title: Decompressive craniectomy in subarachnoid hemorrhage.
abstract: OBJECTIVE
  The aim of this study was to analyze decompressive craniectomy (DC) in the setting of subarachnoid hemorrhage (SAH) with bleeding, infarction, or brain swelling as the underlying pathology in a large cohort of consecutive patients.
  
  
  METHODS
  Decompressive craniectomy was performed in 79 of 939 patients with SAH. Patients were stratified according to the indication for DC: 1) primary brain swelling without or 2) with additional intracerebral hematoma, 3) secondary brain swelling without rebleeding or infarcts, and 4) secondary brain swelling with infarcts or 5) with rebleeding. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months (mRS Score 0-3 favorable vs 4-6 unfavorable).
  
  
  RESULTS
  Overall, 61 (77.2%) of 79 patients who did and 292 (34%) of the 860 patients who did not undergo DC had a poor clinical grade on admission (World Federation of Neurosurgical Societies Grade IV-V, p < 0.0001). A favorable outcome was attained in 21 (26.6%) of 79 patients who had undergone DC. In a comparison of favorable outcomes in patients with primary (28.0%) or secondary DC (25.5%), no difference could be found (p = 0.8). Subgroup analysis with respect to the underlying indication for DC (brain swelling vs bleeding vs infarction) revealed no difference in the rate of favorable outcomes. On multivariate analysis, acute hydrocephalus (p = 0.009) and clinical signs of herniation (p = 0.02) were significantly associated with an unfavorable outcome.
  
  
  CONCLUSIONS
  Based on the data in this study the authors concluded that primary as well as secondary craniectomy might be warranted, regardless of the underlying etiology (hemorrhage, infarction, or brain swelling) and admission clinical grade of the patient. The time from the onset of intractable intracranial pressure to DC seems to be crucial for a favorable outcome, even when a DC is performed late in the disease course after SAH.
authors.affiliation: Department of Neurosurgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany. Gueresir@em.uni-frankfurt.de
authors.forename: Erdem
authors.initials: E
authors.lastname: Güresir
authors.forename: Patrick
authors.initials: P
authors.lastname: Schuss
authors.forename: Hartmut
authors.initials: H
authors.lastname: Vatter
authors.forename: Andreas
authors.initials: A
authors.lastname: Raabe
authors.forename: Volker
authors.initials: V
authors.lastname: Seifert
authors.forename: Jürgen
authors.initials: J
authors.lastname: Beck
mesh_terms: D001929:Brain Edema / Q000601:surgery; D003399:Craniotomy / Q000379:methods*; D019299:Decompression, Surgical / Q000379:methods*; D005260:Female; D006406:Hematoma / Q000601:surgery; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery; D019586:Intracranial Hypertension / Q000601:surgery; D007427:Intracranial Pressure; D008297:Male; D008875:Middle Aged; D013345:Subarachnoid Hemorrhage / Q000601:surgery*; D016896:Treatment Outcome