title: Decompressive hemicraniectomy in subarachnoid haemorrhage: the influence of infarction, haemorrhage and brain swelling.
abstract: OBJECTIVE
  To analyse decompressive hemicraniectomy (DHC) in patients with aneurysmal subarachnoid haemorrhage (SAH) with regard to infarction, haemorrhage or brain swelling.
  
  
  METHODS
  DHC was performed in 43 of 787 patients with SAH. Patients were stratified according to (1) primary brain swelling without and (2) with additional intracerebral haematoma, (3) secondary brain swelling without rebleeding or infarcts and (4) with infarcts or (5) with rebleeding. Outcome was assessed according to the modified Rankin scale at 6 months
  
  
  RESULTS
  Overall, 36 of 43 patients (83.7%) with DHC and 241 of 744 patients (32.4%) without DHC have been of a poor grade on admission (World Federation of Neurological Societies grading 4-5; p<0.0001). Favourable outcome was achieved in 11 of 43 (25.6%) patients with DHC. There was no difference in favourable outcome after primary (25%) versus secondary (26.1%) DHC (p = 1.0). Subgroup analysis (brain swelling vs bleeding vs infarcts) revealed no difference in the rate of favourable outcome. In a multivariate analysis, acute hydrocephalus (p = 0.02) and clinical herniation (p = 0.03) were significantly associated with unfavourable outcome.
  
  
  CONCLUSIONS
  We conclude that primary and secondary hemicraniectomy may be warranted, irrespective of the underlying aetiology-infarction, haemorrhage or brain swelling. The time from onset of intractable ICP to DHC seems to be crucial, rather than the time from SAH to DHC.
authors.affiliation: Department of Neurosurgery, Johann Wolfgang Goethe-University Frankfurt am Main, Schleusenweg 2-16, Frankfurt am Main 60528, Germany. gueresir@em.uni-frankfurt.de
authors.forename: E
authors.initials: E
authors.lastname: Güresir
authors.forename: A
authors.initials: A
authors.lastname: Raabe
authors.forename: M
authors.initials: M
authors.lastname: Setzer
authors.forename: H
authors.initials: H
authors.lastname: Vatter
authors.forename: R
authors.initials: R
authors.lastname: Gerlach
authors.forename: V
authors.initials: V
authors.lastname: Seifert
authors.forename: J
authors.initials: J
authors.lastname: Beck
mesh_terms: D000328:Adult; D001929:Brain Edema / Q000209:etiology / Q000473:pathology*; D020520:Brain Infarction / Q000209:etiology / Q000473:pathology*; D002543:Cerebral Hemorrhage / Q000209:etiology / Q000473:pathology*; D003399:Craniotomy / Q000009:adverse effects* / Q000379:methods; D019299:Decompression, Surgical / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D013345:Subarachnoid Hemorrhage / Q000175:diagnosis / Q000473:pathology / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome