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

Hartmut Vatter,Tamara Kern,Simon Brandecker,Patrick Schuss,Erdem Güresir,Alexis Hadjiathanasiou

doi:10.1007/s10143-020-01383-3

Hartmut Vatter, Tamara Kern + Show 4 more

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https://doi.org/10.1007/s10143-020-01383-3

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Journal: Neurosurgical Review	Publication Date: Sep 12, 2020
Citations: 16	License type: open-access

Affiliation: University of Bonn

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.

Highlights

Patients who present with a poor-grade aneurysmal subarachnoid hemorrhage according to the World Federation of Neurosurgical Societies (WFNS grades IV and V) often have a poor prognosis with high case fatality and disability rates [4, 7, 23, 37]
In aneurysmal subarachnoid hemorrhage (aSAH) severely brain swelling can occur primarily due to initial tissue damage with or without additional intracerebral hemorrhage and secondarily due to vasospasm/infarction
We hypothesized that an early decompressive craniectomy may result in an improved neurological outcome in this severely ill subset of patients due to early control of elevated intracranial pressure (ICP), and we reported our experience with the effect of Primary decompressive craniectomy (PDC) on clinical outcome with long-term follow-up

Summary

Introduction

Patients who present with a poor-grade aneurysmal subarachnoid hemorrhage (aSAH) according to the World Federation of Neurosurgical Societies (WFNS grades IV and V) often have a poor prognosis with high case fatality and disability rates [4, 7, 23, 37]. Brain swelling and elevated intracranial pressure (ICP) are known to worsen outcome following. Significant predictors of unfavorable outcome in patients with poor-grade aSAH are patient age, WFNS grade V, signs of cerebral herniation, aneurysm size, and space-occupying hematoma [28]. Decompressive craniectomy (DC) after traumatic brain injury (TBI) and space occupying stroke has been shown to reduce elevated ICP and improves outcome after ischemic stroke [1, 11, 29, 35]. A systematic review and meta-analysis has shown that the effect of DC on functional outcome versus that of other interventions for refractory intracranial hypertension is still unknown [2]

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