Primary decompressive craniectomy in patients with aneurysmatic subarachnoid hemorrhage. Results of a pilot study in 11 cases

Introduction. Despite the scientific and technical advances of recent years, aneurysmal subarachnoid hemorrhage (aSAH) continues to present a high morbidity and mortality. This fact, together with the impressive results of the primary decompressive craniotomy (PDC) in the malignant infarction of the middle cerebral artery suggests a possible beneficial effect of decompressive technique in aSAH. We present our experience of a pilot study that PDC was used in patients with poor-grade aSAH with associated intracerebral hematoma. Patients and methods. Between March 1(st), 2002 and 31(st) April, 2008, 342 patients with aneurysmatic subarachnoid hemorrhage (aSAH) were treated at our hospital. Of these, 64 had a poor neurological grade (scores of 4 or 5 of the World Federation of Neurosurgical Societies) at the time of admission. The present study examines 11 of those patients who underwent PDC, which is performed in the same clipping and / or evacuation of an associated hematoma. Results. In three patients PDC was performed after endovascular aneurysm treatment because of the need to evacuate an associated hematoma. In the eight remaining patients, PDC was performed in the same clipping and evacuation of the associated hematoma. Outcome evaluation of these eleven patients was conducted 1 year after the operation assessed by the Glasgow Outcome Scale. Six patients survived, and four of them with good results. The PDC was effective in controlling intracranial pressure in all six surviving patients. However, two of these six patients had unfavorable outcomes. Of the five who didn't survive, one patient died from a delayed epidural-subgaleal hematoma as a complication of the decompressive technique, and the other four patients died because of refractory intracranial hypertension. Conclusions. Primary DC may be beneficial in selected subgroups of patients with poor-grade aSAH. However, there is a lack of definitive evidence to support a clear recommendation for its use.