ml in 8 cases (8%). Dynamic CT scan showed that

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preoperative hematoma (80.2±20.5ml, P ＜ 0.05) was significantly

enlarged. Peterson et al found 8.5% (13/153) of TBCs with hematoma

volumes no less than 30ml, and 54% (7/13) underwent surgery(17). This

difference indicated we had taken a more active and practical approach to

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assessing the patient's condition, such as employing the operation-timing

score and its changing trends. (4).

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Timing of operation

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The main focus of TBCs is the development of trends and the treatment

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process. This evolution related to many factors, such as hemorrhagic
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expansion, increasing pericontusional edema, and/or the appearance of

delayed lesions. Twenty-five to forty-five percent of patients with

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cerebral contusion deteriorated in as few as 2 hours postinjury(22).

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Dynamic CT reflected dynamic changes and further deterioration after

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TBI. Newcombe et al pointed out that penumbra exists in TBC, which is

closely related to hematoma and edema expansion(14). Peterson also

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showed that 54% of patients with bifrontal contusion underwent surgical

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treatment because of the delayed worsening.

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The temporal pattern of TBI progression has been widely reported, which

relates to an early evolution phase, within 12–24 h from injury, mainly

due to hematoma expansion and to a late phase, lasting 5–10 days after

injury, due to increased pericontusional edema. Surgery timing has so far

been the most disturbing problem to resolve(1). Serial neurologic

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examinations are the first and most widely used indicators. However, they

are not reliable in deeply comatose and/or sedated patients. Emergency

operation (within24 h postinjury) mainly depended radiological results(11).

Timing of delayed surgery consisted of: 1) hematoma and/or edema size

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expanded; 2) clinical manifestation deteriorated; and/or 3) ICP increased

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significantly. Intracranial hypertension develops in up to 77% of cases,

and raised ICP is related to poorer outcome. The effectiveness of ICP

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monitoring in TBI has been questioned; however, no monitoring

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technique can improve outcomes unless it can drive an appropriate
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intervention. ICP monitoring carries a 0.5% risk of hemorrhage and a 2%

risk of infection(23). This has been our motivation to look for a simpler
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and more effective indicator. GCS scores of 9-13 made up 91% (89/98) of
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cases in this group. Meanwhile, physical examinations and CT

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examinations showed mild disturbances and awaken states. In spite of the

existence of psychiatric symptoms, routine sedative use is not

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recommended in our ICU. ICP monitoring also not routinely performed in

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these patients. The optimal timing of surgery because of the “talk and die”
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characteristic proved to be extremely important in this study.

In view of this, we created a simple and practical TBC score with the

following characteristics:

(1) The score is divided into 4 grades; all TBC patients admitted to ICU

were closely observed and recorded by neurosurgeons.

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(2) The changing curve was drawn as the main basis for judging the

patient’s condition.

(3) The score curve is divided into four categories; if it reaches the last

two, emergency BDC should be implemented without further waiting.

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The advantage of this approach is that it could not only timely and

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accurately monitor the patient's condition in order to select the optimal

timing of surgery, but could also help to avoid the influence of subjective

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factors. This is very helpful for treatment, especially in TBCs. Thus, we

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are also able to avoid premature surgery in a majority of cases. Some
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authors showed that early surgery (≤1 days) did not significantly improve

the prognosis in frontal injury(13). However, we think it is the most

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appropriate solution, especially for awake cases in the ICU. Among them,
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8 (8%) patients were operated on within 1 day, 20 patients (20%) within 2

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days, 31 patients (32%) within 3 days, 32 cases (33%) within 4 days, 6

cases (6%) within 7 days after admitting to ICU, and 1 case (1%) within
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10 days after admission. Studies showed the average hematoma

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development time for frontal lobe contusions (including unilateral and

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bilateral) to be approximately 5 days after admission. A previous study

showed that the timing of the operation in TBCs was 4.5 days after

injury(17). These are basically the same results found in our study. Our

results indicated that operations occurred 4.5±3.4 days postinjury. Based

on the concept of optimal operation timing, we were able to achieve more

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accurate results. This is also consistent with the view that time from

clinical deterioration to operation should be kept to a minimum, which

plays a vital role in improving the outcomes of patients with TBI.

Operating methods

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BDC is used primarily for the treatment of posttraumatic RBE. It was

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initially described by Miyazaki in 1966 and popularized by Kjellberg and

Prieto in 1971(10). It is also used in other diseases, such as aneurysms,

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tumors, and subdural empyema, which lead to intracranial pressure

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increased and swelling of the brain(15). DC has been recommended as a
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second-tier treatment for intracranial hypertension in severe traumatic

brain injury. Delayed DC is increasingly used as a salvage procedure for

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intractable intracranial hypertension in patients with diffuse bilateral

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swelling. Complications such as hematoma, subdural hygroma, and

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hydrocephalus occurred frequently after DC(2). The DC (DECRA)

trial—a randomized trial of early bifrontotemporoparietal DC for patients

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with severe traumatic brain injury with diffuse brain

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swelling—unexpectedly showed a significantly worse outcome at 6

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months in patients in the craniectomy group than in those in the

standard-care group (4). When and how to adopt DC remains a source of

controversy. In this group, all patients underwent a modified BDC: (1)

Shorter skin incision: full coronal skin incision runs from 1.5 to 2 cm

above bilateral zygomatic arch, 0.5 to 1.0 cm pretragal, walking along the
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hairline, for a total incision length of about 22.1 ± 3.1 cm. If there is no

hairline, the skin incision runs approximately 3 cm to the front of the

coronal suture; (2) Amended skin flap: skin was raised in one flap to the

forehead. The temporalis muscle was kept intact on both sides, with only

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the keyhole and temporal line exposed totally. Periosteotomy runs

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respectively apart from the midline 0.5 cm and along the skin edge to

each temporal line; (3) Smaller bone flap: The medial margin of bone flap

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was about 0.5 cm from midline, and the lower margin was about 1.0 cm

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from the superior orbital margin. The lateral margin is located in the
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temporal line, fully exposing the anterior skull base. The bilateral size is

about 4 cm × 6 cm, leaving a strip of midline bone called the bone bridge
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covering the superior sagittal sinus; (4) Dural cut and suture: dura mater
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is cut along the edge of the bone window toward the superior sagittal
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sinus. The periosteum was applicated to relaxation suture dura mater

posthematoma evacuation. Previous surgical experience stressed the

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knowledge that the incision should be large enough from the bilateral
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zygomatic arch extension to the coronal suture and the incision of

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temporal muscle. The bone flap should extend to the temporal region and

middle cranial fossa, forming an extensive resection of bilateral

frontotemporal skull, while at the same time ligation of the superior

sagittal sinus is ligated and the falx cerebri is cut. No patients experienced

complications, and 81% (79/98) recovered well. In this group of patients

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with bilateral frontal hematoma and edema, we found that improved

operation methods could not only effectively reduce intracranial pressure,

but also offers less complications, less risk of injury, and ease of

cranioplasticity.

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Outcome

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In our study, patients in this group were admitted to the ICU for 12.3±3.2

days. Further treatment was carried out in the general ward. The authors

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reported that 39 cases of bifrontal contusion stayed in the ICU for

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15.67±8.72 days. This difference might be associated with the different
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treatment methods in this group and other studies. This treatment method

required timely detection of patients requiring surgery and improved

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surgical methods.
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The good BDC outcomes BDC ranged from 7% to 70% in different

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reports. Elwatidy thought the variation could be due to many factors,

including the operation-timing and methods(5). Whitfield reported good

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outcomes in 69% of BDC cases, 8% with severe disabilities, and 23%

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mortality in a series of 26 patients with posttraumatic refractory

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intracranial hypertension. BDC significantly reduced intracranial

hypertension(26). Due to its limitations, the study could was unable to

reveal the relationship between the timing of surgery and the prognosis.

Polin showed 57% (12/35) favorable outcomes in patients with

posttraumatic intracranial hypertension who underwent BDC within the

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first 48 h of injury(18).

In our study, dynamic CT scans showed satisfactory removal of

hematoma in 98 patients. At 3 days after surgery, the GCS score was 13

in 92 cases (94%) (P < 0.05), 6 in 6 cases (6%), 14 in 93 cases (93%) (P <

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0.05), and 6 in 5 cases (5%) at 7 days post operation. Two patients with

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postoperative cerebrospinal fluid rhinorrhea underwent repairing surgery

1 month later. At the 3-month follow-up, the GOS score was 5 in 79 cases

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(81%) who recovered well, 4 in 14 cases (14%) with mild disability, 3 in

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2 cases (2%) with severe disability, and 2 in 1 case (1%) of vegetative
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survival. Two (2%) patients died.

Two (2%) patients died in our study. One patient suffered from renal
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insufficiency after operation and underwent hemofiltration after 7 days, 1

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case (76y) presented sudden respiratory failure and oxygen saturation

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decreased. After consultation with respiratory department, a diagnosis of

pulmonary embolism was reached. Although the patient received

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application of a respirator and thrombolytic therapy (Heparin), he died 5

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days post operation. This study showed that the multiparameter analysis
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of dynamic CT combined with GCS was the decisive factor for the

treatment and prognosis. The good results we have achieved are due to

using a comprehensive trend score, rather than a simple threshold

determining the optimal treatment. This experience is worthy of further

research and promotion.

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Funding: Henan University of Science and Technology provided

financial support in the form of high-level scientific research project

funding. The sponsor had no role in the design or conduct of this research

( Project number: 2015GJB021).

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Conflict of Interest:

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All authors certify that they have no

affiliations with or involvement in any organization or entity with any

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financial interest (such as honoraria, educational grants, participation in

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speakers' bureaus, membership, employment, consultancies, stock
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ownership, or other equity interest, and expert testimony or

patent-licensing arrangements), or non-financial interest (such as personal

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or professional relationships, affiliations, knowledge, or beliefs) in the

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subject matter or materials discussed in this manuscript.

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Ethical approval: All procedures performed in studies involving

human participants were in accordance with the ethical standards of the

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institutional and/or national research committee and with the 1964

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Helsinki Declaration and its later amendments or comparable ethical

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standards.

Informed consent: Informed consent was obtained from all

individual participants included in the study.

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injury and the frontal lobes: what can we gain with diffusion tensor imaging?

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Figure1：
：CT manifestations of bifrontal contusion

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A：Occipital fracture after countercoup injury; B：Fracture of anterior skull base caused by coup injury; C：The

frontal bone comminuted fracture caused by coup injury; D：Bifrontal contusion injury (before operation).

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Figure2: Surgical incision and image before and after operation
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A：Bifrontal contusion (8h postinjury); B：Bifrontal contusion (1d postinjury); C：Bifrontal contusion (2d post

injury);
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D：Skin incision (right view); E: Skin incision (anterior view); F: Skin incision (left view); G: Anterior view
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post operation.
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Figure3：
：Imaging findings of patients before and after surgery
A：X-ray showed frontal comminuted fracture；B：Forehead skull defect post operation；C：CT scan 3 days after
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injury；D：CT scan 4 days after injury；E：CT scan 8 hours after operation; F：CT scan 3 days after operation; G：
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CT scan 10 days after operation；H：CT bone-window post operation；I：cranioplasticity 3 months post operation.
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Figure4:The changing curve type of operation-timing score
A: Flat type curve, O+Co; B: Mountain type curve, O+Co; C: Hillside type curveⅠ, Ⅱ ,OP; D:
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Hillside type curveⅡ, OP.

O: observe; Co: conservative; OP: operation

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Table 1：
：General data：
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Male Cause Mechanism GCS H/E*（ml） Fracture SH Stay in ICU (d)

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M T 6-8 Tiny Occipital Occipital

62 (63%) 20 (20%) C 9 (9%) 18 (18) 70 (71%) 66 (67%)

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F FH 16 (16%) 9-12 15.1±5.2

36 (37%) 36 (36%) 38 (39%) 73 (74%) 12.3±3.2

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F CC 13-14 30.2±5.1 Frontal Frontal
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42 (42%) 82 (84%) 51 (52%) 8 (8%) 12 (12%) 11 (11%)

* The amount of hematoma edema refers to the first CT scan at admission.

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T: traffic accident; FH: falling from height; F: falling; C: coup injury; CC: contrecoup injury; H/E:

hematoma/edema volume; SH: subcutaneous hematoma.

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Table 2：
：Timing of operation：
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Case GCS IH/E* Timing (d) Timing Score

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8(8%) 6-8 2 ≤1 3

20((20%)) 9-10 2 2 3

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31(32%) 10-12 2 3 3

32(33%) 12-13 1 4 2

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6 (6%) 14 1 7 2
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1 (1%) 14 1 10 2
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*1：tiny and patchy；2：H/E 15.1±5.2ml；

；3：
：H/E 30.2±5.1 ml

IH/E: initial hematoma edema volume

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Abbreviation
TBI: Traumatic brain injury
TBC: Traumatic bifrontal contusions
BDC: bifrontal decompression craniotomy

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GCS: Glasgow coma score
GOS: Glasgow outcome score

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TBI: Traumatic brain injury

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ICU: intensive care unit

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DC: Decompressive craniectomy
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1. 98cases(98/510,19%) were treated with amended bifrontal

hematoma removal and decompression crinietomy. GCS
score at admission 6-8 in 9 cases (8%), 9-12 in 36 cases (31%)
and 13-14 in 52 cases (61%). The first CT scan after

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admission showed tiny and patchy injury in 18 cases (18%),

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hematoma volume 15.1±5.2 ml in 73 cases (74%) and

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hematoma volume 30.2±5.1 ml in 8 cases (8%). Dynamic CT
scan showed that preoperative hematoma( 80.2±20.5ml, P＜
0.05)significantly enlarged.
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2. All patients were performed the surgery-timing score and
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dynamic curve drawing. The fluctuation in the curve is the

best time for surgery. The average operation timing was
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4.5±3.4 days after admission.

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3. Follow-up GOS score 79 (81%) patients recovered well, 14

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(14%) with mild disability, 2 (2%) with severe disability, and

1 (1%) of the plant survival. 2 (2%) cases of death three
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months later. The change trend of operation-timing score is

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gold standard for surgery. Amended BDC can significantly

improve the prognosis of patients.