Bilateral Decompressive Hemicraniectomy for Diffuse Cerebral Edema and Medically Refractory Elevated Intracranial Pressure in Aneurysmal Subarachnoid Hemorrhage: A Case Series

Decompressive hemicraniectomy (DCHC) may be indicated in the setting of subarachnoid hemorrhage (SAH) complicated by persistent elevated intracranial pressure (ICP) that is refractory to medical interventions. Outcomes can be variable as indications for surgery can include focal hematomas, infarctions, and regional or diffuse edema. Bilateral DCHC for medically refractory elevated ICP in the setting of SAH is not well described in the literature, and the viability of this option in terms of patient outcomes is unclear. We describe the cases of four patients with medically refractory ICP secondary to diffuse cerebral edema who underwent bilateral DCHC in the setting of SAH. This is a retrospective case review of four patients with aneurysmal SAH who underwent bilateral DCHC for management of diffuse global edema resulting in medically refractory ICP. We describe two patients who made impressive recoveries after bilateral DCHC and two patients who required significant continued care needs despite ICP control in all patients. Bilateral DCHC is a viable option for control of refractory elevated ICP in SAH patients who develop diffuse cerebral edema. Bilateral DCHC in this setting can be considered after exhaustion of other therapeutic options.