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Vol. 21. Issue 6.
Pages 452-459 (January 2010)
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Vol. 21. Issue 6.
Pages 452-459 (January 2010)
Craniectomía descompresiva primaria en la hemorragia subaracnoidea aneurismática. Resultados de un estudio piloto en 11 casos
Primary decompressive craniectomy in patients with aneurysmatic subarachnoid hemorrhage. Results of a pilot study in 11 cases
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F. Arikan
Corresponding author
arikan@neurotrauma.net

Correspondencia: Servicio de Neurocirugía. Hospital Universitario Vall d’Hebron. Paseo Vall d’Hebron 119-129. 08035 Barcelona.
, J. Vilalta, F.R. Martínez-Ricarte, J. Sahuquillo
Servicio de Neurocirugía, Unidad de Investigación de Neurotraumatología-Neurocirugía. Institut de Recerca Vall d’Hebron. Universidad Autónoma de Barcelona. Unidad de Neuroradiología Intervencionista, Hospital Universitario Vall d’Hebron, Barcelona
F.J. Romero*, I. Porta**
* Unidad de Neuroradiología Intervencionista, Hospital Universitario Vall d’Hebron, Barcelona
** Unidad de Cuidados Intensivos, Hospital Universitario Vall d’Hebron, Barcelona
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Resumen
Introducción

A pesar de los avances científicos y técnicos de los últimos años, la hemorragia subaracnoidea aneurismática (HSAa) sigue presentando una alta morbilidad y mortalidad. Este hecho, junto con los impresionantes resultados de la craneotomía descompresiva primaria (CDP) en el infarto maligno de la arteria cerebral media sugiere la posibilidad que la CDP sea una alternativa terapéutica a considerar en algunos pacientes con una HSAa. Presentamos nuestra experiencia de un estudio piloto en el que se utilizó la CDP en pacientes con HSAa en mal grado neurológico y hematoma intracerebral asociado.

Pacientes y métodos

Entre el 1 de marzo de 2002 y el 31 de abril de 2008, se trataron 342 pacientes con HSAa en nuestro hospital. De estos, 64 tenían una puntuación de 4 ó 5 de la escala de la WFNS (World Federation of Neurosurgical Societies). En el presente estudio prospectivo se analizan 11 pacientes en los que se realizó una CDP durante la misma cirugía de clipaje o/y evacuación del hematoma asociado.

Resultados

En tres pacientes la CDP se realizó después del tratamiento endovascular del aneurisma debido a la necesidad de evacuar el hematoma asociado. En los ocho pacientes restantes, la CDP se realizó durante el clipaje y la evacuación del hematoma asociado. La evaluación de los resultados de estos once pacientes se llevó a cabo al año de la cirugía mediante la escala de resultados de Glasgow. La CDP fue eficaz en el control de presión intracraneal en los pacientes que sobrevivieron. Seis pacientes sobrevivieron, cuatro de ellos con un buen resultado neurológico. Sin embargo, dos de estos seis pacientes tuvieron un resultado desfavorable.

De los cinco pacientes que no sobrevivieron, un paciente murió a causa de un hematoma subgalealepidural diferido como complicación de la CDP, y los restantes cuatro pacientes fallecieron a causa de una hipertensión intracraneal refractaria.

Conclusiones

La CDP puede ser una alternativa terapéutica en un grupo seleccionado de pacientes con HSAa con mal grado neurológico. Sin embargo, en la actualidad hay una falta de evidencia para apoyar unas recomendaciones claras para su uso.

Palabras clave:
Hemorragia subaracnoidea aneurismática
Craniectomía descompresiva
Craniectomía descompresiva profiláctica
Hematoma intracerebral
Abreviaturas:
aSAH
CD
CDP
CDS
HSAa
IMACM
PDC
PIC
WFNS
Summary
Introduction

Despite the scientific and technical advances of recent years, aneurysmal subarachnoid hemorrhage (aSAH) continues to present a high morbidity and mortality. This fact, together with the impressive results of the primary decompressive craniotomy (PDC) in the malignant infarction of the middle cerebral artery suggests a possible beneficial effect of decompressive technique in aSAH. We present our experience of a pilot study that PDC was used in patients with poorgrade aSAH with associated intracerebral hematoma.

Patients and methods

Between March 1st, 2002 and 31st April, 2008, 342 patients with aneurysmatic subarachnoid hemorrhage (aSAH) were treated at our hospital. Of these, 64 had a poor neurological grade (scores of 4 or 5 of the World Federation of Neurosurgical Societies) at the time of admission. The present study examines 11 of those patients who underwent PDC, which is performed in the same clipping and/or evacuation of an associated hematoma.

Results

In three patients PDC was performed after endovascular aneurysm treatment because of the need to evacuate an associated hematoma. In the eight remaining patients, PDC was performed in the same clipping and evacuation of the associated hematoma. Outcome evaluation of these eleven patients was conducted 1 year after the operation assessed by the Glasgow Outcome Scale. Six patients survived, and four of them with good results. The PDC was effective in controlling intracranial pressure in all six surviving patients. However, two of these six patients had unfavorable outcomes.

Of the five who didn’t survive, one patient died from a delayed epidural-subgaleal hematoma as a complication of the decompressive technique, and the other four patients died because of refractory intracranial hypertension.

Conclusions

Primary DC may be beneficial in selected subgroups of patients with poor-grade aSAH. However, there is a lack of definitive evidence to support a clear recommendation for its use.

Key words:
Aneurysmatic subarachnoid hemorrhage
Decompressive craniectomy
Prophylactic decompressive craniectomy
Intracerebral hematoma

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