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.

中文翻译：

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动脉瘤性蛛网膜下腔出血的去骨瓣减压术：谁和何时？– 系统评价和荟萃分析

目的 去骨瓣减压术 (DC) 是治疗顽固性颅内高压的标准神经外科手术。严重的动脉瘤性蛛网膜下腔出血 (aSAH) 患者容易出现颅内高压，在某些情况下需要 DC。然而，aSAH 后 DC 的临床效用仍不清楚。在此，我们提出了一项系统评价和荟萃分析，总结了已发表的关于 aSAH 患者 DC 的研究。材料和方法 我们系统地搜索了 PubMed、Scopus、Web of Science 和 Cochrane 图书馆，查找在 2019 年 7 月 10 日之前发表的关于接受 DC 的 SAH 患者的发生率、结果、适应症、时间和并发症的文章。结果 在确定的 1085 条独特记录中，纳入了 1993 年至 2018 年发表的 28 项观察性研究。总共，提取了 2788 名 aSAH 患者的数据，其中包括 2014 名 DC 患者。平均 DC 率为 10.9%（范围 3.3%-25.6%）。良好的初始临床状况（p = 0.01；比值比 (OR) = 2.93；置信区间 (95 % CI) 1.30-6.61）和年轻患者的年龄（p = 0.02；平均差 (MD) = -4.50；95 % CI） -8.36 - -0.64) 增加了 DC 后获得良好结果的机会。总体而言，原发性 DC 患者比接受继发性 DC 的患者表现出更好的结果趋势（p = 0.08；OR = 1.50；95 % CI 0.96-2.35）。年龄较小（p < 0.00001；MD = -3.63；95 % CI -5.20 至 -2.06），存在脑出血（ICH；p < 0.00001；OR = 6.63；95 % CI 3.98-11.03），初始临床状况不佳p < 0.00001；OR = 4.81；95 % CI 2.88-8.03）和治疗方式（卷曲，p < 0.00001；OR = 0.19；95 % CI 0.10-0。35) 与 DC 的适应症相关。结论 大约 10% 的 aSAH 个体经历 DC。较年轻的个体，初始临床状况不佳，额外的 ICH 和动脉瘤夹闭更有可能被选择进行 DC。由于预期的结果益处，在颅内压升高的情况下，应考虑对具有良好级别 aSAH 的年轻个体进行早期减压。