Primary decompressive craniectomy in poor-grade aneurysmal subarachnoid hemorrhage: long-term outcome in a single-center study and systematic review of literature

Abstract

Primary decompressive craniectomy (PDC) in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) in order to decrease elevated intracranial pressure (ICP) is controversially discussed. The aim of this study was to analyze the effect of PDC on long-term clinical outcome in these patients in a single-center cohort and to perform a systematic review of literature. Eighty-seven consecutive poor-grade SAH patients (World Federation of Neurosurgical Societies (WFNS) grades IV and V) were analyzed between October 2012 and August 2017 at the author’s institution. PDC was performed due to clinical signs of herniation or brain swelling according to the treating surgeon. Outcome was analyzed according to the modified Rankin Scale (mRS). Literature was systematically reviewed up to August 2019, and data of poor-grade aSAH patients who underwent PDC was extracted for statistical analyses. Of 87 patients with poor-grade aSAH in the single-center cohort, 38 underwent PDC and 49 did not. Favorable outcome at 2 years post-hemorrhage did not differ significantly between the two groups (26% versus 20%). Systematic literature review revealed 9 studies: Overall, a favorable outcome could be achieved in nearly half of the patients (49%), with an overall mortality of 24% (median follow-up 11 months). Despite a worse clinical status at presentation (significantly higher rate of mydriasis and additional ICH), poor-grade aSAH patients with PDC achieve favorable outcome in a significant number of patients. Therefore, treatment and PDC should not be omitted in this severely ill patient collective. Prospective controlled studies are warranted.

Comparative study of surgical outcomes between early decompressive craniectomy with clipping and coil embolization followed by decompressive craniectomy

“…Therefore, most relevant studies have been retrospective after performance of DC in poor-grade patients. Although the group with DC had lower mortality and morbidity compared to the group without DC, the group with DC showed higher mortality and morbidity compared to the "good" grade group [5,17]. Previous studies have shown that DC can reduce mortality without sig- grade patients, but the results were inconsistent [3,9,19].…”

“…There was no difference in mRS at the time of admission between the 2 groups, but the functional outcomes (mRS) at discharge were better in the group in which clipping was performed. While mortality was not significantly different between clipping and coiling groups, the clipping group showed a nificantly improving functional outcomes [1,4,5,6,17]. Attempting to clip a cerebral aneurysm in a patient with severe brain swelling can cause additional damage to the brain tissue surrounding the cerebral aneurysm.…”

“…Surgical treatment includes external ventricular drain (EVD), hematoma evacuation during clipping, and craniectomy. Although the utilization of decompressive craniectomy (DC) in aSAH patients is controversial, some highly regarded specialized institutions have demonstrated that DC decreases mortality and morbidity [5][6][7][8][9][10][11][12][13][14].…”

Decompressive hemicraniectomy after aneurysmal subarachnoid hemorrhage—justifiable in light of long-term outcome?

“…Most published series of DHC after SAH report a lower rate of unfavorable outcome after early DHC [ 2 , 12 ]. Early identification of patients with high risk of ICP decompensation is therefore mandatory.…”

PrImary decompressive Craniectomy in AneurySmal Subarachnoid hemOrrhage (PICASSO) trial: study protocol for a randomized controlled trial

“…The sample size/power calculation is based on a retrospective single-center study and literature review [ 14 ].…”