Decompressive hemicraniectomy after aneurysmal subarachnoid hemorrhage

The aim of this study was to document the effects of decompressive hemicraniectomy (DHC) on neurologic outcome in patients treated for aneurysmal subarachnoid hemorrhage (SAH) and developing otherwise uncontrollable intracranial hypertension.

Sixty-six of the 964 patients (6.8%) treated for aneurysmal SAH underwent DHC and were stratified as follows: Group 1, patients undergoing aneurysm clipping and DHC in one surgical sitting (i.e., primary DHC). Group 2, patients receiving aneurysm embolization and thereafter undergoing DHC. Group 3, patients undergoing standard aneurysm surgery and requiring DHC later in the post-SAH period. Group 4, patients with insufficient primary DHC and later requiring surgical enlargement of the craniectomy.

Outcome was not influenced by the timing of DHC, but depended on the pathology underlying intracranial hypertension (i.e., whether lesions were primary hemorrhagic or secondary ischemic in origin). Patients with large hematomas, undergoing primary, secondary, or repeat DHC (46/66) had significantly better outcomes than the 20 patients treated for edema and delayed ischemic infarctions. There were 16 (34.8%) of the 46 patients in the hematoma group, but only 2 (10.0%) of the 20 patients in the ischemia group had favorable neurologic outcomes, defined as modified Rankin Scale scores 0-3 (P value = 0.038).

In the largest series of SAH patients to date who received both microsurgical and endovascular treatment of ruptured aneurysms, and who underwent DHC for otherwise uncontrollable intracranial hypertension. Neurologic outcome was significantly correlated with the pathology underlying intracranial hypertension. DHC beneficially affected neurologic outcomes in patients with space-occupying hematomas, whereas patients suffering delayed ischemic strokes did not benefit to the same extent.