gms | German Medical Science

Objective: Decompressive hemicraniectomy (DHC) has been shown to improve outcome in patients with malignant hemispheric stroke. Comparable results should be expected in patients with subarachnoid hemorrhage (SAH) and intracranial hypertension due to ischemia or brain swelling. However conclusive data on DHC in SAH are still missing. In a first approach, we therefore descriptively evaluated outcome in this subgroup, in regard to patient and SAH characteristics, time point of DHC and its indication.

Methods: In a retrospective single centre analysis, all patients with aneurysmal subarachnoid hemorrhage receiving DHC, treated between January 2006 and December 2014, were identified. Timepoint and indication for DHC, age, initial clinical status, aneurysm localization and treatment, secondary hydrocephalus as well as neurological outcome (modified Rankin scale) were analysed. A mRS of <= 3 at last FU was defined as favourable outcome. For statistical analysis, Mann- Whitney- U- Test was applied.

Results: Fifty patients were evaluated (median age 49.5 (range, 26- 76) years). Initial WFNS grade was I in 11 patients (22%), II in 5 patients (10%), III in 6 patients (12%), IV in 7 patients (14%) and V in 21 patients (42%). 23 Aneurysms were localized at the middle cerebral artery (46%), 9 at the internal cerebral artery (18%), 12 at the anterior communicating artery (24%), 5 at the posterior communicating artery (10%) and one at the posterior cerebral artery (2%). Aneurysm treatment consisted of surgical clipping in 32 patients (64%), endovascular treatment in 17 patients (34%) and no treatment in one patient (2%). The indication for DHC was intracerebral hemorrhage in 9 patients (18%), secondary brain swelling in 22 Patients (44%) or infarction in 19 patients (38%). Craniectomy was rarely performed primarely on the day of bleeding (16%, n=8), but mostly secondarily (84%, n=24). At a median follow up of 19,5 weeks (range 0.3- 402.4), favourable outcome was noticed in 9 Patients (18%). The mortality rate was 24% (n=12). Functional outcome was not associated with timepoint or indication for DHC, age, initial clinical status, aneurysm localisation and treatment or secondary hydrocephalus.

Conclusion: We found no prognostic factor for functional outcome after DHC, but favourable outcome was achieved in almost one- fifth of these vitally endangered patients. Therefore, DHC should be considered as a treatment option in intracranial hypertension after SAH.