Comparative study of surgical outcomes between early decompressive craniectomy with clipping and coil embolization followed by decompressive craniectomy

Aneurysmal subarachnoid hemorrhage (aSAH) is caused by rupture of an intracranial aneurysm and has high morbidity and mortality. Cases of poor grade aSAH have even higher morbidity and mortality [1–3]. Poor grade aSAH refers to modified Fisher grade 3 or higher and Hunt and Hess (H-H) grade 4 or higher aSAH. In Objective: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) has high morbidity and mortality, even when emergency treatment such as decompressive craniectomy (DC), coil embolization, or clipping is performed. The best treatment for acute aSAH, especially in poor-grade aSAH patients, has not been determined. The purpose of this study was to evaluate treatment methods in these patients in order to suggest the best treatment method. Methods: We compared 130 patients with poor-grade aSAH who underwent DC with clipping or coiling (clipping, 102 patients; coiling, 28 patients). We compared functional outcome, mortality, and the time interval between admission and DC surgery between the clipping and coiling groups. Results: There was a significant difference in functional outcomes (modified Rankin score [mRS]) between the clipping and coiling groups. The mean mRS at discharge in the clipping and coil groups was 4.824 and 5.214, respectively (P=0.049). The time interval until DC surgery was also significantly different (161 and 481 minutes in the clipping and coiling groups, respectively; P=0.003). No significant difference was found in mortality between the 2 groups (P=0.301). Conclusion: DC might be helpful for severe brain edema and intracranial pressure control. This procedure was more effective when performed with clipping than with coil embolization. DC with clipping showed better functional outcomes, lower mortality, and more favorable outcomes than DC with coil embolization. This demonstrates that aggressive surgical treatment can be helpful for poorgrade aSAH patients.