Intracranial hypertension in subarachnoid hamorrhage: outcome after decompressive craniectomy.

Intracranial hypertension can occur following aneurysmal subarachnoid haemorrhage (SAH). It can be treated with decompressive craniectomy (DC) with the aim of reducing intracranial pressure, increasing cerebral perfusion and reducing further morbidity and mortality. We studied the outcome of patients undergoing DC following SAH at our institution, to ascertain whether the use of this treatment can be rationalized.

Outcome in patients presenting with an aneurysm related intracerebral haemorrhage in the post-ISAT era.

BACKGROUND: The outcome in patients who present with an aneurysm related intracerebral haemorrhage (ICH) is poor. There are many treatment strategies now available to treat this group of patients. The management approach is dominated by a direct surgical approach for both aneurysm treatment and clot evacuation. It remains unclear, however, whether overall outcomes justify an aggressive treatment approach in this group of patients. We report our results of a pragmatic strategy based on availability of expertise and patient condition in patients presenting with an aneurysm related intracerebral haemorrhage. METHODS: We retrospectively identified and analysed prospectively collected data of SAH patients with concurrent ICH. The grade at presentation, treatment decision, complications, length of hospital stay, discharge destination, and 6 month outcome (Glasgow Outcome Score (GOS) at 6 months) were recorded. FINDINGS: Between August 2008 and January 2010, 40 patients (9.2%) with ICH were identified from the 433 patients with SAH. Twenty five patients (63%) were transferred across to the neurosurgical centre for further investigations and management. Most patients presented with poor WFNS grade (61%) and had right sided middle cerebral artery aneurysms (58%) with frontotemporal (42%) or temporoparietal (42%) haematomas. Management included craniotomy/craniectomy and clipping of the aneurysm in 18 patients (72%), coiling followed by surgical clot evacuation in five (20%), and craniectomy and coiling (4%) or coiling alone (4%). The outcome in treated patients was favourable (GOS 4 or 5) in 46% of patients with a 35% overall mortality. CONCLUSION: The presence of an aneurysm related ICH does not justify a nihilistic approach, as aggressive treatment is associated with a favourable outcome in 46% of patients. In the post-ISAT era, management should be patient specific and consideration should be given to both endovascular and open surgical therapy.