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Multicenter Study
. 2025 Mar 11;167(1):68.
doi: 10.1007/s00701-025-06485-9.

Decompressive craniectomy in aneurysmal subarachnoid hemorrhage: can favorable outcome be achieved?

Teodor Svedung Wettervik  1 , Alba Corell  2   3 , Merete Sunila  2 , Per Enblad  4 , Fartein Velle  4 , Peter Lindvall  5 , Lars Kihlström Burenstam Linder  6   7 , Bjartur Sæmundsson  6   7 , Alexander Fletcher-Sandersjöö  6   7 , Klas Holmgren  5
Affiliations
Multicenter Study

Decompressive craniectomy in aneurysmal subarachnoid hemorrhage: can favorable outcome be achieved?

Teodor Svedung Wettervik et al. Acta Neurochir (Wien). .

Abstract

Background: Decompressive craniectomy (DC) is a last-tier treatment for managing refractory intracranial hypertension in patients with aneurysmal subarachnoid hemorrhage (aSAH), though concerns persist about whether it primarily prolongs survival in a state of severe disability. This study investigated patient characteristics, surgical indications, complications, and outcomes following DC in aSAH.

Methods: In this Swedish, retrospective multi-center study, 123 aSAH patients treated with DC between 2008-2022 were included. Data collection included demographic details, aSAH characteristics, injury severity, DC indication, complications, and outcome at roughly six months post-DC (modified Rankin scale [mRS]) dichotomized as survival vs. mortality (0-5 vs. 6) and favorable vs. unfavorable (0-3 vs. 4-6).

Results: The median age was 53 years and 66% were females. Two thirds presented with a WFNS grade 4-5 and 83% with a Fisher grade 4 hemorrhage. Most aneurysms were located at the middle cerebral artery (65%) and treated with clip ligation (59%). DC significantly reduced midline shift from 9 to 2 mm and obliteration rates of basal cisterns from 95 to 22% (p < 0.05). Reoperation for hematomas or extension of the DC were rare (< 5%). At follow-up, 20% were deceased, while 33% had recovered favorably. In univariate logistic regressions, younger age was associated with favorable outcome and reduced mortality. Other patient demographics, injury severity, and factors related to the DC surgery lacked association with outcome.

Conclusions: aSAH patients treated with DC presented with severe primary brain injuries and signs of intracranial hypertension. DC resulted in radiological improvements regarding mass effect and a low rate of postoperative complications. Although the results were based on a selected population of aSAH patients, an encouraging rate of favorable outcome was found, particularly among younger patients. However, the absence of additional outcome predictors underscores the ongoing challenges in improving patient selection for DC in aSAH.

Keywords: Aneurysmal subarachnoid hemorrhage; Decompressive craniectomy; Intracranial pressure; Outcome; Thiopental.

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Conflict of interest statement

Declarations. Human ethics and consent to participate: The study was approved by the Swedish Ethical Review Authority (Dnr: 2023-02347-01, decision date: 2023-05-17). Informed consent was waived for this retrospective study. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Six-months functional outcome after DC in aSAH. Illustrating the percentage of patients within each mRS category in the aSAH patients treated with DC. Ten patients had no available outcome data and they were excluded from this figure. aSAH = Aneurysmal subarachnoid hemorrhage. DC = Decompressive craniectomy. mRS = Modified Rankin Scale
Fig. 2
Fig. 2
Mortality- and favorable outcome rates for different age categories. Depicting the percentage of patients who were deceased or had reached favorable outcome at follow-up six months after DC with age stratified into decades. Young adolescents and patients in early to middle adulthood (up to 60 years) demonstrated relatively low mortality and high rates of favorable outcomes, whereas individuals above 60 years of age exhibited less favorable recovery. DC = Decompressive craniectomy
See this image and copyright information in PMC

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