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Objectives: There are plenty of scientific papers about efficiency of decompressive craniotomy (DC) for severe traumatic brain injury, acute massive MCA ischemia and also for SAH patients. Sometimes it’s necessary to perform primary DC which is to prevent refractory intracranial hypertension and brain herniation. It’s needed for patients with high risk of brain swallowing. However, it’s hard to anticipate poor condition and progression of hypertensive-dislocation syndrome. Obviously, some patients with poor grade SAH, clipped aneurysm and primary decompressive craniotomy do not experience brain swallowing. In such cases DC is unjustified. On the other hand, sometimes even wide primary DC could be ineffective and does not predict brain swallowing and herniation. There is still no evidence based indications for primary DC. The aim of this research is to discuss and identify indications for primary DC in poor grade SAH patients. Material and methods: We analyzed outcomes of 38 patients from 2010 to 2016, who were suffered from hypertensive-dislocation syndrome (HDS) because of intracranial aneurysm rupture (anterior circulation only) and underwent DC in addition to aneurysm clipping. Each patient has ICP monitoring and everyday TCD ultrasound control. We measured lateral dislocation and brain prolapse in craniotomy defect from 1st to 6th days after operation. Analysis of neurovisualisation, ICP monitoring and clinical presentation was performed. That helps to evaluate justification and efficiency of DC and divide these patients into three DC groups: 1) Unjustified (UJ) 2) Justified and Effective (JE) 3) Justified and Ineffective (JI). Outcomes were checked after 30 days from operation. Results: The Unjustified decompressive craniotomy group (UJ DC group) include 18 patients (47,4%), with excellent condition (GOS 5-4) in 11 patients and 7 favorable (GOS 3) cases. No deaths experienced in this group. This group is consisted of patients with: Hunt-Hess grade (II-IV), intracerebral hematoma volume less than 30 ml., lateral dislocation and brain prolapse 5 mm or less. In the Justified and Ineffective (JI) group were 20 patients (52,6%). Main features were: Hunt-Hess grade (V) intracerebral hematoma volume over 30 ml, lateral dislocation and brain prolapse more than 5 mm(min 5,6 mm – max 19 mm, mean 12 mm (±6mm)). Neurological outcomes were: GOS 5 – 5 patients, GOS 3 -8 patients, GOS 2 – 2 patients, GOS 1 - 1 case. Group of Justified and Ineffective (JI) DC include 3 patients with progressive refractory intracranial hypertension and brain herniation even with primary decompression. All of these patients died (GOS 1) because of severe diffuse delayed cerebral ischemia and brain swallowing. Conclusion: Primary DC should be considered as a method for prophylaxis of hypertensive-dislocation syndrome for patients who have: Hunt-Hess V grade (u-test, p=0,02), intracerebral hematoma volume over 30 ml (u-test, p=0,01)., lateral dislocation and brain prolapse more than 5 mm (u-test, p=0,01). Primary DC does not prevent delayed cerebral ischemia in patients with massive basal SAH. It’s essential to provide conservative treatment and perform secondary DC based on ICP indications.