To outline the rationale for bifrontal decompressive craniectomy (BDC) as a treatment for refractory intracranial hypertension caused by aneurysmal subarachnoid hemorrhage.

BDC is a rarely used intervention for aneurysmal subarachnoid hemorrhage (aSAH), usually reserved for cases with medically refractory intracranial hypertension secondary to mass effect in the anterior cranial fossa. Most evidence comes from studies on traumatic brain injury (TBI). Trials like RESCUEicp are associated with decreased mortality but higher rates of severe disability, while DECRA showed decreased intracranial pressure (ICP) without clear improvement in functional outcomes. Its use in aSAH remains understudied.

A 34-year-old woman was admitted with a ruptured 7 mm anterior communicating artery aneurysm (modified Fisher scale 4, Hunt-Hess grade 4), complicated by severe edema localized in bilateral frontal lobes and increased ICP after coil embolization. Despite maximal medical therapy, ICP exhibited persistent elevations during the first 48 hours of admission. Therefore, the patient underwent bifrontal craniectomy (Kjellberg procedure), evacuation of bifrontal intraparenchymal and subdural hematomas, and placement of an external ventricular drain (EVD).

After decompression, ICP normalized and neurological improvement was gradual. The EVD was removed on hospital day 7. Two weeks later, the patient experienced symptomatic vasospasm of the right middle cerebral artery and bilateral supraclinoid internal carotid arteries, which was successfully treated with intra-arterial verapamil and milrinone. She showed significant improvement in left-arm strength and was transferred to acute rehabilitation.

The case outlines the potential use of BDC as a feasible salvage therapy in aSAH with associated refractory intracranial hypertension. Although evidence outside of TBI is limited, careful assessment of neurological exams, ICP trends, imaging, and outcomes may justify individual therapeutic application in specific patient populations. Multidisciplinary care remains essential for patient selection and improved outcomes.