Outcome of Patients Treated with a Decompressive Craniectomy (DC) after Aneurysmal Subarachnoid Hemorrhage (aSAH)

Introduction: The aim of this work is to report the outcome of patients presenting with aneurysmal subarachnoid hemorrhage (aSAH) who underwent a decompressive craniectomy (DC) in Geneva. Methods: We performed a prospective study, collecting data between 2007 and 2012 in Geneva University Hospital. A total of 284 patients were diagnosed with aSAH and 36 were subjected to a DC during the period. Factors such as age, gender, timing of the craniectomy, side, WFNS score, Fisher grading, vasospasm, follow-up time, number of aneurysms, type of aneurysm, treatment underwent, and complications were documented. The outcome was assessed using the modified Rankin scale. Multiple factor analysis was performed to identify predictive factors for DC and outcome. Differences between groups were assessed using Fisher exact test and a significant level of 0.05. Results: Patients who underwent DC were admitted with significantly more severe WFNS scores than the overall population of aSAH patients (median; [Q1–Q3]: 5; [4–5] vs. 2; [1–4], respectively; p < 0.0001). Fisher grade, age, and type of intervention performed to secure the aneurysm were similar between the DC cohort and overall aSAH cohort. Aneurysm localizations had a different distribution with a predominance of MCA aneurysms in the DC cohort (41.6%) The distribution by mRS for DC patients was significantly shifted to poor prognosis (median; [Q1-Q3]: 6; [4–6] vs. 2; [1–4]; p < 0.0001). Sixty percent of patients died (N = 21) as compared with 17% in the Swiss SOS overall cohort. Only five patients (14%) recovered to an independent life as compared with 54% in the Swiss SOS cohort. Patients over 45 years and with a WFNS score of V have a mortality of 88% and a poor prognosis when they survive (two survivors: mRS 4 and 5). Five patients older than 65 years all died (100% mortality). None of the cases admitted in WFNS V recovered to an mRS <4. Ninety percent of the patients that died (N = 19) were initially WFNS IV or V. All patients that recovered to an independent life were craniectomized on the right side (one bifrontal) and were admitted with a WFNS < 5. Conclusion: The benefits of DC are still controversial. In this study, 60% of patients died; 25.7% were moderately to severely disable but 14.2% could actually resume normal daily activities which would most probably not have been the case without DC. It seems that DC is futile in patients over 45 years and with a WFNS score of V and in patients older than 65 years.

Fig. 1 Outcome of patients with subarachnoid hemorrhage and decompressive craniectomy based on the WFNS at admission showing an mRS shifted to poor prognosis. Patients were admitted with more severe WFNS score than the overall population (p = 0.015).

Fig. 3 Outcome of patients treated with a decompressive craniectomy (DC) after aneurysmal subarachnoid hemorrhage (aSAH) in red. In blue, patients with a ruptured aneurysm but without decompressive craniectomy. Patients over 45 years in the DC cohort had a poor prognosis and patients over 65 were all dead (p < 0.002).