Brain lobectomy for severe head injuries is not a hopeless procedure

INTRODUCTION: Posttraumatic transtentorial herniation or intractable intracranial hypertension are ominous signs, and are associated with very poor outcomes. Aggressive procedures, such as brain lobectomies, may benefit some of these patients. The published experience with brain lobectomies is very limited. PATIENTS: Retrospective study of head injury patients with focal brain lesions and intractable intracranial hypertension or herniation who underwent partial or anatomic brain lobectomies. The following parameters were included in the analysis: age, gender, mechanism of injury, hypotension at admission, initial Glasgow Coma Scale (GCS) score, Abbreviated Injury Scale for head, chest, and abdomen, Injury Severity Score, time from admission to operation, type of brain lobectomy, intensive care unit and hospital stays, survival, and Glasgow Outcome Score. Stepwise logistic regression analysis was used to identify independent risk factors for mortality and functional outcomes. RESULTS: During the 13-year study period, there were 183 patients who underwent brain lobectomy for traumatic injuries. Eighty-eight patients (48.1%) underwent frontal lobectomy, 67 (36.6%) temporal lobectomy, and the remaining 28 (15.3%) other or combination lobectomies. The mean follow-up was 22 days. There were 50 deaths (mortality 27.3%). Excluding patients with major extracranial injuries, there were 47 deaths (26.9%). Patients with blunt trauma had a significantly higher mortality than those with penetrating trauma had (33.1% vs. 12.0%, p = 0.005). Among the risk factors studied, blunt injury mechanism was identified as the only risk factor for mortality. Overall, 48% of the 133 survivors had good functional outcomes, and 51.9% had poor functional outcomes (including 15.0% with persistent vegetative state). Multiple-response logistic regression identified blunt trauma, low initial GCS score, and frontal lobectomy as independent risk factors for poor outcomes. CONCLUSION: Selected severe head injury patients with focal brain lesions and intractable intracranial hypertension or herniation may benefit from brain lobectomies. The survival and functional outcomes after this procedure are acceptable. Blunt trauma, low initial GCS score, and frontal lobectomies are significant risk factors for poor outcomes.