Reappraising the bifrontal decompressive craniectomy: A systematic literature review of indications, outcomes, and clinical applications

<jats:sec id="st1"> <jats:title>Background:</jats:title> <jats:p>Bifrontal decompressive craniectomy (BDC) is used to manage elevated intracranial pressure (ICP) from bilateral frontal swelling caused by severe traumatic brain injury (TBI), malignant cerebral edema, or other acute intracranial pathologies, but conflicting outcome data have been reported. This study aimed to evaluate the efficacy of BDC across various etiologies, identify gaps to guide research, and outline a framework for clinical decision-making.</jats:p> </jats:sec> <jats:sec id="st2"> <jats:title>Methods:</jats:title> <jats:p>A systematic search of MEDLINE, PubMed, Scopus, Embase, and Cochrane databases was conducted. In addition, 3 formalin-fixed, noninjected cadaveric head specimens were dissected to illustrate BDC and its anatomical correlates.</jats:p> </jats:sec> <jats:sec id="st3"> <jats:title>Results:</jats:title> <jats:p>Of 410 articles, 54 met inclusion criteria (742 patients). TBI was the leading etiology (656 of 742 patients; 88.4%), notably from motor vehicle collisions (58.4%) and falls (19.7%). On initial examination, 315 of 519 patients (60.7%) had a Glasgow Coma Scale score ≤8. Mean (standard deviation) time from injury to BDC was 2.5 (1.9) days, intensive care unit stay was 12.9 (5.0) days, hospital stay was 66.7 (38.9) days, and time to cranioplasty was 83.4 (40.7) days. Glasgow Outcome Scale values were reported for 494 patients: 205 patients, 5; 75 patients, 4; 71 patients, 3; 24 patients, 2; and 119 patients, 1.</jats:p> </jats:sec> <jats:sec id="st4"> <jats:title>Conclusion:</jats:title> <jats:p>BDC may offer a survival benefit in patients with otherwise-fatal elevations in ICP, but cases require more detailed tracking. Functional outcomes vary, and the risks of developing severe disability are substantial. Implementing BDC in acute neurocritical care requires ethically grounded patient selection and family counseling, incorporating prognosis, patient values, and shared decision-making.</jats:p> </jats:sec>