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Decompressive Craniectomy in Aneurysmal Subarachnoid Hemorrhage: Relation to Cerebral Perfusion Pressure and Metabolism

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Abstract

Introduction

Outcome is poor in aneurysmal subarachnoid hemorrhage (SAH) patients with intracranial hypertension. As one treatment option for increased intracranial pressure (ICP), decompressive craniectomy (DC) is discussed. Its impact on cerebral metabolism and outcome in SAH patients is evaluated in this pilot study.

Methods

A prospectively collected database of cerebral metabolism in SAH patients was analyzed retrospectively for individuals developing high ICP (>20 mmHg > 6 h/day, n = 18). Patients with intracranial hypertension were classified into groups with (n = 7) and without DC (n = 11). An age-matched control group was established (n = 89). Cerebral perfusion pressure (CPP) and high ICP treatment were analyzed for 7 days after SAH (or 72 h after craniectomy, respectively). Cerebral microdialysates were analyzed hourly. Twelve-month outcome was evaluated.

Results

Groups were comparable for age, WFNS grade, and outcome. ICP was significantly reduced by DC (P < 0.01), however, in 43% of patients the effect was transient. An increase in the lactate/pyruvate ratio (P < 0.001) and glycerol levels (>200 μM) was observed before DC. In the DC group, glucose (P = 0.005) and pyruvate (P = 0.04) were higher, while glycerol levels were lower (P = 0.007) compared to the non-DC group, reflecting better aerobic glucose utilization and reduced cellular stress.

Conclusion

Outcome was poor in all SAH patients with intracranial hypertension. Although glucose utilization was improved after DC, no improvement in outcome could be shown for this small patient population. Future studies will have to demonstrate whether markers of cerebral crisis may support the decision for DC in aneurysmal SAH patients.

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Acknowledgments

The authors acknowledge the technical assistance of Sabine Seidlitz and Jasmin Kopetzki, and the support of the ICU team.

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Authors and Affiliations

  1. Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany

    Alexandra Nagel, Daniela Graetz, Peter Vajkoczy & Asita S. Sarrafzadeh

  2. Clinic of Neurosurgery, Charité Campus Virchow Medical Center, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany

    Asita S. Sarrafzadeh

Authors
  1. Alexandra Nagel
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  2. Daniela Graetz
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  3. Peter Vajkoczy
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  4. Asita S. Sarrafzadeh
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Correspondence to Asita S. Sarrafzadeh.

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Nagel, A., Graetz, D., Vajkoczy, P. et al. Decompressive Craniectomy in Aneurysmal Subarachnoid Hemorrhage: Relation to Cerebral Perfusion Pressure and Metabolism. Neurocrit Care 11, 384–394 (2009). https://doi.org/10.1007/s12028-009-9269-x

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  • DOI: https://doi.org/10.1007/s12028-009-9269-x

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