The Role of Decompressive Craniectomy following Microsurgical Repair of a Ruptured Aneurysm: Analysis of a South Australian Cerebrovascular Registry

Abstract

AbstractBackgroundDecompressive craniectomy (DC) remains a controversial intervention for established or anticipated intracranial hypertension among patients with aneurysmal subarachnoid haemorrhage (aSAH).MethodsWe identified aSAH patients who underwent DC following microsurgical aneurysm repair from a prospectively maintained cerebrovascular registry and compared their outcomes with a propensity-matched cohort who did not. Logistic regression was used to identify predictors of undergoing decompressive surgery and post-operative outcome. The outcomes of interest were inpatient mortality, unfavourable outcome at first and final follow-up, NIS-Subarachnoid Hemorrhage Outcome Measure and modified Rankin Score (mRS) at first and final follow-up.ResultsA total of 246 consecutive patients with aSAH underwent microsurgical clipping of the culprit aneurysm between 01/09/2011 and 20/07/2020. Of these, 46 patients underwent DC and were included in the final analysis. Unsurprisingly, patients treated with DC had a greater chance of unfavourable outcome (p<0.001) and higher median mRS (p<0.001) compared with those who did not at final follow-up. Despite this, almost two-thirds (64.1%) of patients undergoing a DC had a favourable outcome at this time-point. When compared with a propensity-matched cohort who did not, patients treated with DC fared worse at all endpoints. Multivariable logistic regression revealed that the presence of intracerebral haemorrhage (ICH) and increased pre-operative mid-line shift were predictive of undergoing DC, and WFNS grade ≥ 4 and a delayed ischaemic neurological deficit requiring endovascular angioplasty were associated with an unfavourable outcome.ConclusionsOur data suggest that DC can be performed with acceptable rates of morbidity and mortality, particularly among patients who present with lower grade aSAH. Further research is required to determine the superiority, or otherwise, of DC compared with structured medical management of intracranial hypertension in this context, and to identify predictors of requiring decompressive surgery and patient outcome.