Surgery for Brain Edema

Peter Hutchinson, F.R.C.S.(SN); Ivan Timofeev, M.R.C.S.; Peter Kirkpatrick, F.R.C.S.(SN)


Neurosurg Focus. 2007;22(5):E14 

In This Article

Subarachnoid Hemorrhage

In contrast to TBI, there are substantially fewer published studies on the experience of decompressive craniectomy as a treatment for brain edema following SAH. Ziai and colleagues[77] reported on their experience with de compressive craniectomy for intractable cerebral edema in four patients following aneurysmal SAH; one patient died and three had a severe disability (poor results). Recently, data from two other studies have been published. Schirmer and associates[61] have described the results of de compressive hemicraniectomy in the treatment of refractory elevated ICP in 16 patients with aneurysmal SAH. Half of the patients were treated with endovascular coil embolization and the other half with surgical clip application. Sixty-nine percent of patients survived, and at the follow-up (median 450 days) 64% of them had an mRS score of 0 to 3 and 36% a score of 4 to 5. Early craniectomy performed within 48 hours after SAH was associated with a better outcome. These authors concluded that de compressive hemicraniectomy is a useful adjunctive modality in the management of refractory intracranial hypertension in patients with poor-grade aneurysmal SAH, even in the absence of extensive intraparenchymal hemorrhage. Buschmann and colleagues[10] have reported the results of 38 patients following decompressive hemicraniectomy after early aneurysm clipping. They divided the indications for de compressive craniectomy into four groups: 1) signs of brain swelling during aneurysm surgery; 2) ICP elevation and epidural, subdural, or intracerebral hematoma after an eurysm surgery; 3) brain edema and elevated ICP without radiological signs of infarction; and 4) brain edema and elevated ICP with neuroimaging-demonstrated signs of infarction. The pooled data from all 38 patients showed a favorable outcome (GOS Scores 4 and 5) in 53% of patients, severe disability in 26% (GOS Score 3), and death in 21%. After 12 months, a good functional outcome was seen in 52% of the cases in Group 1, in 60% in Group 2, in 83% in Group 3, and in 17% in Group 4. These authors concluded that in more than half of the patients with intractable intracranial hypertension after an eurysmal SAH, a good functional outcome could be achieved after decompressive craniectomy; that patients with progressive brain edema but no radiological signs of infarction and those with hematoma may benefit the most; and that the indication for decompressive craniectomy should be set restrictively if secondary infarction is present.