Decompressive craniectomy in aneurysmal subarachnoid hemorrhage: Who and when? - A systematic review and meta-analysis.

OBJECTIVE: Decompressive craniectomy (DC) is a standard neurosurgical procedure against intractable intracranial hypertension. Patients with severe aneurysmal subarachnoid hemorrhage (aSAH) are prone to intracranial hypertension, necessitating DC in certain cases. However, the clinical utility of DC after aSAH remains unclear. Hereby we present a systematic review and meta-analysis summarizing the published studies on DC in aSAH patients.

MATERIAL AND METHODS: We systematically searched PubMed, Scopus, Web of Science and Cochrane Library for articles published before Jul 10, 2019 reporting on rates, outcome, indications, timing and complications of SAH patients undergoing DC.

RESULTS: Of 1085 identified unique records, 28 observational studies published between 1993 and 2018 were included. In total, data of 2788 aSAH patients was extracted including 2014 patients with DC. The mean DC rate was 10.9 % (range 3.3%-25.6%). Good initial clinical condition (p = 0.01; odds ratio (OR) = 2.93; confidence interval (95 % CI) 1.30-6.61) and younger patients' age (p = 0.02; mean difference (MD) = -4.50; 95 % CI -8.36 - -0.64) increased the chance of good outcome after DC. Overall, patients with primary DC showed a tendency towards better outcome than those that underwent secondary DC (p = 0.08; OR = 1.50; 95 % CI 0.96-2.35). Younger age (p < 0.00001; MD = -3.63; 95 % CI -5.20 to -2.06), presence of intracerebral hemorrhage (ICH; p < 0.00001; OR = 6.63; 95 % CI 3.98-11.03), poor initial clinical condition (p < 0.00001; OR = 4.81; 95 % CI 2.88-8.03) and treatment modality (coiling, p < 0.00001; OR = 0.19; 95 % CI 0.10-0.35) were associated with the indication to DC.

CONCLUSIONS: Around 10 % of aSAH individuals undergo DC. Younger individuals, with poor initial clinical condition, additional ICH and aneurysm clipping are more likely to be selected for DC. Due to expected outcome benefit, younger individuals with good-grade aSAH should be considered for early decompression in case of increased intracranial pressure.