Intracranial Hypertension in Subarachnoid Hamorrhage: Outcome After Decompressive Craniectomy

Holsgrove, Daniel; Kitchen, William John; Dulhanty, Louise; Holland, J; Patel, Hiren C.

doi:10.1007/978-3-319-02411-0_9

Cited by 12 publications

(9 citation statements)

References 8 publications

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“…To support our finding, we documented the time at which the highest mean ICP was recorded, which for most patients was within 3 days after SAH; 97.3 % of patients had encountered their highest mean ICP by 5 days post-SAH. In accordance with our results, a recent study indicated that the number of patients with episodes of elevated ICP reached a maximum at day 3 after SAH and decreased only after day 7 [35]. Our findings emphasize the significance of early administration of raised ICP in patients with SAH.…”

Section: Discussionsupporting

confidence: 95%

Clinical observation of the time course of raised intracranial pressure after subarachnoid hemorrhage

Wang

Jin

et al. 2015

Neurol Sci

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The time course of intracranial pressure (ICP) after subarachnoid hemorrhage (SAH) is not well known. This retrospective study was conducted to investigate the occurrence and the dynamic variation of raised ICP post-SAH. ICP was prospectively studied in 120 patients with SAH who were admitted to neurocritical care within 24 h of hemorrhage. Patients underwent continuous ICP monitoring for at least 7 days, unless they died. Clinical status on admission, radiographic tests, treatment details and neurological outcome on discharge were analyzed in relation to ICP. The highest daily mean ICP and the day when ICP reduced to normal levels were assessed. Of the 120 patients studied, 112 (93.3 %) encountered ICP elevation whilst in hospital. The daily mean ICP was higher in Hunt and Hess grades IV-V patients than grades I-III patients (P = 0.01). The elevated ICP remained at a higher level for the initial 3 days (grades I-III patients) or 4 days (grades IV-V patients), after which the pressure decreased towards normal levels. The in-patient mortality was significantly increased in the high ICP variability group (P = 0.001), which was divided by the cutoff point using receiver operating characteristic curve analysis. Raised ICP mainly occurs within 8 days post-SAH, especially the initial 3-4 days. Those highlight the need for earlier management of ICP after SAH.

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Section: Discussionsupporting

confidence: 95%

Clinical observation of the time course of raised intracranial pressure after subarachnoid hemorrhage

Wang

Jin

et al. 2015

Neurol Sci

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“…In 2007, Schirmer et al [5] performed surface measurements in 16 SAH patients, but did not find any associations between DC extent and patient outcomes in this small cohort. In another small study of 19 SAH cases based on maximum DC diameter [17], the authors were also unable to identify a link between DC size and SAH outcome. The present study therefore provides the first evidence of the clinical impact of size of DC in the context of SAH using a sufficient sample size.…”

Section: Discussionmentioning

confidence: 99%

“…In contrast, less is known about the clinical value of DC size in SAH patients undergoing decompressive surgery. To date, there are only two case series based on surface measurements (n = 16) [5] or maximum DC diameter (n = 19) [17] in SAH patients. These studies, which were limited to very small sample sizes, did not find any associations between DC size and SAH outcome.…”

Section: Introductionmentioning

confidence: 99%

Size does matter: The role of decompressive craniectomy extent for outcome after aneurysmal subarachnoid hemorrhage

Jabbarli

Oppong

et al. 2021

Euro J of Neurology

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Background and purpose In previous studies in patients with traumatic brain injury and ischemic stroke, the size of decompressive craniectomy (DC) was reported to be paramount with regard to patient outcomes. We aimed to identify the impact of DC size on treatment results in individuals with aneurysmal subarachnoid hemorrhage (SAH). Methods The extent of DC in 232 patients with SAH who underwent bifrontal or hemicraniectomy between January 2003 and December 2015 was analyzed using semi‐automated surface measurements. The study endpoints were course of intracranial pressure (ICP) treatment after DC, occurrence of cerebral infarcts, in‐hospital mortality, and unfavorable outcome at 6 months (defined as modified Rankin scale score >3). The associations of DC size with the study endpoints were adjusted for DC timing, patient age, clinical and radiographic severity of SAH, aneurysm location, and treatment modality. Results The mean DC surface area was 100.9 (±45.8) cm2. In multivariate analysis, a large DC (>105 cm2) was independently associated with a lower risk of cerebral infarcts (adjusted odds ratio [aOR] 0.30, 95% confidence interval [CI] 0.16–0.56), in‐hospital mortality (aOR 0.28, 95% CI 0.14–0.56) and unfavorable outcome (aOR 0.51, 95% CI 0.27–0.98). Moreover, SAH patients with a small DC size (<75 cm2) were more likely to require prolonged (>3 days, aOR 3.60, 95% CI 1.37–9.42) and enhanced (aOR 2.31, 95% CI 1.12–4.74) postoperative ICP treatment. Conclusion This is the first study showing the impact of DC size on postoperative ICP control and patient outcome in the context of SAH; specifically, a large craniectomy flap (>105 cm2) might lead to better outcomes in SAH patients requiring decompressive surgery.

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“…Clinically, anisocoria and high WFNS grade (WFNS Grade V relative to Grade IV) at presentation were significantly associated with poor outcome. 21,35,45,47 In 1 study, a favorable outcome was more likely in younger patients (< 60 years old). 27 The severity of midline shift, volume of hematoma measured by CT, and delayed surgical treatment were all significantly associated with unfavorable outcome.…”

Section: Predictors Of Outcomes After DCmentioning

confidence: 94%

“…Detailed study parameters and summary statistics from all included studies (with and without a matched control group) that investigated DC in patients with poor-grade aSAH are listed in Tables 2 and 3, respectively. Of the 15 studies included in this review, all of them were observational cohorts (2 prospective, 27,52 13 retrospective 7, 10,21,[24][25][26]28,34,35,39,44,45,47 ). The years of publication ranged from 2002 to 2015, and the reports represented findings from North America (2 studies), Europe (5), and Asia (8).…”

Section: Study Characteristicsmentioning

confidence: 99%

Effects of decompressive craniectomy on functional outcomes and death in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Alotaibi

El-Karim²,

Samuel³

et al. 2017

Journal of Neurosurgery

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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 did not undergo 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.

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Intracranial Hypertension in Subarachnoid Hamorrhage: Outcome After Decompressive Craniectomy

Cited by 12 publications

References 8 publications

Clinical observation of the time course of raised intracranial pressure after subarachnoid hemorrhage

Clinical observation of the time course of raised intracranial pressure after subarachnoid hemorrhage

Size does matter: The role of decompressive craniectomy extent for outcome after aneurysmal subarachnoid hemorrhage

Effects of decompressive craniectomy on functional outcomes and death in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

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