Background and methods: We report the case of a young woman with delayed cerebral infarction and intracranial hypertension following subarachnoid hemorrhage requiring hemicraniectomy, who underwent multimodality neuromonitoring of the contralateral hemisphere before and after craniectomy.
Results: Intracranial hypertension was preceded by signs of ischemia and impaired brain metabolism diagnosed through cerebral microdialysis and PbtO2 monitoring, as well as a decrease in cerebral perfusion pressure (CPP) to <40 mmHg despite increasing vasopressor requirements. We describe how a comprehensive multimodality neuromonitoring approach was utilized to inform the decision to perform an early decompressive hemicraniectomy. Post-operatively, CPP and intracranial pressure (ICP) normalized, and the patient was weaned off all pressors within hours. The modified Rankin score at 3 and 12 months was 5.
Conclusions: Delayed rescue hemicraniectomy can be life-saving after poor grade SAH. The role of multimodality brain monitoring for determining the optimal timing of hemicraniectomy deserves further study.