Distribution of cisternal blood in patients with acute hydrocephalus after subarachnoid hemorrhage

Post-craniectomy hydrocephalus in adult traumatic brain injury patients: a systematic review and meta-analysis of risk factors and outcome

Traumatic Brain Injury (TBI) is a major cause of death, disability, and healthcare expenses worldwide. Decompressive craniectomy (DC) is a critical surgery used when there is uncontrollable swelling in the brain following a TBI. Research has shown that 27.4% of patients who underwent DC for severe TBI developed hydrocephalus, leading to a significant impact on their quality of life and long-term outlook. We conducted a review of hydrocephalus risk factors in adult TBI patients who underwent DC to better understand the factors contributing to this condition. The comprehensive search strategy covered PubMed, Scopus, Embase, and Web of Science databases from inception to June 2024. The search terms "Craniectomy AND Hydrocephalus AND Trauma* and Decompress*" were applied to titles, abstracts, and keywords. Out of 887 publications found, 591 remained after removing duplicates. After reviewing titles and abstracts, 480 articles were excluded. Of the remaining 111 articles, 87 were excluded for various reasons, leaving 22 for the meta-analysis. The cumulative sample size was 2888, and the incidence of hydrocephalus was 20.5%. We analyzed 28 variables and of them, 13 were associated with hydrocephalus, Subrachnoid hemorrhage (OR:1.75), Intraventricular hemorrhage (OR: 2.49), At least one pupil dilation (OR: 2.01), Preoperative GCS < 6, Craniectomy Margin Distance from Midlineless than 21 mm, size of craniectomy greater than 106.75 cm2, TCHBV greater than 69, bilateral craniectomy (OR: 3.75), Postoperative intracranial infection (OR: 2.7), Postoperative Cerebral infarction (OR: 2.74), interhemispheric Hygroma (OR: 5.53), contralateral Hygroma (OR: 4.18), and bilateral Hygroma (OR: 2.55). Hydrocephalus following DC is notably linked to an adverse outcome (Glasgow Outcome Scale 1, 2, 3 OR: 4.06). After decompressive craniectomy, hydrocephalus significantly affects traumatic brain injury recovery. Our analysis found that the craniectomy margin distance from the midline less than 21 mm is a modifiable risk factor for hydrocephalus development. Other significant risk factors will help diagnose at-risk patients, address hydrocephalus promptly, and ultimately improve patient outcomes.

Comparison of Outcomes of Hinge Craniotomy Versus Decompressive Craniectomy in Patients With Malignant Intracranial Hypertension: A Prospective, Randomized Controlled Study

Objective

This randomized controlled trial (RCT) aimed to compare the short-, mid-, and long-term outcomes in patients with malignant intracranial hypertension undergoing either decompressive craniectomy (DC) or hinge craniotomy (HC).

Methods

In this prospective RCT, 38 patients diagnosed with malignant intracranial hypertension due to ischemic infarction, traumatic brain injury, or non-lesional spontaneous intracerebral hemorrhage, who required cranial decompression, were randomly allocated to the DC and HC groups.

Results

The need for reoperation, particularly cranioplasty, in the DC group was significantly different from that in the HC group. The percentage of brain expansion was higher in the DC group versus the HC group; however, the difference was not significant. There was no significant intergroup difference in the functional outcome according to the modified Rankin Scale or the Glasgow Outcome Scale. Additionally, no significant intergroup differences were observed in the rates of in-hospital complications.

Conclusion

The HC and DC groups did not significantly differ in the rate of hospital complications such as infection, need for reoperation owing to the lack of intracranial pressure control, wound healing problems, or bone infection. Our results suggest that by performing HC, the probability of the need for major surgery (cranioplasty) is reduced, thereby removing financial burden from the patient and the health system.

Trial Registration

Iranian Registry of Clinical Trials Identifier: IRCT20180515039678N1.

Emergency Medical Management of Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage is a medical emergency that necessitates direct transfer to a tertiary referral center specialized in the diagnosis and treatment of this condition. The initial hours after aneurysmal rupture are critical for patients with aneurysmal subarachnoid hemorrhage, both in terms of rebleeding and combating the effect of early brain injury. No good treatment options are available to reduce the risk of rebleeding before aneurysm occlusion. Lowering the blood pressure may reduce the risk of rebleeding but carries a risk of inducing delayed cerebral ischemia or aggravating the consequences of early brain injury. Early brain injury after aneurysmal rupture has an important effect on final clinical outcome. Proper cerebral perfusion is pivotal in these initial hours after aneurysmal rupture but threatened by complications such as neurogenic pulmonary edema and cardiac stunning, or by acute hydrocephalus, which may necessitate early drainage of cerebrospinal fluid.

Outcomes of Cranioplasty: A Single-Center Experience

Background Cranioplasty (CP) is a common cranial reconstructive procedure. It is performed after craniectomy due to various causes such as relieving increased intracranial pressure, infection, and tumor infiltration. Although CP is an easy procedure, it is associated with a high rate of complications. We aimed to retrospectively investigate the outcomes of CP at the King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah (KAMC-J). Methods This is a retrospective observational study that included all patients who had CP (first time or redo) at KAMC-J from 1st January 2010 to 31st December 2020. Patients with congenital cranial malformation were excluded.  Result A total of 68 patients underwent CP. Of those, 23 (34%) had complications. The most common complication was infection (10.3%). Twelve of the 23 patients had major complications that necessitated reoperation. Of those 12, six underwent redo CP; three out of these six patients had further complications which were also managed surgically. On bivariate analysis, cranial defects over 50 cm² were associated with a higher rate of both infection and hydrocephalus (p=0.018) while the frontal site was associated with a higher rate of infection (p=0.014). Moreover, traumatic brain injury as an etiology was exclusively associated with post-cranioplasty hydrocephalus (p=0.03).  Conclusion Patients undergoing CP after craniectomy are prone to a considerably high rate of adverse outcomes. The overall rate of complications in this study was 34%, with an infection rate of 10.3% and a 1.5% mortality rate. Consistent with other studies, larger cranial defects as well as frontal sites have a higher rate of infection.

Acute hydrocephalus and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage

BACKGROUND

Delayed cerebral infarction (DCIn) following aneurysmal subarachnoid hemorrhage (aSAH) is a major cause of morbi-mortality; yet, the causes for DCIn remain incompletely understood.

OBJECTIVE

We tested the hypothesis that acute hydrocephalus could be related to the occurrence of DCIn, independently of the occurrence and severity of vasospasm.

METHODS

Radiological and clinical data of patients treated at a single large volume academic center for aSAH between 2017 and 2019 were retrospectively analyzed. DCIn was defined as imaging stigma of cerebral infarction visible on 6-week imaging follow-up after aSAH. Hydrocephalus was defined on baseline imaging as a relative bicaudate index above 1. Cerebral vasospasm was defined by reduction of artery diameter in comparison with initial diameter. We used uni- and multivariable models to test the associations between these variables, hydrocephalus and DCIn.

RESULTS

Of 164 included patients, vasospasm occurred in 58 patients (35.4%), and DCIn in 47 (28.7%). Acute hydrocephalus was present in 85 patients (51.8%) on baseline CT. No relation was found between acute hydrocephalus and delayed cerebral infarction in our multivariate analysis (adjusted OR: 1.20 95% CI [0.43-3.37]; p = 0.732). Only vasospasm occurrence was independently associated with DCIn (adjusted OR: 10.97 95% CI [4.60-26.01]).

CONCLUSION

Our study did not show an association between acute hydrocephalus and DCIn after aSAH, after adjustment for the presence and severity of cerebral vasospasm.

Aggravation of Enlarged Perivascular Spaces in the Centrum Semiovale of Patients with Aneurysmal Subarachnoid Hemorrhage

PURPOSE

This study aimed to investigate whether enlarged perivascular spaces (ePVS) within the basal ganglia (BG) or centrum semiovale (CSO) aggravate in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

We retrospectively evaluated 139 patients who had undergone brain magnetic resonance imaging (MRI) within 1 month of aSAH occurrence from January 2007 to November 2018. Follow-up brain MRI of 99 patients were available. We scored ePVS in the BG and CSO on a score of 0-4 (0 = no ePVS, 4 ≥ 40 ePVS) on initial and follow-up T2-weighted MRI. Aggravation of ePVS was defined as an ePVS score increase of ≥ 1 on follow-up MRI compared to the initial score. We compared the characteristics between patients with and without aggravation of ePVS and investigated associated variables using logistic regression.

RESULTS

Aggravation of ePVS in the CSO and BG was noted in 31 (31.3%) and 6 (6.1%) patients, respectively. After adjusting for age, sex, and the MRI follow-up period, aggravation of ePVS in the CSO was independently associated with a high Fisher grade (p = 0.007) and high burden of initial ePVS in the CSO (p = 0.049).

CONCLUSION

Aggravation of ePVS, particularly those in the CSO, had occurred in the long-term follow-up of aSAH patients. This was independently associated with a high burden of aSAH. The amount of subarachnoid blood might have aggravated the drainage of interstitial fluid through glymphatic dysfunction.

Transient acute hydrocephalus after aneurysmal subarachnoid hemorrhage and aneurysm embolization: a single-center experience

PURPOSE

Acute hydrocephalus is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). It can be self-limiting or require cerebrospinal fluid diversion. We aimed to determine the transient acute hydrocephalus (TAH) rate in patients with aSAH treated endovascularly and evaluate its predictive factors.

METHODS

A retrospective review of 357 patients with aSAH who underwent endovascular treatment from March 2013 to December 2019 was performed. Clinical and radiographic data were analyzed and risk factors with potential significance for acute hydrocephalus were identified. We constructed a new risk score, the Drainage Or Transiency of Acute Hydrocephalus after Aneurysmal SAH (DOTAHAS) score, that may differentiate patients who would experience TAH from those needing surgical interventions.

RESULTS

Acute hydrocephalus occurred in 129 patients (36%), out of whom in 66 patients (51%) it was self-limiting while 63 patients (49%) required external ventricular drainage placement. As independent risk factors for acute hydrocephalus, we identified older age, poor initial clinical condition, aSAH from posterior circulation, and the extent of cisternal and intraventricular hemorrhage. The following three factors were shown to predict acute hydrocephalus transiency and therefore included in the DOTAHAS score, ranging from 0 to 7 points: Hunt and Hess grade ≥ 3 (1 point), modified Fisher grade 4 (2 points), and Ventricular Hijdra Sum Score (vHSS) ≥ 6 (4 points). Patients scoring ≥ 3 points had significantly higher risk for EVD (P < 0.0001) than other patients.

CONCLUSION

The newly developed DOTAHAS score can be useful in identifying patients with transient acute hydrocephalus. Further score evaluation is needed.

The risk factors of shunt-dependent hydrocephalus after subarachnoid space hemorrhage of intracranial aneurysms

Shunt-dependent hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) which indicated intensive care unit stay and unfavorable outcome. Our aim is to study the risk factors of shunt-dependent hydrocephalus after aneurysmal subarachnoid space hemorrhage. Patients with intracranial aneurysms treated in our department from January 2014 to October 2018 were included in the study. Patients' age, gender, history of hypertension and diabetes, location of aneurysms, Glasgow coma scale (GCS) score, Hunt-Hess grading, intraventricular hemorrhage, therapeutic option, shunt placement, clinical outcome, length of stay were analyzed. The follow-up period was 1 to 5 years. Statistics included Chi-squared, Student t test, 1-way analysis of variance, Pearson correlation coefficient, and multivariate logistic regression. About 845 cases with intracranial aneurysms treated in our department were included in the study. The mean age was 52.19 ± 9.51 years and the sex ratio was 317/528. About 14.3% (121/845) of the patients developed shunt-dependent hydrocephalus in the follow-up period. According to our results, older than 60, Hunt-Hess grading, GCS, coma, posterior circulation aneurysm, external ventricular drainage, and decompress craniotomy were risk factors of shunt dependency (P < .05). Moreover, older than 60, GCS 3 to 8, Hunt-Hess 3 to 5, and posterior circulation aneurysm were the independent risk factors of shunt dependency. Moreover, shunt dependency was related to longer hospital stay and unfavorable outcome (P < .05). In conclusion, patients older than 60, GCS 3 to 8, Hunt-Hess 3 to 5, and posterior circulation aneurysm need more strict observation and longer follow-up. Timely and appropriate treatment may benefit patients in recovery, while further exploration is still needed in the future.

Predicting factors for shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Chronic hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) is a major complication that leads to a medical burden and poor clinical outcomes. The aim of this study was to evaluate the predictive factors of shunt-dependent hydrocephalus focusing on postoperative fever and infection.

METHOD

A total of 418 patients were included in this study and the patient demographic features, radiologic findings, days of fever burden, and infection were compared between the shunt (n = 72) and no shunt group (n = 346). Days of fever burden was defined as the total number of days with the highest body temperature ≥ 38.0 °C each day from day 1 to day 14. Pneumonia, urinary tract infection (UTI), meningitis, and bacteremia were recorded in all patients.

RESULTS

The independent predictive factors for shunt-dependent hydrocephalus were older age ≥ 65, microsurgical clipping, placement of extraventricular drainage (EVD), days of fever burden, and infection. The incidence of shunt dependency was 2.4% in the no fever burden patients (n = 123), 14.9% in the 1-3 days of fever burden patients (n = 161), 27.0% in the 4-6 days of fever burden patients (n = 74), and 41.7% in the ≥ 7 days of fever burden patients with statistical significance among groups (p < 0.001).

CONCLUSION

The rate of shunt dependency increased proportionally as the days of fever burden increased. Older age (≥ 65), microsurgical clipping, placement of EVD, days of fever burden, and infection were independent predictive factors for shunt dependency. Proper postoperative care for maintaining normal body temperature and preventing infectious disease can help reduce the rate of shunt dependency and improve clinical outcomes.

A novel score to predict shunt dependency after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Feasible clinical scores for predicting shunt-dependent hydrocephalus (SDHC) after aneurysmal subarachnoid hemorrhage (aSAH) are scarce. The chronic hydrocephalus ensuing from SAH score (CHESS) was introduced in 2015 and has a high predictive value for SDHC. Although this score is easy to calculate, several early clinical and radiological factors are required. The authors designed the retrospective analysis described here for external CHESS validation and determination of predictive values for the radiographic Barrow Neurological Institute (BNI) scoring system and a new simplified combined scoring system.

METHODS

Consecutive data of 314 patients with aSAH were retrospectively analyzed with respect to CHESS parameters and BNI score. A new score, the shunt dependency in aSAH (SDASH) score, was calculated from independent risk factors identified with multivariate analysis.

RESULTS

Two hundred twenty-five patients survived the initial phase after the hemorrhage, and 27.1% of these patients developed SDHC. The SDASH score was developed from results of multivariate analysis, which revealed acute hydrocephalus (aHP), a BNI score of ≥ 3, and a Hunt and Hess (HH) grade of ≥ 4 to be independent risk factors for SDHC (ORs 5.709 [aHP], 6.804 [BNI], and 4.122 [HH]; p < 0.001). All 3 SDHC scores tested (CHESS, BNI, and SDASH) reliably predicted chronic hydrocephalus (ORs 1.533 [CHESS], 2.021 [BNI], and 2.496 [SDASH]; p ≤ 0.001). Areas under the receiver operating curve (AUROC) for CHESS and SDASH were comparable (0.769 vs 0.785, respectively; p = 0.447), but the CHESS and SDASH scores were superior to the BNI grading system for predicting SDHC (BNI AUROC 0.649; p = 0.014 and 0.001, respectively). In contrast to CHESS and BNI scores, an increase in the SDASH score coincided with a monotonous increase in the risk of developing SDHC.

CONCLUSIONS

The newly developed SDASH score is a reliable tool for predicting SDHC. It contains fewer factors and is more intuitive than existing scores that were shown to predict SDHC. A prospective score evaluation is needed.

Adult posthaemorrhagic hydrocephalus animal models

Posthaemorrhagic hydrocephalus (PHH) is often associated with high morbidity and mortality and serves as an important clinical predictor of poor outcomes after intracranial haemorrhage (ICH). We are lack of effective medical intervention methods to improve functional outcomes in patients with PHH because little is still known about the mechanisms of PHH pathogenesis. Animal models play a key role in the study of PHH. Developed a suitable animal model that will help us to be better to find preventative strategies and improve the prognosis of patients with PHH. The purpose of this review is to summarize the body of knowledge gained from animal studies.

Current Management of Aneurysmal Subarachnoid Hemorrhage Guidelines from the Canadian Neurosurgical Society

Published medical evidence pertaining to the management of aneurysmal subarachnoid hemorrhage (SAH) was critically reviewed in order to prepare practice guidelines for this condition. SAH should be considered as a possible cause of all sudden and/or unusual headaches, and every attempt should be made to recognize mild SAHs, as they are still frequently misdiagnosed. The first test for SAH is computed tomography (CT), followed by lumbar puncture when the CT is negative for intracranial bleeding (the case in only several per cent of patients within 24 hours of aneurysm bleeding). Urgent cerebral angiography is necessary to detect the underlying cerebral aneurysm. The advantage of rapid diagnosis of SAH followed by early aneurysm repair is minimizing the risk of catastrophic aneurysm rebleeding. Early surgery for aneurysm repair is often possible and is recommended, unless the aneurysm location or size renders it technically difficult to expose in clot-laden subarachnoid cisterns beneath an acutely swollen brain. Aneurysm ablation is optimally accomplished with open microsurgery and clipping of the aneurysm neck, although other options include proximal parent artery occlusion, “trapping” of the aneurysmal segment of the artery, and embolization of thrombogenic materials (e.g., platinum “microcoils”) directly into the aneurysm dome using endovascular techniques. Neurological outcome following SAH is also optimized through the prevention of secondary SAH complications, and further management specific for ruptured cerebral aneurysms can include anticonvulsants, neuroprotectants, and various agents and techniques to prevent or reverse delayed-onset cerebral vasospasm. All patients with aneurysmal SAH should be treated with the calcium antagonist nimodipine, and in certain circumstances patients should receive anticonvulsants. Induced arterial hypertension, hypervolemia and in some instances percutaneous balloon angioplasty are recommended to reverse vasospasm causing symptomatic cerebral ischemia prior to cerebral infarction.

Shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage: the role of intrathecal interleukin-6

OBJECT

Aneurysmal subarachnoid hemorrhage (SAH) has been reported to induce an intrathecal inflammatory reaction reflected by cytokine release, particularly interleukin-6 (IL-6), which correlates with early brain damage and poor outcome. The present study examines intrathecal IL-6 production together with clinical parameters, as a predictor of posthemorrhagic shunt dependency.

METHODS

Among 186 SAH patients admitted between July 2010 and December 2012, 82 received external ventricular drainage due to acute hydrocephalus. In these patients, cerebrospinal fluid (CSF) concentrations of IL-6 were measured within the first 14 days after SAH. Patients whose IL-6 values were not determined regularly and those who did not survive until discharge were excluded. The peak value of IL-6, ventricular infection during the hospital stay, microbial CSF culture, patient's age and sex, Hunt and Hess grade, and aneurysm location were assumed as predictive for shunt dependency.

RESULTS

Sixty-nine patients were included, 24 of whom underwent shunt surgery. Peak IL-6 values of ≥10,000 pg/ml were significantly associated with a higher incidence of shunt dependency (p = 0.009). Additional risk factors were aneurysm location on the anterior cerebral artery and its branches or in the posterior circulation (p = 0.025), and age ≥60 years (p = 0.014). In a multivariate analysis, IL-6 ≥10,000 pg/ml appeared to be the only independent predictor for shunt dependency (p = 0.029) CONCLUSION: CSF IL-6 values of ≥10,000 pg/ml in the early post-SAH period may be a useful diagnostic tool for predicting shunt dependency in patients with acute posthemorrhagic hydrocephalus. The development of shunt-dependent posthemorrhagic hydrocephalus remains a multifactorial process.

Impact of intraventricular hemorrhage measured by Graeb and LeRoux score on case fatality risk and chronic hydrocephalus in aneurysmal subarachnoid hemorrhage

BACKGROUND

Reliable prognostic tools to estimate the case fatality rate (CFR) and the development of chronic hydrocephalus (CHC) in aneurysmal subarachnoid hemorrhage (SAH) are not well defined. This study aims to investigate the practicability and reliability of Fisher, Graeb, and LeRoux scores for SAH patient prognosis.

METHODS

A total of 206 patients with aneurysmal SAH were retrospectively analyzed in prediction of CFR and CHC. Clinical data was evaluated and grading was performed using Fisher, Graeb, and LeRoux scores. Univariate and multivariate analyses were performed to identify relevant predictive parameters.

RESULTS

CFR was 17.0 % and was associated with higher age, higher Hunt & Hess (H&H) grade, lower Glasgow Coma Scale (GCS) at admission, as well as a higher Fisher, Graeb, and LeRoux score (p < 0.001). There were 19.9 % that developed CHC requiring permanent cerebrospinal fluid diversion. Low initial GCS (p = 0.003), high H&H (p < 0.001), intracerebral hematoma (p = 0.003), high Fisher (p = 0.047), Graeb and LeRoux scores (p < 0.001) were associated with a higher rate of ventricular-peritoneal shunting (VPS) in surviving patients. In multivariate analyses, Graeb score (odds ratio (OR) 1.183 [1.027, 1.363], p = 0.020), LeRoux score (OR 1.120 [1.013-1.239, p = 0.027), and H&H (OR 2.715 [1.496, 4.927], p = 0.001) remained independent prognostic factors for VPS.

CONCLUSIONS

Graeb or LeRoux scores improve the prediction of shunt dependency and in parts of CFR in aneurysmal SAH patients therefore confirming the relevance of the extent and distribution of intraventricular blood for the clinical course in SAH.

Factors that predict hydrocephalus following intraventricular hemorrhage

OBJECTIVE

To evaluate potential risk factors that can predict the development of hydrocephalus (HCP) in adult patients with intraventricular hemorrhage (IVH).

METHODS

Retrospective analysis of all adult patients presented to King Fahad Medical City between 2004 and 2011 with intraventricular hemorrhage to evaluate different variables and their association with HCP.

RESULTS

A total of 31 patients were included in the study, 14 patients (45.16%) developed HCP. Seventy-four percent of HCP patients (10 out of 14) had Graeb classification of ≥6 and/or had IVH affecting all ventricles, while 76% of the patients without HCP (13 out of 17) had a Graeb classification of <6 and/or had IVH only in the lateral ventricles (8 out of 17) or lateral ventricles and either third or fourth ventricle (5 out of 17). Statistical analysis showed that HCP is significantly associated with both Graeb classification of 6 or greater number of IVH affecting all ventricles and 3 versus 1-2 affected ventricles; (OR (95% CI, p value), respectively, 19.3(2, >20), p value<0.05; 8.5 (1.6, >30), p value<0.05.

CONCLUSION

HCP following IVH is present in approximately half of all IVH cases. In the present retrospective study, it was found that patients with higher grades of IVH and/or a greater number of affected ventricles had a greater risk of developing HCP.

The influence of decompressive craniectomy on the development of hydrocephalus: a review

Decompressive craniectomy (DC) is widely used to treat intracranial hypertension following traumatic brain injury (TBI) or cerebral vascular disease. Many studies have discussed complications of this procedure, and hydrocephalus is a common complication of DC. To further evaluate the relationship between DC and hydrocephalus, a review of the literature was performed. Numerous complications may arise after DC, including contusion or hematoma expansion, epilepsy, herniation of the cortex through a bone defect, CSF leakage through the scalp incision, infection, subdural effusion, hydrocephalus and “syndrome of the trephined”. Several hydrocephalus predictors were identified; these included DC, distance from the midline, hygroma, age, injury severity, subarachnoid or intraventricular hemorrhage, delayed time to craniotomy, repeated operation, and duraplasity. However, results differed among studies. The impact of DC on hydrocephalus remains controversial.

Comparison of Incidence and Risk Factors for Shunt-dependent Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage Patients

Objective

The objective of this study was to compare the incidence of ventricular shunt placement for shunt-dependent hydrocephalus (SDHC) after clipping versus coiling of ruptured aneurysms.

Materials and Methods

A retrospective review was conducted in 215 patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent surgical clipping or endovascular coiling during the period from May 2008 to December 2011. Relevant clinical and radiographic data were analyzed with regard to the incidence of hydrocephalus and ventriculo-peritoneal shunt (VPS). Patients treated with clipping were assigned to Group A, while those treated with coiling were assigned to Group B.

Results

Of 215 patients (157 clipping, 58 coiling), no significant difference in the incidence of final VPS was observed between treatment modalities (15.3% vs. 10.3%) (p = 0.35). Independent risk factors for VPS for treatment of chronic hydrocephalus were as follows: (1) older than 65 years, (2) poorer Hunt-Hess grade IV and V, (3) Fisher grade III and IV, and (4) particularly initial presence of an intraventricular hemorrhage.

Conclusion

In this study comparing two modalities for treatment of aneurysm, there was no difference in the incidence of chronic hydrocephalus requiring VPS. A significantly higher rate of shunt dependency was observed for age older than 65 years, poor initial neurological status, and thick SAH with presence of initial intraventricular hemorrhage. By understanding these factors related to development of SDHC and results, it is expected that management of aneurysmal SAH will result in a better prognosis.

Predictors of shunt-dependent chronic hydrocephalus after aneurysmal subarachnoid haemorrhage

INTRODUCTION

Chronic hydrocephalus is a common complication that can occur after aneurysmal subarachnoid haemorrhage (SAH). The purpose of this study was to investigate clinical risk factors that could predict the occurrence of shunt-dependent chronic hydrocephalus after aneurysmal SAH.

METHODS

Eighty-eight consecutive patients who underwent either surgery or transarterial endovascular embolization as a treatment for cerebral aneurysm within 72 h -after experiencing SAH from March 2005 to July 2006 were studied retrospectively to assess the risk factors that might predict shunt-dependent chronic hydrocephalus. Clinical and demographic factors were examined, including age, sex, initial admission mean arterial blood pressure (MABP), blood sugar level at admission, fever frequency, initial external ventricular drainage (EVD), Fisher grade, Hunt and Hess grade, intraventricular haemorrhage (IVH) and treatment methods to define predictors of shunt-dependent hydrocephalus. The length of hospital stay and modified Rankin scale recorded 6 months after SAH were also evaluated; these parameters were compared between the shunt-dependent and non-shunt-dependent groups.

RESULTS

Of the 88 patients, 22 (25%) underwent shunt placement to treat their chronic hydrocephalus. The average length of hospital stay was 33.9 days for the shunt-treated group and 14 days for the non-shunt-treated group. The non-shunt-treated group scored an average of 1.05 on the modified Rankin scale compared with 2.77 for the shunt-treated group. A univariate analysis revealed that several admission variables were associated with long-term shunt-dependent hydrocephalus: (1) increased age (p = 0.023); (2) initial admission MABP (p = 0.027); (3) a high Fisher grade (p = 0.031); (4) a poor admission Hunt and Hess grade (p = 0.030); (5) the presence of IVH (p = 0.029), and (6) initial EVD (p < 0.0001). The factor most commonly associated with shunt-dependent hydrocephalus over the course of hospital days was fever frequency (p < 0.0001).

CONCLUSIONS

Chronic hydrocephalus after aneurysmal SAH has a multifactorial aetiology. Understanding the risk factors that predict the occurrence of chronic hydrocephalus may help neurosurgeons to expedite permanent cerebrospinal fluid diversion, which could decrease both the cost and length of hospital stay and prevent further complications.

European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage

BACKGROUND

Intracranial aneurysm with and without subarachnoid haemorrhage (SAH) is a relevant health problem: The overall incidence is about 9 per 100,000 with a wide range, in some countries up to 20 per 100,000. Mortality rate with conservative treatment within the first months is 50-60%. About one third of patients left with an untreated aneurysm will die from recurrent bleeding within 6 months after recovering from the first bleeding. The prognosis is further influenced by vasospasm, hydrocephalus, delayed ischaemic deficit and other complications. The aim of these guidelines is to provide comprehensive recommendations on the management of SAH with and without aneurysm as well as on unruptured intracranial aneurysm.

METHODS

We performed an extensive literature search from 1960 to 2011 using Medline and Embase. Members of the writing group met in person and by teleconferences to discuss recommendations. Search results were graded according to the criteria of the European Federation of Neurological Societies. Members of the Guidelines Committee of the European Stroke Organization reviewed the guidelines.

RESULTS

These guidelines provide evidence-based information on epidemiology, risk factors and prognosis of SAH and recommendations on diagnostic and therapeutic methods of both ruptured and unruptured intracranial aneurysms. Several risk factors of aneurysm growth and rupture have been identified. We provide recommendations on diagnostic work up, monitoring and general management (blood pressure, blood glucose, temperature, thromboprophylaxis, antiepileptic treatment, use of steroids). Specific therapeutic interventions consider timing of procedures, clipping and coiling. Complications such as hydrocephalus, vasospasm and delayed ischaemic deficit were covered. We also thought to add recommendations on SAH without aneurysm and on unruptured aneurysms.

CONCLUSION

Ruptured intracranial aneurysm with a high rate of subsequent complications is a serious disease needing prompt treatment in centres having high quality of experience of treatment for these patients. These guidelines provide practical, evidence-based advice for the management of patients with intracranial aneurysm with or without rupture. Applying these measures can improve the prognosis of SAH.

CT evaluation of lateral ventricular dilatation after subarachnoid hemorrhage: baseline bicaudate index values [correction of balues]

OBJECTIVES

To define baseline bicaudate index (BCI) values in patients with subarachnoid hemorrhage (SAH).

METHODS

We reviewed the clinical and radiological information on consecutive adult patients admitted with acute SAH to our hospital between 1 January 2002 and 1 January 2008. Patients without diagnosis of acute hydrocephalus were entered into this study. Age-stratified BCI values were calculated.

RESULTS

Our study cohort comprised 108 patients (66 women, 61%). The clinical status at presentation was excellent with a median score of 1 on the World Federation of Neurological Surgeons Scale. Cisternal blood burden was mild to moderate with a median Hijdra score of 17 (out of 30). The upper limits of normal (ninety-fifth percentile) for BCI were 0·12 at age 45 years and under, 0·14 at 55 years, 0·16 at 65 years, and 0·17 thereafter.

CONCLUSION

Albeit not perfect, the BCI is a commonly used linear measure of the lateral ventricular size. We present baseline BCI values in a cohort of patients with acute SAH. A diagnosis of hydrocephalus can be made when the BCI value exceeds the upper limit of normal for age.

Toward changing of the pathophysiologic basis of acute hydrocephalus after subarachnoid hemorrhage: a preliminary experimental study

BACKGROUND

Acute hydrocephalus (ventricular enlargement within 72 hours) is a common complication in patients with aneurysmal subarachnoid hemorrhage (SAH). Cerebrospinal fluid (CSF) secretion may be increased in the early phases of SAH, but it has not been proved definitively. We studied the histologic features of choroid plexus (CP) in the early and late phases of SAH.

METHODS

This study was conducted on 20 rabbits, with 5 rabbits in the control group, 5 rabbits in the sham group, and 10 rabbits in the SAH group. In the SAH group, five of the animals were decapitated after 2 days of cisternal blood injections, and the other five animals were decapitated after 14 days of injections. The CP of lateral ventricles were obtained from coronary sections of brains at the level of the temporal horns of the lateral ventricles. Sections were stained with hematoxylin and eosin and Masson trichrome for SAH-related damage and examined stereologically to discern water-filled vesicles, which were counted. Sections were compared statistically.

RESULTS

The mean numbers of water vesicles were different after SAH between the early decapitated group (group III) and the late decapitated group (group IV). The mean numbers of water vesicles were 2.80 (± 0.05) in the control group (group I), 2.76 (± 0.02) in the sham group (group II), 14.68 (± 0.06) in the early decapitated group (group III), and 4.78 (± 0.13) in the late decapitated group (group IV). Total number of fluid-filled vesicles of CP was also assessed stereologically; the total numbers were 840 (± 16) in group I, 828 (± 7) in group II, 4404 (± 19) in group III, and 1434 (± 41) in group IV. The numbers of water-filled cisterns were significantly increased in the early phases of SAH (P < 0.05).

CONCLUSIONS

In SAH with aneurysm rupture, increased CSF secretion seems to be triggered by hemorrhage in the early phase, but it is not possible in the late phase because of CP degeneration. In the early phase of hemorrhage, CSF secretion may be stimulated by the irritant receptor glossopharyngeal and vagal nerve endings, which innervate the healthy CP epithelium and arteries. Our findings may be accepted as being causative. It is likewise possible that CSF blockage per se leads to hydrocephalus, and the morphologic changes are sequelae that occur later in the course of disease. This is the first study to show the water vesicles of CP as a causative factor in the development of acute hydrocephalus after SAH.

Effect of cisternal drainage on the shunt dependency following aneurysmal subarachnoid hemorrhage

Objective

Shunt-dependent chronic hydrocephalus (SDCH) is known to be a major complication associated with aneurysmal subarachnoid hemorrhage (aSAH). Old age is known to be one of numerous factors related to the development of SDCH. This study investigated whether postoperative cisternal drainage affects the incidence of SDCH and clinical outcome in elderly patients with aSAH.

Methods

Fifty-nine patients participated in this study. All patients underwent aneurysmal clipping with cisternal cerebrospinal fluid (CSF) drainage. Clinical variables relevant to the study included age, sex, location of ruptured aneurysm, CT finding and clinical state on admission, clinical outcome, and CSF drainage. We first divided patients into two groups according to age (<70 years of age and ≥70 years of age) and compared the two groups. Secondly, we analyzed variables to find factors associated with SDCH in both groups (<70 years of age and ≥70 years of age).

Results

Of 59 patients, SDCH was observed in 20 patients (33.9 %), who underwent shunt placement for treatment of hydrocephalus. Forty seven percent of cases of acute hydrocephalus developed SDCH. In the elderly group (≥70 years of age), the duration and amount of CSF drainage did not affect the development of chronic hydrocephalus.

Conclusion

In elderly patients, although the incidence of SDCH was significantly higher, clinical outcome was acceptable. The duration and the amount of cisternal drainage did not seem to be related to subsequent development of chronic hydrocephalus within elderly patients aged 70 or older.

Ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus

OBJECTIVE

Ventriculoperitoneal shunt surgery remains the most widely accepted neurosurgical procedure for the management of hydrocephalus. However, shunt failure and complications are common and may require multiple surgical procedures during a patient's lifetime. The purpose of this study is to evaluate the ventriculoperitoneal shunt surgery and the incidence of shunt revision in adult patients with hemorrhage-related hydrocephalus.

METHODS

Adult patients who underwent ventriculoperitoneal shunt placement for hemorrhage-related hydrocephalus from October 1990 to October 2009 were included in this study. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively.

RESULTS

A total of 133 adult patients with the median age of 54.5 years were included. Among patients, 41% were males, and 62% Caucasians. The overall shunt revision rate was 51.9%. The shunt revision rate within the first 6 months after the initial placement of ventriculoperitoneal shunts was 45.1%. The median time to first shunt revision was 0.50 (95% CI, 0.24-9.2) months. No significant association was observed between perioperative variables (gender, ethnicity, hydrocephalus type, or hemorrhage type) and the shunt revision rate in these patients. Major causes of shunt revision include infection (3.6%), overdrainage (7.6%), obstruction (4.8%), proximal shunt complication (7.6%), distal shunt complication (3.6%), old shunt dysfunction (6.8%), valve malfunction (10.0%), externalization (3.6%), shunt complication (12.0%), shunt adjustment/replacement (24.0%) and other (16.4%).

CONCLUSION

Although ventriculoperitoneal shunting remains to be the treatment of choice for adult patients with post hemorrhage-related hydrocephalus, a thorough understanding of predisposing factors related to the shunt failure is necessary to improve treatment outcomes.

A phase-contrast MRI study of acute and chronic hydrodynamic alterations after hydrocephalus induced by subarachnoid hemorrhage

OBJECTIVE

To determine acute intracranial hydrodynamic changes after subarachnoid hemorrhage (SAH) via phase-contrast MRI (PC-MRI) analysis of the CSF stroke volume in the aqueduct (SVaq) and the foramen magnum (SVfm).

METHODS

A prospective PC-MRI study was performed on 34 SAH patients in the acute and late phase. Data on CSF flow and hemorrhage site were analyzed according to acute or chronic hydrocephalus (HC).

RESULTS

In the acute phase, CSF analysis was performed for 31 patients, 12 of whom presented HC. All 12 had an abnormal SVaq; those with communicating HC (n = 7) had an elevated SV and those with noncommunicating HC (n = 5) had a nil SV. None of the patients with a normal SVaq (n = 11) developed acute HC. Intraventricular bleeding led to more cases of acute HC (P = .005), which was communicating in 58% of cases. In the chronic phase, CSF analysis was performed for 27 patients, 7 of whom presented HC. None of these 7 patients displayed a depressed SVaq.

CONCLUSION

SAH led to changes in cerebrospinal fluid hydrodynamics in the majority of patients. Acute HC was communicating in most cases, even when there was intraventricular bleeding. In the late phase, all chronic HC were communicating and did not display aqueductal stenosis.

The role of lumbar drainage to prevent shunt-dependent hydrocephalus after coil embolization for aneurysmal subarachnoid hemorrhage in good-grade patients

OBJECTIVE

To evaluate the role of lumbar drainage in the prevention of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms by coil embolization in good-grade patients.

METHODS

One-hundred-thirty consecutive patients with aneurysmal subarachnoid hemorrhage in good-grade patients (Hunt & Hess grades I-III), who were treated by coil embolization between August 2004 and April 2010 were retrospectively evaluated. Poor-grade patients (Hunt & Hess grades IV and V), a history of head trauma preceding the development of headache, negative angiograms, primary subarachnoid hemorrhage (SAH), and loss to follow-up were excluded from the study. We assessed the effects on lumbar drainage on the risk of shunt-dependent hydrocephalus related to coil embolization in patients with ruptured intracranial aneurysms.

RESULTS

One-hundred-twenty-six patients (96.9%) did not develop shunt-dependent hydrocephalus. The 2 patients (1.5%) who developed acute hydrocephalus treated with temporary external ventricular drainage did not require permanent shunt diversion. Overall, 4 patients (3.1%) required permanent shunt diversion; acute hydrocephalus developed in 2 patients (50%). There was no morbidity or mortality amongst the patients who underwent a permanent shunt procedure.

CONCLUSION

Coil embolization of ruptured intracranial aneurysms may be associated with a lower risk for developing shunt-dependent hydrocephalus, possibly by active management of lumbar drainage, which may reflect less damage for cisternal anatomy than surgical clipping. Coil embolization might have an effect the long-term outcome and decision-making for ruptured intracranial aneurysms.

Early Ventriculoperitoneal Shunt Placement After Severe Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

This study investigated the outcome of early shunt placement in patients with poor-grade subarachnoid hemorrhage and the effect of intraventricular hemorrhage (IVH) and high proteinaceous cerebrospinal fluid (CSF) on subsequent shunt performance.

METHODS

This study included 33 consecutive patients with initial Fisher grade (3/4) subarachnoid hemorrhage who had undergone conversion from external ventricular drainage (EVD) to a ventriculoperitoneal (VP) shunt and whose computed tomography scan showed IVH at the time of shunt placement. Early weaning from an EVD and conversion to a VP shunt was performed irrespective of IVH or high protein content in the CSF.

RESULTS

The mean interval from EVD to VP shunt placement was 6.4 days. The mean volume of IVH was 9.44 mL, and the mean value of IVH/whole ventricle volume ratio (ie, percentage of blood suspension in the CSF) was 9.81%. The mean perioperative protein level in the CSF was 149 mg/dL. During the follow-up period, 2 patients (6.1%) required VP shunt placement, and no patients experienced complications of ventriculitis or shunt-related infection.

CONCLUSION

Based on our data, earlier EVD weaning and shunt placement can effectively treat subarachnoid hemorrhage–induced hydrocephalus in patients with severe subarachnoid hemorrhage. This procedure resulted in no shunt-related infections and a 6.1% revision rate. There were fewer adverse effects of IVH and protein on shunt performance. Therefore, weaning from an EVD and conversion to a permanent VP shunt need not be delayed because of IVH or proteinaceous CSF.

Gravitational valves in supine patients with ventriculo-peritoneal shunts

BACKGROUND

In the subgroup of bedridden hydrocephalic patients with ventriculo-peritoneal shunts and gravitational valves, we occasionally observed persisting hydrocephalic complaints even when mechanical or infection-related obstruction was excluded.

METHODS

To investigate the cause of these hydrocephalic symptoms, in vitro and in vivo analyses were used to determine valve opening, intra-abdominal and hydrostatic pressure of an Aesculap-Miethke 10/40 cm H2O gravitational valve at different angles of upper body and head inclination.

FINDINGS

Since hydrostatic pressure is lacking, the resulting intra-ventricular pressures are shown to peak up to 27 cm H2O in supine patients with head, but not upper body inclined.

CONCLUSIONS

We conclude that in the subgroup of bedridden patients with ventriculo-peritoneal shunts and gravitational valves, upright posture is a prerequisite for proper cerebrospinal fluid drainage.

Prediction of ventriculoperitoneal shunt dependency in patients with aneurysmal subarachnoid hemorrhage

OBJECT

Patients with subarachnoid hemorrhage treated using external ventricular drainage due to obstructive hydrocephalus commonly remain shunt-dependent. Based on identified risk factors for external ventricular drain (EVD) challenge failure, the authors sought to determine the likelihood that a patient will require a permanent shunt.

METHODS

The authors reviewed 89 consecutive cases of aneurysmal subarachnoid hemorrhage with obstructive hydrocephalus for parameters associated with EVD challenge failure and permanent shunt requirement. Significant parameters were combined in a discriminant function analysis to create a failure risk index (FRI). Linear regression analysis was performed correlating the FRI with the actual rate of shunt dependency.

RESULTS

Patients requiring a permanent shunt had: a larger third ventricular diameter (7.0 vs 5.4 mm; p = 0.02) and a higher Hunt and Hess grade (3 vs 2; p = 0.02) at the time of admission; and a larger third ventricular diameter (6.6 vs 5.2 mm; p = 0.04), a larger bicaudate diameter (31.9 vs 30.2 mm; p = 0.03), and higher CSF protein levels (76.5 vs 40.3 mg/dl; p < 0.0001) at the onset of EVD challenge. These patients were also more likely to be female (p = 0.01) and have a posterior circulation location of their aneurysm (p = 0.01). The FRI score was calculated based on a weighted combination of the above parameters. Linear regression analysis between FRI values and the percentage of patients who required a permanent shunt had a correlation coefficient of 91%; the risk of a permanent shunt requirement increased linearly with a rising FRI score.

CONCLUSIONS

An FRI score created by discriminant function analysis can predict whether or not a permanent shunt is required, even if separate factors are not in agreement with each other or show a weak correlation when considered separately. An increased FRI score was strongly and linearly correlated with the risk of EVD challenge failure. A prospective study is necessary to validate the FRI.

[Acute CSF changes in the mesencephalon aqueduct after subarachnoid hemorrhage as measured by PC-MRI]

PURPOSE

Determining acute intracranial hydrodynamic changes after subarachnoid hemorrhage through an analysis of the CSF stroke volume (SV) as measured by phase-contrast MRI (PC-MRI) in the mesencephalon aqueduct.

METHOD

A prospective study was performed in 33 patients with subarachnoid hemorrhage. A PC-MRI imaging study was performed n the acute phase (< 48 hours). CSF flow was measured in the aqueduct. The appearance of acute hydrocephalus (HCA) was then compared with data on CSF flow, and the location of the intraventricular and perimesencephalic bleeding.

RESULTS

CSF analysis was performed on 27 patients, 11 of whom presented with an acute HCA. All 11 patients had an abnormal SV in the aqueduct: patients with a communicating HCA had an increased SV (n=8); and patients with a noncommunicating HCA had a nil SV (n=3). Patients with a normal SV in the aqueduct did not develop an acute HCA. Intraventricular bleeding significantly led to HCA (P=0.02), which was of the communicating type in 70% of cases.

CONCLUSION

Subarachnoid hemorrhage leads to intracranial CSF hydrodynamic modifications in the aqueduct in the majority of patients. CSF flow can help us to understand the mechanism of the appearance of acute HCA. Indeed, hydrocephalus occurred - of the communicating type in most cases - even in the presence of intraventricular bleeding.

Predisposing factors related to shunt-dependent chronic hydrocephalus after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Hydrocephalus is a common sequelae of aneurysmal subarachnoid hemorrhage (SAH) and patients who develop hydrocephalus after SAH typically have a worse prognosis than those who do not. This study was designed to identify factors predictive of shunt-dependent chronic hydrocephalus among patients with aneurysmal SAH, and patients who require permanent cerebrospinal fluid diversion.

METHODS

Seven-hundred-and-thirty-four patients with aneurysmal SAH who were treated surgically between 1990 and 2006 were retrospectively studied. Three stages of hydrocephalus have been categorized in this paper, i.e., acute (0-3 days after SAH), subacute (4-13 days after SAH), chronic (>/=14 days after SAH). Criteria indicating the occurrence of hydrocephalus were the presence of significantly enlarged temporal horns or ratio of frontal horn to maximal biparietal diameter more than 30% in computerized tomography.

RESULTS

Overall, 66 of the 734 patients (8.9%) underwent shunting procedures for the treatment of chronic hydrocephalus. Statistically significant associations among the following factors and shunt-dependent chronic hydrocephalus were observed. (1) Increased age (p < 0.05), (2) poor Hunt and Hess grade at admission (p < 0.05), (3) intraventricular hemorrhage (p < 0.05), (4) Fisher grade III, IV at admission (p < 0.05), (5) radiological hydrocephalus at admission (p < 0.05), and (6) post surgery meningitis (p < 0.05) did affect development of chronic hydrocephalus. However the presence of intracerebral hemorrhage, multiple aneurysms, vasospasm, and gender did not influence on the development of shunt-dependent chronic hydrocephalus. In addition, the location of the ruptured aneurysms in posterior cerebral circulation did not correlate with the development of shunt-dependent chronic hydrocephalus.

CONCLUSION

Hydrocephalus after aneurysmal SAH seems to have a multifactorial etiology. Understanding predisposing factors related to the shunt-dependent chronic hydrocephalus may help to guide neurosurgeons for better treatment outcomes.

VENTRICULOPERITONEAL SHUNTING AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

OBJECTIVE

The goals of this study were to investigate the risk factors, indications, complications, and outcome for patients with ventriculoperitoneal shunts (VPSs) after subarachnoid hemorrhage and to define a subgroup eligible for future prospective studies designed to clarify indications for placement of a VPS.

METHODS

Clinical characteristics of 236 prospectively evaluated patients with subarachnoid hemorrhage and 6 months of follow-up were analyzed. Hydrocephalus was estimated by the relative bicaudate index (RBCI) measured on computed tomographic scans at the time of shunting. Patients were divided into three groups by ventricle size: Group 1 included 121 patients with small ventricles (RBCI &lt;1.0), Group 2 included 88 patients with borderline ventricle size (RBCI 1.0–1.4), and Group 3 included 27 patients with markedly enlarged ventricles (RBCI &gt;1.4).

RESULTS

Initially, 86 patients (36%) underwent ventriculoperitoneal shunting: 19 in Group 1 (16%), 43 in Group 2 (49%), and 24 in Group 3 (90%). Indications for placement of a VPS, risk factors, and outcome differed markedly by group. Four patients (3% of those not initially shunted) developed delayed hydrocephalus requiring a VPS, including one in Group 2 (2%). The 6-month shunt complication rate was 13%. Evaluation of patients in Group 2 indicated that functional status was an important factor in selecting candidates for shunting, and that patients receiving shunts and shunt-free patients demonstrated improvement in functional status during follow-up.

CONCLUSION

Although we currently use a proactive shunting paradigm for posthemorrhagic hydrocephalus, this report demonstrates that a conservative approach to patients with borderline ventricle size (i.e., RBCI of 1.0–1.4) and normal intracranial pressure should be evaluated in a prospective randomized trial.

Risk factors related to hydrocephalus after traumatic subarachnoid hemorrhage

BACKGROUND

Posttraumatic hydrocephalus is a common complication of head injury. However, hydrocephalus after tSAH has seldom been addressed. We present this clinical study to determine the incidence of hydrocephalus and analyze the risk factors for developing hydrocephalus in patients with tSAH.

METHODS

A consecutive series of 301 patients with tSAH were retrospectively reviewed to determine the effects of the admission GCS score, age, sex, decompressive craniectomy, intraventricular hemorrhage, and features of tSAH (according to the initial computerized tomography scans) on the development of hydrocephalus. Risk factors for hydrocephalus were evaluated by using logistic regression analysis.

RESULTS

Of the 301 patients, hydrocephalus was observed in 36 (11.96%). Increasing age (P< .05), intraventricular hemorrhage (P< .05), and thickness (P< .01) or distribution (P< .05) of tSAH were significantly associated with the development of hydrocephalus. No relationship was found between hydrocephalus and sex, admission GCS score, location of tSAH, or decompressive craniectomy.

CONCLUSION

Hydrocephalus frequently occurs in patients with tSAH. Increasing age, low GCS score on admission, intraventricular hemorrhage, and severe SAH could be risk factors for facilitating the development of hydrocephalus.

Risk of shunt-dependent hydrocephalus after occlusion of ruptured intracranial aneurysms by surgical clipping or endovascular coiling: a single-institution series and meta-analysis

OBJECTIVE

To compare the risk of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms by clipping versus coiling.

METHODS

We analyzed 596 patients prospectively added to our database from July of 1999 to November of 2005 concerning the risk of shunt dependency after clipping versus coiling. Factors analyzed included age; sex; Hunt and Hess grade; Fisher grade; acute hydrocephalus; intraventricular hemorrhage; angiographic vasospasm; and number, size, and location of aneurysms. In addition, a meta-analysis of available data from the literature was performed identifying four studies with quantitative data on the frequency of clip, coil, and shunt dependency.

RESULTS

The institutional series revealed Hunt and Hess grade, Fisher grade, acute hydrocephalus, intraventricular hemorrhage, and angiographic vasospasm as significant (P < 0.05) risk factors for shunt dependency after a univariate analysis. In a multivariate logistic regression analysis, we isolated intraventricular hemorrhage, acute hydrocephalus, and angiographic vasospasm as independent, significant risk factors for shunt dependency. The meta-analysis, including the current data, revealed a significantly higher risk for shunt dependency after coiling than after clipping (P = 0.01).

CONCLUSION

Clipping of a ruptured aneurysm may be associated with a lower risk for developing shunt dependency, possibly by clot removal. This might influence long-term outcome and surgical decision making.

Lymphoma and leukemia cells possess fractal dimensions that correlate with their biological features

BACKGROUND

Living cells can be viewed as complex adaptive systems that exhibit non-linear dynamics and fractal features. We investigated the fractal qualities of normal and malignant hematological cells and their potential as a tool for characterizing cell phenotype and clinical behavior.

METHODS

A mathematical algorithm and an optic tool for fractal analysis of nuclei were developed. A total of 4,713 lymphoid cells derived from 66 patients of five distinct diagnostic groups (normal and reactive lymphocytes, low-grade lymphomas and an aggressive lymphoma) were assessed for their fractal dimension. In addition, in 19 patients fractal analysis of leukemia cells was compared to clinical endpoints.

RESULTS

After validating our method, hematological cells possessed fractal dimensions corresponding to their clinical entity. There was a highly significant overall difference in fractal dimensions between various types of hematological malignancies. A preliminary correlation was found between the fractal dimension and the clinical outcome of leukemia patients.

CONCLUSIONS

Hematological cells possess fractal dimensions that correlate with their biological properties. Measurement of fractal dimension seems to be a sensitive method to assess the hematological cell phenotype and to define a clinical group. This tool may be potentially useful for the evaluation of clinical behavior of hematological diseases.

Improvement after treatment of hydrocephalus in aneurysmal subarachnoid haemorrhage: implications for grading and prognosis

Two patients with aneurysmal subarachnoid haemorrhage and hydrocephalus are presented. On admission they scored E1M4V1 and E1M3Vtube on the Glasgow Coma Scale. The first patient recovered to E3M5Vtube after treatment of hydrocpehalus by extraventricular drainage. The second recovered to E2M5Vtube and later E4M6V4 after treatment of hydrocephalus with lumbar drainage. Based on the literature it is argued that these cases are no exception as to the improvement after treatment of hydrocephalus. The prognosis of patients with hydrocephalus after a subarachnoid haemorrhage, improves in parallel with the Glasgow Coma Scale after treatment of hydrocephalus. Therefore decision making on whether or not to treat a patient with a subarachnoid haemorrhage should be postponed until after treatment of hydrocephalus, if present.

Delirium in Acute Subarachnoid Haemorrhage

BACKGROUND

Delirium may be a presenting feature in acute subarachnoid haemorrhage (SAH). The aim of this study was to investigate the risk factors for delirium in acute SAH and to analyse the relation between delirium and location and amount of haematic densities and hydrocephalus.

METHODS

We assessed delirium in a sample of 68 consecutive patients with acute (< or =4 days) SAH (33 aneurysmal, 33 non-aneurysmal, including 9 with perimesencephalic haemorrhage), before aneurysmal treatment, using DSM-IV-R criteria and the Delirium Rating Scale (DRS). DRS scores were related to: (1) the total amount of haematic densities at 10 basal cisterns/fissures and in the 4 ventricles, using a validated rating scale, (2) the haematic densities in the prepontine cistern and the convexity of the brain and (3) hydrocephalus, using the bicaudate index, obtained from a review of admission CT scans.

RESULTS

Eleven acute SAH patients presented with delirium. Older age (U = 316.5, p = 0.04), alertness disturbance (chi(2) = 5.1, p = 0.02, OR = 7.6, 95% CI = 1.5-37.3), aphasia (U = 61.5, p = 0.007) and a Hunt and Hess score >2 (U = 362.5, p = 0.02) were associated with delirium. Higher amounts of intraventricular haematic densities (chi(2) = 4.43, p = 0.04, U = 158, p = 0.001) and hydrocephalus (U = 215, p = 0.009) were also associated with higher DRS scores. Two delirious patients had basofrontal haematomas.

CONCLUSIONS

Delirium was detected in 16% of acute SAH patients. Intraventricular bleeding, hydrocephalus and basofrontal haematomas contribute to the pathogenesis of delirium, through damage to anatomical networks subserving sustained attention, declarative memory and the expression of emotional behaviour.

Fenestration of the Lamina Terminalis as a Valuable Adjunct in Aneurysm Surgery

OBJECTIVE:

Hydrocephalus, vasospasm, and frontobasal injury are common complications after aneurysmal subarachnoid hemorrhage (SAH) from anterior communicating artery aneurysms. Previous studies have suggested that fenestration of the lamina terminalis (FLT) during surgery may be associated with reduced rates of shunt-dependent hydrocephalus and vasospasm. We report 106 patients affected by anterior communicating artery aneurysms and Fisher Grade 3 aneurysmal SAH and the affect of FLT on shunt-dependent hydrocephalus, vasospasm, and frontobasal injury.

METHODS:

During a 3-year period, 53 patients underwent FLT and 53 did not. We prospectively evaluated admission and discharge clinical grades, hydrocephalus at admission, occurrence of clinical vasospasm, need for interventional vasospasm therapy, frontobasal hypodensity incidence, and permanent ventriculoperitoneal shunting requirement. Follow-up ranged from 3 to 35 months (mean, 17.9 mo).

RESULTS:

Shunting incidence after aneurysmal SAH with hydrocephalus was 4.25% in patients who underwent FLT and 13.9% in patients who did not (P&lt; 0.001). Clinical cerebral vasospasm occurred in 29.6% of patients who underwent FLT and in 54.7% of patients who did not (P&lt; 0.001). Frontobasal hypodensity was identified postoperatively in 0% of patients who underwent FLT and in 5% of patients who did not. Good outcome was reported in 69.81% of patients who underwent FLT and in 33.96% of patients who did not (P&lt; 0.001). Poor outcome was associated with higher Hunt and Hess grades, need for ventricular drainage, elevated intracranial pressure, and multiple interventional vasospasm therapies. No complications were linked to FLT.

CONCLUSION:

FLT was associated with statistically significant decreases in shunting rates, incidence of vasospasm, and better outcomes. We recommend its routine use in patients with Fisher Grade 3 anterior communicating artery aneurysmal SAH.

Shunt-dependent hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality

OBJECT

This study was designed to determine whether the frequency of shunt-dependent hydrocephalus in patients suffering from aneurysmal subarachnoid hemorrhage (SAH) differs when comparing surgical clip application with endovascular obliteration of ruptured aneurysms.

METHODS

In this prospective nonrandomized study, 245 patients with aneurysmal SAH treated using either surgical clip application or endovascular coil embolization were studied at our institution between September 1997 and March 2003. One hundred eighty patients underwent clip application and 65 had coil embolization. In those patients who underwent clip application of anterior circulation aneurysms, the lamina terminalis was systematically fenestrated. The occurrence of acute, asymptomatic, and shunt-dependent hydrocephalus was analyzed in both treatment groups. A subgroup analysis of patients with good clinical grade (World Federation of Neurosurgical Societies [WFNS] Grades I-III) and better Fisher Grade (1-3) and of patients with Fisher Grade 4 hemorrhage was performed. Acute hydrocephalus was observed in 19% of surgical cases and 46% of endovascular ones. The occurrence of asymptomatic hydrocephalus was similar in both treatment groups (p = 0.4). Shunt-dependent hydrocephalus occurred in 14% of surgical cases and 19% of endovascular cases. This difference did not reach statistical significance (p = 0.53). Logistic regression models controlling for patient age, WFNS grade, Fisher grade, and acute hydrocephalus in patients with good clinical grade and better Fisher grade revealed no significant difference in the rate of shunt-dependent hydrocephalus in both therapy groups (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.2-2.65). Results of similar models indicated that among patients with intraventricular hemorrhage (IVH), surgical clip application carried a lower risk of shunt-dependent hydrocephalus (OR 0.32, 95% CI 0.14-0.75) compared with that for endovascular embolization.

CONCLUSIONS

Shunt-dependent hydrocephalus was comparable in the two treatment groups, even in patients with better clinical and radiological grades on admission. Only patients in the endovascular therapy group who had experienced IVH showed a higher likelihood of shunt-dependent hydrocephalus.

Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage

OBJECTIVE

The purpose of this study was to identify factors predictive of shunt-dependent hydrocephalus among patients with aneurysmal subarachnoid hemorrhage. The data can be used to predict which patients in this group have a high probability of requiring permanent cerebrospinal fluid diversion.

METHODS

Seven hundred eighteen patients with aneurysmal subarachnoid hemorrhage who were treated between 1990 and 1999 were retrospectively studied, to identify factors contributing to shunt-dependent hydrocephalus. With these data, a stepwise logistic regression procedure was used to determine the effect of each variable on the development of hydrocephalus and to create a scoring system.

RESULTS

Overall, 152 of the 718 patients (21.2%) underwent shunting procedures for treatment of hydrocephalus. Four hundred seventy-nine of the patients (66.7%) were female. Of the factors investigated, the following were associated with shunt-dependent hydrocephalus, as determined with a variety of statistical methods: 1) increasing age (P < 0.001), 2) female sex (P = 0.015), 3) poor admission Hunt and Hess grade (P < 0.001), 4) thick subarachnoid hemorrhage on admission computed tomographic scans (P < 0.001), 5) intraventricular hemorrhage (P < 0.001), 6) radiological hydrocephalus at the time of admission (P < 0.001), 7) distal posterior circulation location of the ruptured aneurysm (P = 0.046), 8) clinical vasospasm (P < 0.001), and 9) endovascular treatment (P = 0.013). The presence of intracerebral hematomas, giant aneurysms, or multiple aneurysms did not influence the development of shunt-dependent hydrocephalus.

CONCLUSION

The results of this study can help identify patients with a high risk of developing shunt-dependent hydrocephalus. This may help neurosurgeons expedite treatment, may decrease the cost and length of hospital stays, and may result in improved outcomes.

Study of corpus callosum in experimental hydrocephalic wistar rats

PURPOSE: Hydrocephalus causes countless cerebral damages, especially on the structures around the ventricles. Hydrocephalic children present deficiencies in the nonverbal skills more than in the verbal skills, and not always revertible with an early treatment. As the corpus callosum has an important role in the nonverbal acquisition it is possible that the injuries in this structure are responsible for the cognitive dysfunctions of these children. This present study tries to establish the alterations caused by hydrocephalus on the corpus callosum of developing Wistar rats, induced by intracisternal injection of kaolin. METHODS : Seven, fourteen and twenty one days after the injection, the animals were killed, and the corpus callosum was dissected and prepared for the study of the axonal fibers. RESULTS AND CONCLUSION: The seven-day old rats in hydrocephalus development presented a delay in myelination in relation to the control rats. With the fourteen-day old rats in hydrocephalus development the corpus callosum showed a recovery of myelin, but with the twenty one-day old rats in hydrocephalus development the axonal fibers were damaged and reduced in number.