Decompressive hemicraniectomy in patients with subarachnoid hemorrhage and intractable intracranial hypertension.

BACKGROUND AND PURPOSE: To evaluate the outcome of patients with aneurysmal subarachnoid hemorrhage (aSAH) developing intractable intracranial hypertension and treated by decompressive hemicraniectomy (DHC). METHODS: Of 193 patients with aSAH 38 patients were treated with DHC after early aneurysm clipping. Indications for DHC were 1. Signs of brain swelling during aneurysm surgery (group 1: primary DHC). 2. Intracranial pressure- (ICP)-elevation and epidural, subdural or intracerebral hematoma after aneurysm surgery (group 2: secondary DHC due to hematoma) 3. Brain edema and elevated ICP without radiological signs of infarction (group 3: secondary DHC without infarction). 4. Brain edema and elevated ICP with radiological signs of infarction (group 4: secondary DHC with infarction). RESULTS: Thirty-one patients (81.6%) suffered from high grade aSAH Hunt & Hess 4-5. 21 belonged to group 1, five to group 2, six to group 3 and six to group 4. Of a total of 38 patients a good functional outcome according to Glasgow Outcome Score (GOS 4 & 5) could be reached in 52.6% of the cases. 26.3% survived severely disabled (GOS 3), no case suffered from a vegetative state (GOS 2) but 21.1% died (GOS 1). After 12 months good functional outcome could be achieved in 52.4% of the cases in group 1, in 60% in group 2, in 83.3% in group 3 and in 16.7% in group 4. CONCLUSIONS: In more than half of the patients with intractable intracranial hypertension after aSAH a good functional outcome could be achieved after DHC. Patients with progressive brain edema without radiological signs of infarction and those with hematoma may benefit most. The indication for DHC should be set restrictively if secondary infarcts are manifest.

Biochemical investigations of CAPD: plasma levels of trace elements and amino acids and impaired glucose tolerance during the course of treatment.

Investigations have been initiated into the effect of CAPD on the plasma concentrations of trace elements and amino acids, and in particular the response of patients to an oral glucose tolerance test (OGTT) during the course of treatment. Six months CAPD had no effect on the plasma concentrations of aluminium, fluoride, zinc and copper. Levels of aluminium and fluoride were above the normal range. Loss of amino acids in the dialysate correlated with their plasma concentrations. No changes were observed in the E/NE, Val/Gly or Tyr/Phe ratios during nine months treatment. Five CAPD patients demonstrated an impaired glucose tolerance in response to an OGTT after one month of treatment and a further deterioration occurred in the glucose tolerance of three patients after another six months CAPD. In a preliminary investigation with fructose substituted for glucose in the dialysate of one patient, an improvement in the OGTT and rate of insulin secretion was observed after 3 days dialysis against fructose.