Article
Decompressive craniectomy in patients with aneurysmal subarachnoid hemorrhage – a single-center matched pair analysis
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Authors
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Yoichi Uozumi
- Neurochirurgische Klinik und Poliklinik, Universitätsklinikum Heidelberg, Germany; Department of Neurosurgery, National Defense Medical College, Tokorozawa, Japan
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Oliver W. Sakowitz
- Neurochirurgische Klinik und Poliklinik, Universitätsklinikum Heidelberg, Germany
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Berk Orakcioglu
- Neurochirurgische Klinik und Poliklinik, Universitätsklinikum Heidelberg, Germany
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Daniel Haux
- Neurochirurgische Klinik und Poliklinik, Universitätsklinikum Heidelberg, Germany
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Edgar Santos
- Neurochirurgische Klinik und Poliklinik, Universitätsklinikum Heidelberg, Germany
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M. Modar Kentar
- Neurochirurgische Klinik und Poliklinik, Universitätsklinikum Heidelberg, Germany
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Andreas Unterberg
- Neurochirurgische Klinik und Poliklinik, Universitätsklinikum Heidelberg, Germany
| Published: | September 16, 2010 |
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Outline
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Objective: Decompressive craniectomy (DC) has been shown to improve outcome in patients with massive ischemic infarction and severe head injury. However, the role of DC in aneurysmal subarachnoid hemorrhage (aSAH) patients is still controversial. In this study we analyzed the outcome of aSAH patients who were treated with DC. A matched-pair analysis was performed to compare outcomes of patients with DC to a second cohort of aSAH patients who were treated without DC. We compared the 1-month and 1-year outcomes in these two groups prospectively.
Methods: From January 2004 to July 2009, 295 aSAH patients were treated with clipping or coiling at a single university hospital. Among them, 54 required DC as judged by the treating neurosurgeon. Of the remaining group, 54 matched controls were found. The match was conducted on the basis of epidemiological and potential prognostic factors, such as age, gender, WFNS grade, Fisher group and occurrence of vasospasm. Outcome was assessed by the extended Glasgow outcome scale.
Results: A total of 108 aSAH patients (52.1 ± 9.2 years, range 27-77, median WFNS: 5) were enrolled. Control patients were matched successfully. However, there were more patients in the DC group who also underwent aneurysm obliteration by clipping, especially when located on segments of the middle cerebral artery. Fifty-two of 54 (96.3%) patients treated with DC were dependent or dead (GOSe 1-4) at 1 month, compared with 48 of 54 (88.9%) treated without DC. There was no significant difference between the groups (p=0.27). One-year outcomes were available for 103 patients (95.4%). Thirty-seven of 52 (71.2%) patients treated with DC were dependent or dead at 1 year, compared with 27 of 51 (52.9%) patients in the control group. There was no significant difference between the groups (p=0.07). This result was unaffected by age, sex and WFNS grade. Subgroup analyses whether DC was performed primarily or delayed, and whether DC was performed due to spasm, hematoma, or vessel occlusion failed to detect any significant difference in 1 month and 1 year outcomes.
Conclusions: In this study, DC did not seem to improve the outcome in poor-grade aSAH patients. However, despite the severity of aSAH, the necessity to perform DC and poor short-term results, almost 30% recovered to a good long-term outcome similar to matched controls. Based on this, DC treatment should not be withheld if deemed necessary by the treating neurosurgeon.
