• Alexandra Nagel, Daniela Graetz, Peter Vajkoczy, and Asita S Sarrafzadeh.
• Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany. alexandra.nagel@charite.de
• Neurocrit Care. 2009 Dec 1;11(3):384-94.

IntroductionOutcome 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.MethodsA 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.ResultsGroups 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 muM) 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.ConclusionOutcome 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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