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Abstract and Introduction
Abstract
Object. The aim of this study was to analyze decompressive craniectomy (DC) in the setting of subarachnoid hemorrhage (SAH) with bleeding, infarction, or brain swelling as the underlying pathology in a large cohort of consecutive patients.
Methods. Decompressive craniectomy was performed in 79 of 939 patients with SAH. Patients were stratified according to the indication for DC: 1) primary brain swelling without or 2) with additional intracerebral hematoma, 3) secondary brain swelling without rebleeding or infarcts, and 4) secondary brain swelling with infarcts or 5) with rebleeding. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months (mRS Score 0–3 favorable vs 4–6 unfavorable).
Results. Overall, 61 (77.2%) of 79 patients who did and 292 (34%) of the 860 patients who did not undergo DC had a poor clinical grade on admission (World Federation of Neurosurgical Societies Grade IV–V, p < 0.0001). A favorable outcome was attained in 21 (26.6%) of 79 patients who had undergone DC. In a comparison of favorable outcomes in patients with primary (28.0%) or secondary DC (25.5%), no difference could be found (p = 0.8). Subgroup analysis with respect to the underlying indication for DC (brain swelling vs bleeding vs infarction) revealed no difference in the rate of favorable outcomes. On multivariate analysis, acute hydrocephalus (p = 0.009) and clinical signs of herniation (p = 0.02) were significantly associated with an unfavorable outcome.
Conclusions. Based on the data in this study the authors concluded that primary as well as secondary craniectomy might be warranted, regardless of the underlying etiology (hemorrhage, infarction, or brain swelling) and admission clinical grade of the patient. The time from the onset of intractable intracranial pressure to DC seems to be crucial for a favorable outcome, even when a DC is performed late in the disease course after SAH.
Introduction
DECOMPRESSIVE craniectomy lowers elevated ICP in patients with an intractable increase in pressure following brain trauma or cerebral infarction and improves outcome in patients with large territorial infarctions of the MCA.
In patients with aneurysmal SAH, brain swelling can occur very early after the ictus ("primary") and later in the course of the disease as the result of complications associated with SAH ("secondary"; for example, cerebral infarction or bleeding). Regardless of its origin, brain swelling is known to worsen outcomes following SAH. Its medical treatment is highly significant and often effective, although it can also be associated with severe side effects. Because of the unknown functional recovery, especially in poor-clinical-grade patients with SAH and associated elevated ICP, the indication for aggressive surgical treatment options such as DC is controversial. Recent literature dealing with DC has included patients with ICH and SAH only or had excluded patients treated with endovascular coiling. There are sparse data concerning the etiology of the mass effect that leads to DC—such as a space-occupying infarct, an ICH, or brain swelling without bleeding or infarction—which might per se significantly affect outcome.
The purpose of the present analysis was to update another recent study in providing comprehensive clinical material and to analyze outcomes in a larger cohort of consecutive patients with primary and secondary DC, stratified according to the different underlying pathologies—that is, bleeding, infarction, or brain swelling—to find predictors that may guide treatment.
Parts of the clinical material have been published in a predecessor study.
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