gms | German Medical Science

Objective: The role of decompressive craniectomy (DC) has been well established in malignant middle cerebral artery infarction. However, scarce data exists on secondary DC in aneurysmal subarachnoid hemorrhage. To date, only few case series report on this procedure, with low patient numbers. We present our single-center experience with secondary DC in aSAH.

Methods: We conducted a retrospective study of patients admitted to our department with aSAH between 2006-2016 who underwent secondary DC, defined as DC performed after aneurysmal treatment. Demographic and clinical data were recorded, and statistical analysis was performed using IBM® SPSS® v. 21.

Results: A total of 431 patients with aSAH were screened. Of these, 39 underwent secondary DC. Mean age was 49 years, while the majority (n=25) were females. Most patients (n=24) presented with high-grade (Hunt&Hess) aSAH, with n=31 exhibiting Fisher 4, and n=23 intraparenchymal hematoma at presentation. Indication for DC was therapy-refractory intracranial hypertension (n=28); in n=25 this was due to vasospasm-associated infarctions. Postoperative hematoma was an indication for DC in n=3, and anisocoria with an increase in midline shift in n=8 patients. Outcome was poor in the entire patient cohort: n=14 had modified Rankin scale (mRS) 6, n=20 mRS 5, n=2 mRS 4, and n=3 mRS 3.

Conclusion: Our series is the third largest reporting on secondary DC in aSAH to date. It reflects how secondary DC constitutes a last resort in aSAH patients with poor prognosis and extremely high mortality. This poses the question as to whether or not DC is being performed too late, when severe and irreversible brain damage has occurred. In view of the latter, reliable predictors are needed to identify which patients would benefit from an earlier DC in the setting of aSAH.