Bilateral Decompressive Hemicraniectomy for Diffuse Cerebral Edema and Medically Refractory Elevated Intracranial Pressure in Aneurysmal Subarachnoid Hemorrhage: A Case Series

Abstract

Decompressive hemicraniectomy (DCHC) may be indicated in the setting of subarachnoid hemorrhage (SAH) complicated by persistent elevated intracranial pressure (ICP) that is refractory to medical interventions. Outcomes can be variable as indications for surgery can include focal hematomas, infarctions, and regional or diffuse edema. Bilateral DCHC for medically refractory elevated ICP in the setting of SAH is not well described in the literature, and the viability of this option in terms of patient outcomes is unclear. We describe the cases of four patients with medically refractory ICP secondary to diffuse cerebral edema who underwent bilateral DCHC in the setting of SAH. This is a retrospective case review of four patients with aneurysmal SAH who underwent bilateral DCHC for management of diffuse global edema resulting in medically refractory ICP. We describe two patients who made impressive recoveries after bilateral DCHC and two patients who required significant continued care needs despite ICP control in all patients. Bilateral DCHC is a viable option for control of refractory elevated ICP in SAH patients who develop diffuse cerebral edema. Bilateral DCHC in this setting can be considered after exhaustion of other therapeutic options.

Case report: Invasive neuromonitoring in status epilepticus induced hypoxic ischemic brain injury

“…Although literature explores the use of BDC in TBI ( 25 ), SAH ( 26 ) and cerebral venous sinus thrombosis ( 27 ), we found no literature on BDC for DCE and medically refractory intracranial hypertension in HIBI, and particularly SE-induced HIBI. In this report, we describe the first case report of a patient where BDC was utilized as a means of controlling refractory elevated ICP in the setting of DCE following SE-induced HIBI.…”

Intracranial Pressure Monitoring and Management in Aneurysmal Subarachnoid Hemorrhage

“…Nevertheless, bilateral decompression remains a viable option as a rescue therapy when maximal medical management has been exhausted. It represents the most promising intervention in situations where clinicians have explored all other available alternatives and there is a diffuse cerebral pathology [ 74 ].…”

Size of Craniectomy Predicts Approach-Related Shear Bleeding in Poor-Grade Subarachnoid Hemorrhage

“…In case of secondary bone flap ommitance, the initial craniotomy may not be large enough to provide sufficient ICP control and secondary enlargement of initially to small craniotomy might be necessary [ 12 ]. In case of persistent intracranial hypertension after the initial DC, even a bilateral decompression was suggested to improve the outcome in selected patients [ 13 ]. The aim of this study is to analyze the size of the DC and its effect on approach-related complications in patients undergoing emergent clipping and decompressive craniectomy due to aneurysm-related SAH.…”