Decompressive craniectomies improve survival and outcome in poor grade subarachnoid hemorrhage

Introduction: While in the treatment of patients in good to moderate clinical condition (Hunt and Hess (H&H) grade I to III) after subarachnoid hemorrhage (SAH) the main aspects of treatment including early aneurysm surgery within 72 hours after the bleeding are no longer under debate, the extent of therapy in so called poor grade SAH (H&H grade IV and V) is still controversial. In our institution we attempt an aggressive therapeutic approach also in poor grade SAH including early operation of the aneurysm and decompressive craniectomies (DC) in selected cases. Material and Methods: To evaluate this regimen we retrospectively followed the course of 43 patients admitted to our institution after severe SAH in a 36 month period (24 patients grade IV, 19 patients grade V H&H). Minimum follow-up period was 6 months and outcome was assessed according to the Glasgow Outcome Score (GOS). Treatment included early aneurysm surgery in 33 cases, coiling in 2 cases, standard neurosurgical intensive care therapy and 14 large fronto-temporo-parietal decompressive craniectomies with duraplasty ( grade IV, 16.7%; grade V, 52.6%). 8 patients did not receive further treatment due to decerebrate rigidity. Results: Of 43 Patients suffering from SAH grade IV and V, 22 patients survived longer than 6 months after the initial bleeding (51.2%). This rate was higher in patients in grade IV (14 of 24, 58.9%) than in grade V (8 of 19, 42%). Very good or good outcome (GOS 4 and 5) could be achieved in 13 patients (30%; grade IV, grade V). DC had a strong impact on survival and outcome in grade V patients: 60% ( ) patients survived after DC totalling 75% ( ) of all survivers in this group. Furthermore, outcome was strongly affected by DC: 67% ( ) of patients with a very good (GOS 5) and all patients ( ) with a good outcome (GOS 4) received decompressive craniectomies. Conclusion: Aggressive therapy also of poor grade SAH patients is justified. Decompressive craniectomies should be considered an important additional treatment modality. So called poor grade aneurysms do not necessarily result in an unfavourable neurological outcome.