Long-term functional outcomes and predictors of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms in the BRAT trial: revisiting the clip vs coil debate

Risk of Shunting After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose—

Shunt dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) is a common sequela that may lead to poor neurological outcome and predisposes to various interventions, admissions, and complications. We reviewed post-aSAH shunt dependency in a population-based sample and tested the feasibility of a clinical risk score to identify subgroups of aSAH patients with increasing risk of shunting for hydrocephalus.

Methods—

A total of 1533 aSAH patients from the population-based Eastern Finland Saccular Intracranial Aneurysm Database (Kuopio, Finland) were used in a recursive partitioning analysis to identify risk factors for shunting after aSAH. The risk model was built and internally validated in random split cohorts. External validation was conducted on 946 aSAH patients from the Southwestern Tertiary Aneurysm Registry (Dallas, TX) and tested using receiver-operating characteristic curves.

Results—

Of all patients alive ≥14 days, 17.7% required permanent cerebrospinal fluid diversion. The recursive partitioning analysis defined 6 groups with successively increased risk for shunting. These groups also successively risk stratified functional outcome at 12 months, shunt complications, and time-to-shunt rates. The area under the curve–receiver-operating characteristic curve for the exploratory sample and internal validation sample was 0.82 and 0.78, respectively, with an external validation of 0.68.

Conclusions—

Shunt dependency after aSAH is associated with higher morbidity and mortality, and prediction modeling of shunt dependency is feasible with clinically useful yields. It is important to identify and understand the factors that increase risk for shunting and to eliminate or mitigate the reversible factors. The aSAH-PARAS Consortium (Aneurysmal Subarachnoid Hemorrhage Patients’ Risk Assessment for Shunting) has been initiated to pool the collective insights and resources to address key questions in post-aSAH shunt dependency to inform future aSAH treatment guidelines.

Elderly age associated with poor functional outcome after rupture of anterior communicating artery aneurysms

The effect of age on patient outcomes after rupture of the anterior communicating artery (Acom) aneurysms is not well-defined. We performed a retrospective cohort study of patients presenting to our institution with a ruptured Acom aneurysm between 2003 and 2012. Patients were divided into two groups on the basis of age at presentation, with patients 65years and older categorized as the elderly group. The effect of elderly age on patient outcomes was then evaluated using multivariate logistic regression analysis. There were 147 patients presenting with a ruptured Acom aneurysm. Of these, 41 (27.9%) were 65years or older. Patients in the elderly group were more likely to be female (68.3% vs. 40.6%, p=0.0026), and less likely to be active smokers (22.0% vs. 60.4%, p<0.0001) or to abuse alcohol (7.3% vs. 21.7%, p=0.0404). Elderly patients were more likely to have a history of hypertension (70.7% vs. 52.8%, p=0.0487) and coronary artery disease (19.5% vs. 2.8%, p=0.0006). Elderly patients were more likely to require a ventriculostomy (61.0% vs. 37.7%, p=0.0109) and ultimately to require permanent cerebrospinal fluid diversion (36.6% vs. 17.0%, p=0.0106). On adjusted analysis, age 65 years or older was associated with a greater likelihood of poor outcome at last follow-up within 1year of aneurysmal subarachnoid hemorrhage (odds ratio=3.76, 95% confidence interval: 1.30-11.78, p=0.0144). Our results suggest that elderly age is an independent risk factor for poor functional outcome after rupture of an Acom aneurysm.

The CHESS score: a simple tool for early prediction of shunt dependency after aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Acute hydrocephalus is an early and common complication of aneurysmal subarachnoid hemorrhage (SAH). However, considerably fewer patients develop chronic hydrocephalus requiring shunt placement. Our aim was to develop a risk score for early identification of patients with shunt dependency after SAH.

METHODS

Two hundred and forty-two SAH individuals who were treated in our institution between January 2008 and December 2013 and survived the initial impact were retrospectively analyzed. Clinical parameters within 72 h after the ictus were correlated with shunt dependency. Independent predictors were summarized into a new risk score which was validated in a subsequent SAH cohort treated between January and December 2014.

RESULTS

Seventy-five patients (31%) underwent shunt placement. Of 23 evaluated variables, only the following five showed independent associations with shunt dependency and were subsequently used to establish the Chronic Hydrocephalus Ensuing from SAH Score (CHESS, 0-8 points): Hunt and Hess grade ≥IV (1 point), location of the ruptured aneurysm in the posterior circulation (1 point), acute hydrocephalus (4 points), the presence of intraventricular hemorrhage (1 point) and early cerebral infarction on follow-up computed tomography scan (1 point). The CHESS showed strong correlation with shunt dependency (P = 0.0007) and could be successfully validated in both internal SAH cohorts tested. Patients scoring ≥6 CHESS points had significantly higher risk of shunt dependency (P < 0.0001) than other patients.

CONCLUSION

The CHESS may become a valuable diagnostic tool for early estimation of shunt dependency after SAH. Further evaluation and external validation will be required in prospective studies.

Endovascular Coiling versus Surgical Clipping for Poor-Grade Ruptured Intracranial Aneurysms: Postoperative Complications and Clinical Outcome in a Multicenter Poor-Grade Aneurysm Study

BACKGROUND AND PURPOSE

Endovascular coiling is an alternative to surgical clipping for ruptured intracranial aneurysms. However, no large multicenter prospective study has compared coiling and clipping in patients with poor-grade ruptured aneurysms. We aimed to determine differences in postoperative complications and clinical outcome between the 2 treatments in this group of patients.

MATERIALS AND METHODS

A Multicenter Poor-Grade Aneurysm Study was a prospective, multicenter, observational registry of consecutive patients who presented with poor-grade ruptured aneurysms. Three hundred sixty-six patients were enrolled from October 2010 to March 2012. "Poor-grade aneurysm" was defined as a World Federation of Neurosurgical Societies grade of IV or V at the time of aneurysm treatment. Two hundred sixty-two patients received aneurysm treatment within 21 days and were included. Clinical outcomes were assessed at discharge and at 6 and 12 months by the modified Rankin Scale.

RESULTS

One hundred thirty-three (50.8%) patients underwent endovascular coiling. Unadjusted analysis showed that the outcome rate (mRS 0-1 or mRS 0-2) at 6 and 12 months in patients undergoing coiling was higher than that in patients undergoing clipping. In adjusted analyses, there was no statistically significant difference in outcomes at 6 and 12 months between the 2 groups. The risk of radiologic hydrocephalus was higher in patients treated with coiling than that in those treated with clipping (adjusted OR, 3.36; 95% CI, 1.13-10.01; P = .030).

CONCLUSIONS

The long-term outcome in selected patients was similar between endovascular coiling and clipping for poor-grade ruptured aneurysms. The risk of radiologic hydrocephalus was higher after endovascular treatment of poor-grade aneurysms.

Endovascular Treatment of Intracranial Aneurysms with the WEB Device: A Systematic Review of Clinical Outcomes

BACKGROUND AND PURPOSE

Despite the improvement in technology, endovascular treatment of bifurcation intracranial wide-neck aneurysms remains challenging, mainly due to the difficulty of maintaining coils within the aneurysm sac without compromising the patency of bifurcation arteries. The Woven EndoBridge (WEB) device is a recent intrasaccular braided device specifically dedicated to treating such aneurysms with a wide neck by disrupting the flow in the aneurysmal neck and promoting progressive aneurysmal thrombosis.

MATERIALS AND METHODS

Using several health data bases, we conducted a systematic review of all published studies of WEB endovascular treatment in intracranial aneurysms from 2010 onward to evaluate its efficacy and safety profile.

RESULTS

The literature search identified 6 relevant studies (7 articles) including wide-neck bifurcation aneurysms in ≥80% of cases. Clinical data supporting the efficacy and safety of the WEB are limited to noncomparative cohort studies with large heterogeneity from a methodologic standpoint. The WEB deployment was feasible with a success rate of 93%-100%. Permanent morbidity (mRS of >1 at last follow-up) and mortality were measured at 2.2%-6.7% and 0%-17%, respectively. The adequate occlusion rate (total occlusion or neck remnant) varied between 65% and 85.4% at midterm follow-up (range, 3.3-27.4 months).

CONCLUSIONS

Endovascular treatment of bifurcation wide-neck aneurysms with the WEB device is feasible and allows an acceptably adequate aneurysm occlusion rate; however, the rate of neck remnants is not negligible. The WEB device needs further clinical and anatomic evaluation with long-term prospective studies, especially of the risk of WEB compression. Prospective controlled studies should be encouraged.

Predictors of Shunt-Dependent Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Shunt-dependent hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH). There is a need to identify patients who require ventriculoperitoneal shunt (VPS) insertion so that any modifiable risk factors can be addressed early after aSAH.

METHODS

Exploratory analysis was performed on 413 patients enrolled in CONSCIOUS-1, a prospective randomized controlled trial of patients with aSAH treated with clazosentan. The association between clinical and neuroimaging covariates and VPS placement was first determined by univariate analysis. Covariates with P < 0.15 on univariate analysis were then analyzed in a multivariate logistic regression model. Receiver operating characteristic curve analysis was used to define optimal predictive thresholds. The published literature was reviewed to determine the overall rate of VPS insertion after aSAH.

RESULTS

Overall, 17.2% (71/413) of patients required VPS insertion. Multivariate analysis demonstrated that insertion of an external ventricular drain (odds ratio, 6.21; 95% confidence interval, 2.51-16.91) and increasing volume of cerebrospinal fluid (CSF) drainage per day (odds ratio, 1.004; 95% confidence interval, 1.000-1.009) were associated with VPS insertion. Receiver operating characteristic curve analysis revealed an optimal daily CSF output threshold of 78 mL was predictive of VPS insertion. Among 41,789 patients with aSAH from 66 published studies, the overall VPS insertion rate was 12.7%.

CONCLUSIONS

The presence of an external ventricular drain and increased daily CSF output (above 78 mL/day) seems to be predictive of subsequent VPS insertion after aSAH. Although we could not identify modifiable risk factors for needing a VPS, nevertheless, these findings identify patients at greatest risk of VPS placement and inform treatment decisions as well as patient expectations.