title: Effects of decompressive craniectomy on functional outcomes and death in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.
abstract: OBJECTIVE Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) (World Federation of Neurosurgical Societies Grade IV or V) are often considered for decompressive craniectomy (DC) as a rescue therapy for refractory intracranial hypertension. The authors performed a systematic review and meta-analysis to assess the impact of DC on functional outcome and death in patients after poor-grade aSAH. METHODS A systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were identified through the Ovid Medline, Embase, Web of Science, and Cochrane Library databases from inception to October 2015. Only studies dedicated to patients with poor-grade aSAH were included. Primary outcomes were death and functional outcome assessed at any time period. Patients were grouped as having a favorable outcome (modified Rankin Scale [mRS] Scores 1-3, Glasgow Outcome Scale [GOS] Scores 4 and 5, extended Glasgow Outcome Scale [GOSE] Scores 5-8) or unfavorable outcome (mRS Scores 4-6, GOS Scores 1-3, GOSE Scores 1-4). Pooled estimates of event rates and odds ratios with 95% confidence intervals were calculated using the random-effects model. RESULTS Fifteen studies encompassing 407 patients were included in the meta-analysis (all observational cohorts). The pooled event rate for poor outcome across all studies was 61.2% (95% CI 52%-69%) and for death was 27.8% (95% CI 21%-35%) at a median of 12 months after aSAH. Primary (or early) DC resulted in a lower overall event rate for unfavorable outcome than secondary (or delayed) DC (47.5% [95% CI 31%-64%] vs 74.4% [95% CI 43%-91%], respectively). Among studies with comparison groups, there was a trend toward a reduced mortality rate 1–3 months after discharge among patients who underwent DC (OR 0.58 [95% CI 0.27–1.25]; p = 0.168). However, this trend was not sustained at the 1-year follow-up (OR 1.09 [95% CI 0.55-2.13]; p = 0.79). CONCLUSIONS Results of this study summarize the best evidence available in the literature for DC in patients with poor-grade aSAH. DC is associated with high rates of unfavorable outcome and death. Because of the lack of robust control groups in a majority of the studies, the effect of DC on functional outcomes versus that of other interventions for refractory intracranial hypertension is still unknown. A randomized trial is needed.
authors.affiliation: 1Division of Neurosurgery, Department of Surgery, and.|2Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario.
authors.forename: Naif M
authors.initials: NM
authors.lastname: Alotaibi
authors.affiliation: 1Division of Neurosurgery, Department of Surgery, and.
authors.forename: Ghassan Awad
authors.initials: GA
authors.lastname: Elkarim
authors.affiliation: 1Division of Neurosurgery, Department of Surgery, and.
authors.forename: Nardin
authors.initials: N
authors.lastname: Samuel
authors.affiliation: 3Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada.
authors.forename: Oliver G S
authors.initials: OGS
authors.lastname: Ayling
authors.affiliation: 1Division of Neurosurgery, Department of Surgery, and.|2Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario.
authors.forename: Daipayan
authors.initials: D
authors.lastname: Guha
authors.affiliation: 4Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California.
authors.forename: Aria
authors.initials: A
authors.lastname: Fallah
authors.affiliation: 1Division of Neurosurgery, Department of Surgery, and.|5Division of Neurosurgery, King Saud University, Riyadh, Saudi Arabia.
authors.forename: Abdulrahman
authors.initials: A
authors.lastname: Aldakkan
authors.affiliation: 6Division of Neurosurgery, St. Michael's Hospital; and.|7Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Ontario, Canada.
authors.forename: Blessing N R
authors.initials: BNR
authors.lastname: Jaja
authors.affiliation: 6Division of Neurosurgery, St. Michael's Hospital; and.|7Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Ontario, Canada.
authors.forename: Airton Leonardo
authors.initials: AL
authors.lastname: de Oliveira Manoel
authors.affiliation: 1Division of Neurosurgery, Department of Surgery, and.
authors.forename: George M
authors.initials: GM
authors.lastname: Ibrahim
authors.affiliation: 1Division of Neurosurgery, Department of Surgery, and.|6Division of Neurosurgery, St. Michael's Hospital; and.|7Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Ontario, Canada.
authors.forename: R Loch
authors.initials: RL
authors.lastname: Macdonald
mesh_terms: D056424:Decompressive Craniectomy; D023261:Glasgow Outcome Scale; D006801:Humans; D013345:Subarachnoid Hemorrhage / Q000601:surgery*; D016896:Treatment Outcome
keywords: DC = decompressive craniectomy; GOS = Glasgow Outcome Scale; GOSE = extended GOS; H&H = Hunt and Hess; ICP = intracranial pressure; OCEBM = Oxford Centre for Evidence-Based Medicine; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; TBI = traumatic brain injury; WFNS = World Federation of Neurosurgical Societies; aSAH = aneurysmal subarachnoid hemorrhage; decompressive craniectomy; hemicraniectomy; mRS = modified Rankin Scale; subarachnoid hemorrhage; vascular disorders