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. 2024 Aug 10;166(1):332.
doi: 10.1007/s00701-024-06221-9.

Primary decompressive craniectomy in patients with large intracerebral hematomas due to aneurysmal subarachnoid hemorrhage

Fabian Wenz  1 , Andreas Ziebart  2 , Katharina A M Hackenberg  2 , Gabriel J E Rinkel  2 , Nima Etminan  2 , Amr Abdulazim  2
Affiliations

Primary decompressive craniectomy in patients with large intracerebral hematomas due to aneurysmal subarachnoid hemorrhage

Fabian Wenz et al. Acta Neurochir (Wien). .

Abstract

Background: Decompressive craniectomy (DC) can alleviate increased intracranial pressure in aneurysmal subarachnoid hemorrhage patients with concomitant space-occupying intracerebral hemorrhage, but also carries a high risk for complications. We studied outcomes and complications of DC at time of ruptured aneurysm repair.

Methods: Of 47 patients treated between 2010 and 2020, 30 underwent DC during aneurysm repair and hematoma evacuation and 17 did not. We calculated odds ratios (OR) for delayed cerebral ischemia (DCI), angiographic vasospasm, DCI-related infarction, and unfavorable functional outcome (extended Glasgow Outcome Scale 1-5) at three months. Complication rates after DC and cranioplasty in the aneurysmal subarachnoid hemorrhage patients were compared to those of all 107 patients undergoing DC for malignant cerebral infarction during the same period.

Results: In DC versus no DC patients, proportions were for clinical DCI 37% versus 53% (OR = 0.5;95%CI:0.2-1.8), angiographic vasospasm 37% versus 47% (OR = 0.7;95%CI:0.2-2.2), DCI-related infarctions 17% versus 47% (OR = 0.2;95%CI:0.1-0.7) and unfavorable outcome 80% versus 88% (OR = 0.5;95%CI:0.1-3.0). ORs were similar after adjustment for baseline predictors for outcome. Complications related to DC and cranioplasty occurred in 18 (51%) of subarachnoid hemorrhage patients and 41 (38%) of cerebral infarction patients (OR = 1.7;95%CI:0.8-3.7).

Conclusions: In patients with aneurysmal subarachnoid hemorrhage and concomitant space-occupying intracerebral hemorrhage, early DC was not associated with improved functional outcomes, but with a reduced rate of DCI-related infarctions. This potential benefit has to be weighed against high complication rates of DC in subarachnoid hemorrhage patients.

Keywords: Complications; Decompressive craniectomy; Delayed cerebral ischemia; Intracerebral hemorrhage; Subarachnoid hemorrhage.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Fig. 1
Fig. 1
Effect of decompressive craniectomy on radiological and functional outcome. Radiological and functional outcome of patients treated with (DC +) and without (DC-) decompressive craniectomy; Unfavorable outcome is extended Glasgow outcome scale of 1 – 5 3 months after discharge; Multivariate analysis was adjusted for age, WFNS grade, midline-shift, clot volume and EVD placement; OR = odds ratio; CI = confidence interval; DCI = delayed cerebral ischemia
Fig. 2
Fig. 2
Stacked histograms of functional outcome. Functional outcome (extended Glasgow Outcome Scale) after 3 months of patients treated with (DC +) and without (DC-) decompressive craniectomy
See this image and copyright information in PMC

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