A Narrative Review of the Bifrontal Decompressive Craniotomy in Clinical Practice

The bifrontal approach, pioneered by Kjellberg in 1971, remains one of the few anterior approaches to the skull, yet no unified review of its historical and modern use currently exists. A literature search was conducted using PubMed, focusing on adult studies involving bifrontal decompressive craniotomy (DC). Bifrontal DC is indicated for severe traumatic brain injury with frontal lesions, elevated intracranial pressure refractory to medical management, and certain cases of cerebrovascular accidents. Randomized trials, including DECRA and RESCUEicp, have demonstrated the procedure’s efficacy in reducing mortality and intracranial pressure, though long-term neurological outcomes remain mixed. Military neurosurgeons have reported success with early bifrontal craniectomy in combat trauma, and civilian studies highlight its utility in managing traumatic bifrontal contusions. Surgeon preference and individual skill were frequently cited as deciding factors in the approach selected. Despite its versatility, poor rates of upper recovery have been reported, along with high rates of cerebrospinal fluid (CSF) leaks and wound complications. Despite its drawbacks, the bifrontal approach remains a viable option in the neurosurgeon’s toolbox, allowing wide exposure and straightforward surgical planning, thus minimizing retraction injury. Future research and clarification could be directed towards the management of the superior sagittal sinus laceration and optimized placement of the posterior burr holes.