Time Is Brain! Analysis of 245 Cases with Decompressive Craniectomy due to Subarachnoid Hemorrhage

Decompressive craniectomy (DC) may become a life-saving measure for patients with subarachnoid hemorrhage (SAH). However, the benefit of early DC has not been shown yet. We aimed at identifying the clinical value of DC timing.

We retrospectively analyzed 245 patients with SAH who underwent DC between January 2003 and December 2015. The cohort was stratified into primary (at admission, n = 171) and secondary DC (n = 74). In addition, primary DC was subdivided into early (≤24 hours after ictus, n = 120) and delayed (n = 51).

There was no difference between primary and secondary DC (65.5% and 74.3%, P = 0.1828) with regard to unfavorable outcome at 6 months after SAH (defined as modified Rankin scale >3). However, individuals with early primary DC presented with significantly better functional outcome than the remaining cohort (P = 0.014, odds ratio [OR] = 2.02) and even compared with the subgroup with delayed primary DC (P = 0.023, OR = 2.42). Among individuals with World Federation of Neurosurgical Societies Grade <5 at admission, the benefits of early DC were more impressive: lower rates of unfavorable outcome (P = 0.003, OR = 0.28), in-hospital mortality (P = 0.031, OR = 0.37), and cerebral infarctions (P = 0.028, OR = 0.38) on the follow-up computed tomography scans.

Not the timing of DC indication (primary/secondary), but rather the actual time left between the ictus and DC is crucial for the functional improvement of patients with SAH requiring DC. Especially, individuals without the signs of severe early brain injury strongly benefit from early DC.