Clinical characteristics and surgical outcomes of patients with aneurysmal subarachnoid hemorrhage and acute subdural hematoma undergoing decompressive craniectomy.

OBJECTIVE: This report presents 12 consecutively managed patients with aneurysmal subarachnoid hemorrhage (SAH) associated with acute subdural hematoma (ASDH) who underwent decompressive craniectomy (DC) with special attention to their clinical characteristics and surgical outcomes. METHODS: We retrospectively reviewed medical charts, radiologic findings, surgical notes, and video records. RESULTS: Among these 12 patients (mean age 59.1 years, 4 men, 8 women), the Hunt and Kosnik clinical grade was grade V in 7 patients (58.3%), grade IV in 2 patients (16.7%), grade III in 2 patients (16.7%), and grade II in 1 patient (8.3%). The aneurysms were located on the internal carotid artery in four patients, the middle cerebral artery in six patients, and the anterior communicating artery in two patients. Computed tomography findings on admission revealed ASDH in all patients. In addition, SAH was seen in 11 patients. An intracerebral hematoma was found in eight patients, intraventricular hemorrhaging occurred in four, and an acute hydrocephalus was seen in one patient. All patients underwent a microsurgical clipping procedure and an additional DC. Symptomatic vasospasm was confirmed in six (50%), and eight patients with chronic hydrocephalus received a ventriculoperitoneal shunt (67%). The Glasgow Outcome Scale at discharge showed good recovery in five patients (41.7%), severe disability in four (33.3%), vegetative state in two (16.7%), and death in one patient (8.3%). A favorable outcome was achieved in five patients (41.7%). CONCLUSIONS: We suggest that the DC was effective for reducing morbidity and mortality in poor grade patients with SAH presenting with ASDH.

Surgical outcome following decompressive craniectomy for poor-grade aneurysmal subarachnoid hemorrhage in patients with associated massive intracerebral or Sylvian hematomas.

BACKGROUND: Patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) presenting with large intracerebral (ICH) or sylvian hematomas (SylH) have poor outcomes due to the mass effect of significant brain stem compression following mass effect. On the other hand, decompressive craniectomy (DC) can reduce morbidity and mortality in critically ill patients with massive ischemic infarction and severe head injury. However, the role of DC in SAH patients is not fully understood. We investigated the outcome of DC in poor-grade SAH presenting with large ICH or SylH. METHODS: 110 consecutive patients with poor-grade SAH (Hunt & Kosnik (H&K) grades IV and V, and Fisher group 4) were admitted to our hospital between April 1, 1993, and July 30, 2004. We treated 57 of those who presented with large ICH or SylH using DC. We retrospectively reviewed medical charts, radiological findings, operative notes, and video records. RESULTS: Among the 57 patients (mean age 57.8, male 29, female 28), 25 were classified as H&K grade IV and 32 as grade V. Ruptured aneurysms were located on the internal carotid artery in 11 and the middle cerebral artery in 46 patients. 50 of the aneurysms were small, 5 were medium, and 2 were large. Rerupture was preoperatively confirmed in 13 (22.8%). Hypothermia was applied to 17 (29.8%). The Glasgow Outcome Scale on discharge showed good recovery, moderate recovery, severe disability, vegetative state, and death in 8 (14.0%), 13 (22.8%), 16 (28.1%), 8 (14.0%), and 12 (21.1%), respectively. The outcomes of grade IV patients were favorable and poor in 14 (56.0%) and 10 (40.0%), respectively, and 1 (4.0%) died. CONCLUSION: Several experimental studies have also indicated that DC significantly improves outcome due to reduced intracranial pressure or increased perfusion pressure. Urgent DC for poor-grade SAH with space-occupying hematoma can lead to survival with good recovery in some patients.