Use of Prophylactic Decompressive Craniectomy in Middle Cerebral Artery Aneurysmal Subarachnoid Hemorrhage Patients Presenting with Associated Large Hematoma

Park, Chang Kyu; Min, Kyung Soo; Lee, Mou Seop; Kim, Young Gyu; Kim, Dong Ho

Abstract

OBJECTIVE
Patients who present with a poor Hunt-Hess grade (IV or V) after aneurysmal subarachnoid hemorrhage (SAH) often have a poor prognosis. However, there may be subgroups of these patients for whom the sustained increased intracranial pressure predominates due to a large sylvian hematoma and for which rapid decompression of these predominant pathological processes may result in an improved outcome. We report here on the use of prophylactic decompressive craniectomy in patients who present in a poor neurological condition or they have a focal neurologic deficit, such as motor aphasia, after SAH from middle cerebral artery aneurysms with associated large sylvian fissure hematomas.
METHODS
Twelve patients (mean age: 52yr, age range: 13-71yr) presented with middle cerebral artery (MCA) aneurysmal SAH (one with Hunt-Hess grade III, five with Hunt-Hess grade IV and six Hunt-Hess grade V). They all had large hematomas (mean hematoma volume: 70ml, range: 30-120ml). All the patients underwent emergency operation. One patient whose Hunt-Hess grade was III underwent decompressive craniectomy because she had motor aphasia due to a focal mass effect of the hematoma. Five of them underwent operation without conventional angiography. All the patients were treated with large craniectomy and duraplasty.
RESULTS
All patients underwent craniectomy without operative complications. The results for this study demonstrated that craniectomy patients had a remarkably high rate of good recovery or they had moderately disabled outcomes. The outcomes of the craniectomy patients were three grade 5s, four grade 4s, one grade 3 and four grade 1s for the GOS.
CONCLUSION
The data in this study showed that decompressive craniectomy can be performed safely as part of the initial management for patients with SAH and who also present with large hematomas. We suggest decompressive craniectomy when patients with a large hematoma present not only with deteriorated mentality due to the increased intracranial pressure, but also with focal neurologic deficits such as motor aphasia due to the local mass effect.