Platform Presentation The Joint Annual Meeting of the Stroke Society of Australasia (SSA) and Smartstrokes 2023

The Role of Decompressive Craniectomy Following Microsurgical Repair of a Ruptured Aneurysm: Analysis of a South Australian Cerebrovascular Registry (#34)

Tom O'Donohoe 1 , Christopher Ovenden 1 , George Bouras 2 , Seevakan Chidambaram 2 , Stephanie Plummer 1 , Andrew Davidson 3 , Timothy Kleinig 4 , Amal Abou-Hamden 1
  1. Neurosurgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
  2. University of Adelaide, Adelaide, South Australia, Australia
  3. Neurosurgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
  4. Stroke, Royal Adelaide Hospital, Adelaide, South Australia, Australia

Background: Decompressive craniectomy (DC) remains a controversial intervention for established or anticipated intracranial hypertension among patients with aneurysmal subarachnoid haemorrhage (aSAH).

Aims: We aimed to describe the outcome of patients undergoing this procedure, compare their outcomes with a propensity matched cohort who did not undergo decompression and identify predictors of patient outcome.

Methods: We identified aSAH patients who underwent DC following microsurgical aneurysm repair from a prospectively maintained cerebrovascular registry and compared their outcomes with a propensity-matched cohort who did not. Logistic regression was used to identify predictors of undergoing DC and post-operative outcome. The outcomes of interest were inpatient mortality, unfavourable outcome (mRS ≥4) and NIS-Subarachnoid Hemorrhage Outcome Measure at first and final follow-up.

Results: A total of 246 consecutive patients with aSAH underwent microsurgical clipping of the culprit aneurysm between 01/09/2011 and 20/07/2020. Of these, 46 patients underwent DC and were included in the final analysis. Unsurprisingly, patients treated with DC had a greater chance of unfavourable outcome (p<0.001) and higher median mRS (p<0.001) compared with those who did not at final follow-up. Despite this, almost two-thirds (64.10%) of patients undergoing a DC had a favourable outcome at this time-point. When compared with a propensity-matched cohort who did not, patients treated with DC fared worse at all endpoints. Multivariable logistic regression revealed that increased pre-operative mid-line shift was predictive of undergoing DC, and age ≥ 65 and WFNS grade ≥ 4 were associated with unfavourable outcome.

Conclusion: Our data suggest that DC can be performed with acceptable rates of morbidity and mortality, particularly among younger patients who present with lower grade aSAH. Further research is required to determine the superiority, or otherwise, of DC compared with structured medical management of intracranial hypertension in this context, and to identify predictors of requiring decompressive surgery and patient outcome.