Shunt-dependent hydrocephalus after subarachnoid haemorrhage and aneurysm surgery: timing of surgery is not a risk factor

Cerebrospinal fluid drainage and chronic hydrocephalus in aneurysmal subarachnoid hemorrhage patients with intraventricular hemorrhage

Background

Patients with intraventricular hemorrhage (IVH) are at a higher risk of developing hydrocephalus and often require external ventricular drainage or long-term ventriculoperitoneal shunt surgery.

Objective

To investigate whether cerebrospinal fluid drainage in patients with IVH due to aneurysmal subarachnoid hemorrhage (aSAH) reduces the incidence of chronic hydrocephalus.

Method

A retrospective analysis was conducted on patients with aSAH treated at our hospital between January 2020 and December 2022. The first analysis compared patients with and without IVH, while the second analysis compared IVH patients with and without chronic hydrocephalus. The third analysis compared IVH patients who underwent in different drainage methods which is lumbar drainage (LD) or external ventricular drainage (EVD). The primary outcome measure was the incidence of chronic hydrocephalus.

Result

Of the 296 patients hospitalized with aSAH, 108 (36.5%) had IVH, which was associated with a significantly higher incidence of chronic hydrocephalus compared to patients without IVH (49.1% vs. 16.5%, p < 0.001). Multivariate logistic regression analysis showed that IVH was independently associated with the formation of chronic hydrocephalus (OR: 3.530, 95% CI: 1.958-6.362, p < 0.001). Among the 108 IVH patients, 53 (49.1%) developed chronic hydrocephalus. Multivariate logistic regression analysis revealed that the Hunt Hess grade at admission (OR: 3.362, 95% CI: 1.146-9.863, p = 0.027) and postoperative cerebrospinal fluid drainage (OR: 0.110, 95% CI: 0.036-0.336, p < 0.001) were independent risk factors for the development of chronic hydrocephalus in IVH patients. Among all IVH patients who underwent cerebrospinal fluid drainage, 45 (75%) received continuous lumbar puncture drainage, and 15 (25%) received external ventricular drainage. Univariate analysis did not show a statistically significant difference between the two groups in terms of postoperative chronic hydrocephalus (p = 0.283). However, multivariate logistic regression analysis suggested that the drainage methods of LD and EVD might be associated with the development of chronic hydrocephalus.

Conclusion

The presence of IVH increases the risk of chronic hydrocephalus in patients with aSAH, and postoperative cerebrospinal fluid drainage appears to reduce this risk. The specific effects of lumbar puncture drainage and ventricular drainage on the incidence of chronic hydrocephalus require further investigation.

Neutrophil Count on Admission Predicts Acute Symptomatic Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

To investigate the association between immunologic counts on admission and acute symptomatic hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

We conducted a retrospective analysis of 143 consecutive patients with aSAH. Patient demographics, clinical parameters, laboratory values, and radiographic imaging were obtained. Univariate and multivariate logistic regression analyses were performed to investigate parameters independently associated with acute symptomatic hydrocephalus. Receiver operating characteristic (ROC) curve analysis determined the best threshold value of neutrophil count to differentiate patients with and without hydrocephalus.

RESULTS

Overall, acute symptomatic hydrocephalus developed in 39.16% of patients. In an adjusted multivariate logistic regression model, Hunt and Hess grade 4-5 (odds ratio [OR]: 16.052, 95% confidence interval [CI]: 1.188-216.983; P = 0.037), modified Fisher score 3-4 (OR: 10.107, 95% CI: 1.715-59.572; P = 0.011), intraventricular hemorrhage (OR: 4.578, 95% CI: 1.417-14.788; P = 0.011), neutrophil count (OR: 1.183, 95% CI: 1.033-1.354; P = 0.015), and prior ischemic stroke (OR: 7.003, 95% CI: 1.293-37.929; P = 0.024) were significantly associated with hydrocephalus. ROC analysis for neutrophil count confirmed an acceptable area under the curve (AUC 0.780, 95% CI: 0.701-0.859; P < 0.001). The best threshold value of neutrophil count to predict hydrocephalus was ≥9.80 × 10³/mL. Overall, 81.25% of patients who developed shunt dependence had a neutrophil count ≥9.80 × 10³/mL on admission (P = 0.003).

CONCLUSIONS

Neutrophil count ≥9.80 × 10³/mL on admission predicts acute symptomatic hydrocephalus after aSAH in an adjusted multivariate logistic regression model. Moreover, shunt dependence was associated with higher neutrophil counts.

Cerebrospinal Fluid Output as a Risk Factor of Chronic Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Chronic shunt-dependent hydrocephalus is a well-known complication of subarachnoid hemorrhage. Although the risk factors have been extensively investigated, most fail to predict permanent shunt dependency. It is unknown whether the volume of cerebrospinal fluid (CSF) from external ventricular drainage and the daily volume of drainage during the acute hydrocephalus phase (first 72 hours) can predict shunt dependency. We aimed to determine whether CSF output during the acute hydrocephalus phase is a risk factor for shunt dependency.

METHODS

Patients with aneurysmal subarachnoid hemorrhage and hydrocephalus treated with external ventricular drainage were prospectively registered in our database between January 2017 and March 2020. Factors evaluated for predicting shunt dependency included age; sex; Hunt and Hess grade; World Federation of Neurological Surgeons grade; acute hydrocephalus; modified Fisher grade; aneurysm treatment modality; hospital length of stay; modified Rankin score; average daily overall CSF production; average CSF output for the first 24, 48, and 72 hours; external ventricular drainage days; the number of wean/clamp failures; and ventriculoperitoneal shunting.

RESULTS

Univariate analysis identified Hunt and Hess grade; acute hydrocephalus at onset; external ventricular drainage; overall CSF output; average CSF output for the first 24, 48, and 72 hours; and CSF output until the first clamp as significant risk factors for shunt dependency (P < 0.001). In a multivariate logistic regression analysis, overall CSF output and average CSF output for the first 72 hours were significant risk factors for shunt dependency.

CONCLUSIONS

Overall CSF output, especially during the acute hydrocephalus phase (first 72 hours), predicts the development of chronic hydrocephalus.

Effect of Microscopic Third Ventriculostomy (Lamina Terminalis Fenestration) on Shunt-needed Hydrocephalus in Patients with Aneurysmal Subarachnoid Hemorrhage

There are reports that in patients with aSAH (aneurysmal subarachnoid hemorrhage), LTF (lamina terminalis fenestration) reduces the rate of shunt-needed hydrocephalus via facilitation of CSF (cerebrospinal fluid) dynamic, diminished leptomeningeal inflammation, and decreased subarachnoid fibrosis. Regarding the conflicting results, this study was conducted to evaluate the effects of LTF on decreased shunt-needed hydrocephalus in patients with aSAH. A cross-sectional retrospective study was carried out to survey all patients with confirmed aSAH operated from March 2011 to September 2016 in an academic vascular center (Rasool Akram Hospital in Tehran, Iran). Of a total of 151 patients, 72 patients were male and 79 were female. The mean age of the participants was 51 years. A transiently CSF diversion (EVD - external ventricular drainage) was performed (the acute hydrocephalus rate) on 21 patients (13.9%). In 36 patients (23.8%), aneurysm occlusion with LTF and in 115 patients (76.2%) only aneurysm occlusion surgery was performed. In hydrocephalus follow-up after surgery, 13 (12%) patients needed shunt insertion (the rate of shunt-needed hydrocephalus). The statistical analysis demonstrated no significant relation between LTF and shunt-needed hydrocephalus. Confirmation of the hypothesis that LTF may decrease the rate of shunt-needed hydrocephalus can significantly decrease morbidity, mortality, and treatment costs of shunting (that is a simple, but a potentially dangerous procedure). So, it is advised to plan and perform an RCT (randomized controlled trial) that can remove the confounding factors, match the groups, and illustrate the exact effect of LTF on shunt-needed hydrocephalus.

Validation of shunt dependency prediction scores after aneurysmal spontaneous subarachnoid hemorrhage

BACKGROUND

Currently available scores for predicting shunt dependency after aneurysmal spontaneous subarachnoid hemorrhage (aSAH) are limited and not widely accepted. The key purpose of this study was to validate a recently created score for shunt dependency in aSAH (SDASH) in an independent population of aSAH patients. We compared this new SDASH score based on a combination of the Hunt and Hess grade, Barrow Neurological Institute (BNI) score, and the presence or not of acute hydrocephalus with other published predictive scores.

METHODS

The SDASH score, Hijdra score, BNI grading system, chronic hydrocephalus ensuing from SAH score (CHESS), Graeb score, and modified Graeb score (mGS) were calculated for a cohort of aSAH patients. Logistic regression analysis was used to determine the reliability of the SDASH score, and the area under the curve (AUC) of the receiver operating characteristics (ROC) curve was used to assess the discriminative ability of the model.

RESULTS

In 214 patients with aSAH, 40 (18.7%) developed shunt-dependent hydrocephalus (SDHC). The AUC for the SDASH score was 0.816. The SDASH score reliably predicted SDHC in aSAH (odds ratio: 2.93, 95% CI: 1.99-4.31; p < 0.001) with no statistically significant differences being found between the SDASH score and the CHESS score (AUC: 0.816), radiological-based Graeb score (AUC: 0.742), or modified Graeb score (AUC: 0.741). However, the Hijdra score (AUC: 0.673) and BNI grading system (AUC: 0.616) showed lower predictive values than the SDASH score.

CONCLUSIONS

Our findings support the ability of the SDASH score to predict shunt dependency after SAH in a population independent to that used to develop the score. The SDASH score may aid in the early management of hydrocephalus in aSAH, and it does not differ greatly from other predictive scores.

External Validation of Scoring Models to Predict Shunt Insertion after Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

The current study is an external validation of 4 scoring models proposed in the literature for predicting ventriculoperitoneal shunt insertion after aneurysmal subarachnoid hemorrhage (aSAH) using retrospective patient data from Sheffield Teaching Hospital (STH).

METHODS

Data were collected on various demographics, and patients were individually scored using the 4 scoring models. Models were compared with each other using receiver-operator characteristic curves. The best model had the highest area under the curve.

RESULTS

A total of 301 aSAH patients were referred to the neurosurgery department in STH between 1 January 2014 and 31 December 2017. Scoring model 4 also had the largest area under the curve of 0.853 (P < 0.001), and scoring model 3 had the lowest area under the curve of 0.654 (P = 0.036).

CONCLUSIONS

Scoring model 4 was found to be the best scoring model out of the 4 scoring models externally validated to predict shunt dependency after an aSAH in STH patients. Scoring model 4 is less applicable in modern practice due to a higher proportion of coiling and use of the Hunt and Hess scale grade. A new scoring model is needed to predict shunt insertion in modern practice.

Retrospective Analytic Study of Neurosurgical Patients Who Developed Postoperative Hydrocephalus

Objective This article discusses the causes, primary pathologies, management, and prognosis of patients who did not have hydrocephalus in preoperative stage, underwent definitive surgical procedure, and developed postoperative hydrocephalus requiring cerebrospinal fluid (CSF) diversion procedures.

Methods Retrospective data collection was done from operation theatre (OT) department database and patient records were obtained for the patients after, related literature was searched, all possible risk factors were analyzed, and our results were compared with other studies.

Results A total of 80 cases were found eligible for the study. Decompressive craniectomy was the most common cause followed by aneurysmal subarachnoid hemorrhage (SAH), intraventricular, and cerebellopontine angle (CPA) tumors. Rate of postsurgical hydrocephalus was 15 to 16%. Cases of decompressive craniectomy presented late, only few cases required diversion procedures during the immediate postop period, mostly aneurysm cases and tumors bed bleed. Out of total 6 mortalities, none of them were directly attributable to hydrocephalus. Since most patient presented after initial stabilization, permanent ventriculoperitoneal shunting was found to be the best option.

Conclusion Cases of decompression surgery should be under vigilant follow-up after discharge and even after cranioplasty for risk of development of hydrocephalus and requirement of permanent shunting. Cases with intraventricular hemorrhage or SAH should be considered as future candidate with risk of developing hydrocephalus. Lamina terminalis opening whenever possible results in favorable outcome in cases of anterior circulation aneurysms. CSF protein analysis in cases of intraventricular and CPA tumors should be done whenever possible, preferably routinely.

Efficacy of translamina terminalis ventriculostomy tube in prevention of chronic hydrocephalus after aneurysmal subarachnoid hemorrhage

Background

Chronic shunt-dependent hydrocephalus is still a common complication after aneurysmal SAH (aSAH) and is associated with increased morbidity. Pathology of chronic shunt-dependent hydrocephalus after aSAH is complex and multifactorial which makes its prevention challenging. We thought to evaluate whether external ventricular drainage (EVD) through fenestrated lamina terminalis would decrease the rate of chronic shunt-dependent hydrocephalus after aSAH.

Methods

A retrospective analysis of 68 consecutive patients with aSAH who underwent microsurgical clipping of the ruptured aneurysm. Patients were divided into two groups: Group A included patients with lamina terminalis fenestration without insertion of ventriculostomy tube and Group B included patients with EVD through fenestrated lamina terminalis. Demographic, clinical, radiological, and outcome variables were compared between groups.

Results

Group A comprised 29 patients with mean age of 47.8 years and Group B comprised 39 patients with mean age of 46.6 years. Group B patients had statistically significant (P < 0.05) lower incidence of chronic shunt- dependent hydrocephalus than Group A patients (30.8% vs. 55.2%, respectively).

Conclusion

EVD through fenestrated lamina terminalis is safe and may be effective in decreasing the incidence of chronic shunt-dependent hydrocephalus after aSAH.

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.

Prognostic Model for Chronic Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Patients with aneurysmal subarachnoid hemorrhage (aSAH) are at risk of the development of chronic shunt-dependent hydrocephalus. However, identification of shunt-dependent patients remains challenging. We sought to develop a prognostic model to identify patients with aSAH at risk of chronic shunt-dependent hydrocephalus. In addition to the well-known prognostic variables, blood clearance in the cerebrospinal fluid (CSF) spaces was considered.

METHODS

We retrospectively analyzed the data from 227 patients treated at our institution from January 2012 to January 2016. The outcome was ventriculoperitoneal shunt placement within 30 days after aSAH. The candidate prognostic variables were patient age, World Federation of Neurological Surgeons grade and Fisher grade, external ventricular drainage, ventricular and intracerebral hemorrhage, and interval to blood clearance in the peripheral/basal CSF spaces. Adjustment for multiple testing was performed. Multivariable logistic regression analysis was used for model development. Bootstrapping was applied for internal validation. The model performance measures included indexes for explained variance (R²), calibration (graphic plot, Hosmer-Lemeshow test), and discrimination (c-statistic).

RESULTS

Of the 227 patients, 90 (39.6%) required a ventriculoperitoneal shunt. The constructed prognostic model combined external ventricular drainage placement, the presence of ventricular blood, and the duration of blood clearance in the basal cisterns. The model performance was promising, with an R² of 33% (20% after bootstrapping), the calibration plot was adequate, the Hosmer-Lemeshow test result was not significant, and the c-statistic was 0.85 (0.84 as assessed after bootstrapping) indicating a good discriminating prognostic model.

CONCLUSIONS

Our prognostic model could help identify patients requiring permanent CSF diversion after aSAH, although additional modification and external validation are needed. Interventions aimed at accelerating the clearance of blood in the basal cisterns might have the potential to prevent the development of chronic hydrocephalus after aSAH.

Predictors of hydrocephalus as a complication of non-traumatic subarachnoid hemorrhage: a retrospective observational cohort study in 107 patients

Background

The predictors of shunt dependency such as amount of subarachnoid blood, acute hydrocephalus (HC), mode of aneurysm repair, clinical grade at admission and cerebro spinal fluid (CSF) drainage in excess of 1500 ml during the 1st week after the subarachnoid hemorrhage (SAH) have been identified as predictors of shunt dependency. Therefore our main objective is to identify predictors of CSF shunt dependency following non-traumatic subarachnoid hemorrhage.

Methods

We performed a retrospective study including patients from January 1st 2012 to September 30th 2014 between 16 and 89 years old and had a non-traumatic subarachnoid hemorrhage in cranial computed tomography (CCT). We excluded patients with the following characteristics: Patients who died 3 days after admittance, lesions in brainstem, previous surgical treatment in another clinic, traumatic brain injury, pregnancy and disability prior to SAH.

We performed a descriptive and comparative analysis as well as a logistic regression with the variables that showed a significant difference (p < 0.05). Hence we identified the variables concerning HC after non traumatic SAH and its correlation.

Results

One hundred and seven clinical files of patients with non-traumatic SAH were analyzed. Twenty one (48%) later underwent shunt treatment. Shunt patients had significantly clinical and corroborated with doppler ultrasonography vasospasmus (p = 0.015), OR = 5.2. The amount of subarachnoidal blood according to modified Fisher grade was (p = 0.008) OR = 10.9. Endovascularly treated patients were less often shunted as compared with those undergoing surgical aneurysm repair (p = 0.004).

Conclusion

Vasospasmus and a large amount of ventricular blood seem to be a predictor concerning hydrocephalus after non-traumatic SAH. Hence according to our results the presence of these two variables could alert the treating physician in the decision whether an early shunt implantation < 7 days after SAH should be necessary.

Cerebrospinal fluid circulation and hydrocephalus

Hydrocephalus (HC) is classically defined as dynamic imbalance between the production and absorption of cerebrospinal fluid (CSF) leading to enlarged ventricles. Potential causative factors include various brain disorders like tumors causing obstruction of CSF flow within the ventricular system or the subarachnoid space. Classification of HC is based on the site of CSF flow obstruction guiding optimal treatment, with endoscopic third ventriculostomy in intraventricular obstruction and CSF shunt in communicating HC. Another clinically relevant classification is acute and chronic; the most frequent chronic form is idiopathic normal-pressure hydrocephalus (iNPH). The reported incidence of HC varies according to the study population and classification used. The incidence of congenital HC is approximately 0.4-0.6/1,000 newborns and the annual incidence of iNPH varies from 0.5/100,000 to 5.5/100,000. Radiologically, ventricular dilatation may be nonspecific, and differentiation of iNPH from other neurodegenerative diseases may be ambiguous. There are no known specific microscopic findings of HC but a systematic neuropathologic examination is needed to detect comorbid diseases and possible etiologic factors of HC. Depending on the etiology of HC, there are several nonspecific signs potentially to be seen.

Predictors of Shunt-dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage? A Systematic Review and Meta-Analysis

BACKGROUND

Hydrocephalus is a well-recognized complication after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to identify predictors for shunt-dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis.

METHODS

A systematic search was conducted using the Embase, MEDLINE, and Web of Science databases for studies pertaining to aSAH and SDHC. Risk factors were assessed by meta-analysis when they were reported by at least 2 studies. The results were presented as odd ratios or risk ratios according to the study design with the corresponding 95% confidence intervals (CI).

RESULTS

Twenty-five studies were included. In primary analysis of 14 potential risk factors, 12 were identified as predictors of SDHC after aSAH including age ≥50 years, female gender, high Hunt-Hess grade, Glasgow Coma Scale ≤8, Fisher grade ≥3, acute hydrocephalus, external ventricular drainage insertion, intraventricular hemorrhage, postcirculation aneurysm, anterior communicating artery aneurysm, meningitis, and rebleeding. The meta-analysis based on cohort studies found a significantly increased risk for SDHC in patients with aSAH treated by coiling (risk ratio, 1.16; 95% CI, 1.05-1.29), while the meta-analysis based on case-controlled studies failed to replicate this finding (odds ratio, 1.27; 95% CI, 0.95-1.71).

CONCLUSIONS

Several new predictors of SDHC after aSAH were identified that may assist with the early recognition and prevention of SDHC. The controversial evidence found in this study was insufficient to support the potential of neurosurgical clipping for reducing the risk of shunt dependency. Further well-designed studies are warranted to explore the effect of treatment modality on SDHC risk.

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.

Meta-analysis and systematic review of risk factors for shunt dependency after aneurysmal subarachnoid hemorrhage

OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) may be complicated by hydrocephalus in 6.5%-67% of cases. Some patients with aSAH develop shunt dependency, which is often managed by ventriculoperitoneal shunt placement. The objectives of this study were to review published risk factors for shunt dependency in patients with aSAH, determine the level of evidence for each factor, and calculate the magnitude of each risk factor to better guide patient management. METHODS The authors searched PubMed and MEDLINE databases for Level A and Level B articles published through December 31, 2014, that describe factors affecting shunt dependency after aSAH and performed a systematic review and meta-analysis, stratifying the existing data according to level of evidence. RESULTS On the basis of the results of the meta-analysis, risk factors for shunt dependency included high Fisher grade (OR 7.74, 95% CI 4.47-13.41), acute hydrocephalus (OR 5.67, 95% CI 3.96-8.12), in-hospital complications (OR 4.91, 95% CI 2.79-8.64), presence of intraventricular blood (OR 3.93, 95% CI 2.80-5.52), high Hunt and Hess Scale score (OR 3.25, 95% CI 2.51-4.21), rehemorrhage (OR 2.21, 95% CI 1.24-3.95), posterior circulation location of the aneurysm (OR 1.85, 95% CI 1.35-2.53), and age ≥ 60 years (OR 1.81, 95% CI 1.50-2.19). The only risk factor included in the meta-analysis that did not reach statistical significance was female sex (OR 1.13, 95% CI 0.77-1.65). CONCLUSIONS The authors identified several risk factors for shunt dependency in aSAH patients that help predict which patients are likely to require a permanent shunt. Although some of these risk factors are not independent of each other, this information assists clinicians in identifying at-risk patients and managing their treatment.

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.

Daily drained CSF volume is a predictor for shunt dependence - A retrospective study

OBJECTIVES

Acute hydrocephalus ensues from various intracranial processes and is usually treated using external ventricular drainage (EVD). After the acute phase, a clamp trial is usually performed to identify patients requiring permanent CSF shunting. The aim of our study was to identify simple and clinically accessible factors that can help predict the result of the EVD clamp trial.

METHODS

86 patients were selected for this retrospective analysis. Average CSF drained volume over 3 days given a constant EVD pressure level of 15 cm H2O and other clinical and laboratory parameters were statistically compared with the result of an EVD clamp trial.

RESULTS

The univariate analysis identified significant differences between the groups of patients who failed or passed the EVD clamp trial for the mean daily drained volume over 3 days (Mann-Whitney U-test, p<0.01). In the multivariate logistic regression, the average daily CSF output over 3 days was also significant (p=0.02), no other significant factors could be identified. Using hierarchical clustering, the best threshold daily value for EVD clamp trial failure was found at 130 ml (mean daily drained CSF volume) with the sensitivity of 64.5% and specificity of 83.6% (chi-square 20.6, p<0.01).

CONCLUSION

We have identified a simple, clinically available factor for identifying patients who are likely to fail the EVD clamp trial.

Aneurysm location and clipping versus coiling for development of secondary normal-pressure hydrocephalus after aneurysmal subarachnoid hemorrhage: Japanese Stroke DataBank

OBJECT

The present study aimed to investigate aneurysm locations and treatments for ruptured cerebral aneurysms associated with secondary normal-pressure hydrocephalus (sNPH) after subarachnoid hemorrhage (SAH) by using comprehensive data from the Japanese Stroke DataBank.

METHODS

Among 101,165 patients with acute stroke registered between 2000 and 2013, 4693 patients (1482 men, 3211 women) were registered as having had an SAH caused by a ruptured saccular aneurysm. Of them, 1448 patients (438 men and 1010 women; mean age 61.9 ± 13.4 years) who were confirmed to have or not have coexisting acute hydrocephalus and sNPH were included for statistical analyses. Locations of the ruptured aneurysms were subcategorized into 1 of the following 4 groups: middle cerebral artery (MCA; n = 354), anterior communicating artery and anterior cerebral artery (ACA; n = 496), internal carotid artery (ICA; n = 402), and posterior circulation (n = 130). Locations of 66 of the ruptured aneurysms were unknown/unrecorded. Treatments included craniotomy and clipping alone in 1073 patients, endovascular coil embolization alone in 285 patients, and a combination of coiling and clipping in 17 patients. The age-adjusted and multivariate odds ratios from logistic regression analyses were calculated after stratification using the Fisher CT scale to investigate the effects of the hematoma volume of SAH.

RESULTS

Acute hydrocephalus was confirmed in 593 patients, and 521 patients developed sNPH. Patients with a ruptured ACA aneurysm had twice the risk for sNPH over those with a ruptured MCA aneurysm. Those with an ACA aneurysm with Fisher Grade 3 SAH had a 9-fold-higher risk for sNPH than those with an MCA aneurysm with Fisher Grade 1 or 2 SAH. Patients with a ruptured posterior circulation aneurysm did not have any significant risk for sNPH. Clipping of the ruptured aneurysm resulted in twice the risk for sNPH over coil embolization alone.

CONCLUSIONS

Patients with low-grade SAH caused by a ruptured MCA aneurysm had a low risk for the development of sNPH. In contrast, patients with high-grade SAH caused by a ruptured ACA aneurysm had a higher risk for sNPH. Endovascular coiling might confer a lower risk of developing sNPH than microsurgical clipping.

Predictors of shunt dependency after aneurysmal subarachnoid hemorrhage: results of a single-center clinical trial

BACKGROUND

Hydrocephalus (HC) after aneurysmal subarachnoid hemorrhage (aSAH) is a common sequel. Proper selection of patients in need of permanent cerebrospinal fluid (CSF) diversion is, however, not straightforward. The aim of this study was to identify predictors of CSF shunt dependency following aSAH.

METHODS

We re-analyzed data acquired from aSAH patients previously enrolled in a prospective, controlled single-center clinical trial in which shunt dependency was not one of the end points. In the present study patients were allocated into two groups: those receiving a shunt (here denoted as shunt dependent) and those not receiving a shunt, based on a clinical decision process. Predictors of shunt dependency were identified by applying uni- and multivariable analysis. We tested a set of predefined possible risk factors based on the results of the clinical trial, including the impact of CSF drainage volume exceeding 1,500 ml during the 1st week after ictus.

RESULTS

Ninety patients were included in the study. Significant predictors of shunt dependency were poor clinical grade at admission [odds ratio (OR) 4.7, 95% confidence interval (CI) 1.2-18.4], large amounts of subarachnoid blood (OR 3.8, 95% CI 1.0-14.0), large ventricular size on preoperative cerebral computer tomographic (CT) scans (OR 1.0, 95% CI 1.0-1.1), and CSF volume drainage exceeding 1,500 ml during the 1st week after the ictus (OR 16.3, 95% CI 4.0-67.1). Age ≥70 years, larger amounts of intraventricular blood, vertebrobasilar aneurysm, and endovascular treatment tended to increase the likelihood of receiving a shunt. Outcome was not significantly different between shunted and non-shunted patients.

CONCLUSIONS

In this cohort of patients with clinical grade aSAH at admission, larger amounts of subarachnoid blood and large ventricular size on preoperative cerebral CT, and CSF drainage in excess of 1,500 ml during the 1st week after the ictus were significant predictors of shunt dependency. Shunt dependency did not hamper outcome.

Predictors of in-hospital shunt-dependent hydrocephalus following rupture of cerebral aneurysms

The development of shunt-dependent hydrocephalus is a well-recognised complication after aneurysmal subarachnoid haemorrhage, and negatively impacts on outcomes among survivors. This study aimed to identify early predictors of shunt dependency in a large administrative dataset of aneurysmal subarachnoid haemorrhage patients. We reviewed the National Hospital Morbidity Database in Australia for the years 1998 to 2008 and investigated the incidence of ventricular shunt placement following aneurysmal subarachnoid haemorrhage admissions. Putative risk factors were evaluated with univariate and multivariate logistic regression analysis to identify independent predictors of outcome. The following variables were considered: poor admission neurological grade; aneurysm location; intracerebral haemorrhage; intraventricular haemorrhage; acute hydrocephalus requiring the insertion of an external ventricular drain; surgical clipping; endovascular coiling; meningitis; and prolonged period of external ventricular drainage. A total of 10807 patients hospitalised for aneurysmal subarachnoid haemorrhage were identified. Among them, 701 (6.5%) required a permanent cerebrospinal fluid diversion procedure during the same admission as the aneurysmal subarachnoid haemorrhage. On multivariate analysis, poor admission neurological grade, acute hydrocephalus, the presence of intraventricular haemorrhage, ruptured vertebral artery aneurysm, surgical clipping, endovascular coiling, meningitis, and a prolonged period of external ventricular drainage were significant predictors of shunt dependency. A patient with a ruptured middle cerebral artery aneurysm was unlikely to develop shunt dependency (odds ratio 0.58; 95% confidence interval 0.46-0.73; p < 0.001).

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.

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.

Predictors and outcomes of shunt-dependent hydrocephalus in patients with aneurysmal sub-arachnoid hemorrhage

BACKGROUND

Hydrocephalus following spontaneous aneurysmal sub-arachnoid hemorrhage (SAH) is often associated with unfavorable outcome. This study aimed to determine the potential risk factors and outcomes of shunt-dependent hydrocephalus in aneurysmal SAH patients but without hydrocephalus upon arrival at the hospital.

METHODS

One hundred and sixty-eight aneurysmal SAH patients were evaluated. Using functional scores, those without hydrocephalus upon arrival at the hospital were compared to those already with hydrocephalus on admission, those who developed it during hospitalization, and those who did not develop it throughout their hospital stay. The Glasgow Coma Score, modified Fisher SAH grade, and World Federation of Neurosurgical Societies grade were determined at the emergency room. Therapeutic outcomes immediately after discharge and 18 months after were assessed using the Glasgow Outcome Score.

RESULTS

Hydrocephalus accounted for 61.9% (104/168) of all episodes, including 82 with initial hydrocephalus on admission and 22 with subsequent hydrocephalus. Both the presence of intra-ventricular hemorrhage on admission and post-operative intra-cerebral hemorrhage were independently associated with shunt-dependent hydrocephalus in patients without hydrocephalus on admission. After a minimum 1.5 years of follow-up, the mean Glasgow outcome score was 3.33 ± 1.40 for patients with shunt-dependent hydrocephalus and 4.21 ± 1.19 for those without.

CONCLUSIONS

The presence of intra-ventricular hemorrhage, lower mean Glasgow Coma Scale score, and higher mean scores of the modified Fisher SAH and World Federation of Neurosurgical grading on admission imply risk of shunt-dependent hydrocephalus in patients without initial hydrocephalus. These patients have worse short- and long-term outcomes and longer hospitalization.

Incidence of ventricular shunt placement for hydrocephalus with clipping versus coiling for ruptured and unruptured cerebral aneurysms in the Nationwide Inpatient Sample database: 2002 to 2007

BACKGROUND

Few studies have compared the incidence of ventricular shunt placement for hydrocephalus after clipping versus coiling of cerebral aneurysms.

OBJECTIVE

The Nationwide Inpatient Sample (NIS) database was used to compare, on a national level, the incidence of ventricular shunt placement after clipping versus coiling of ruptured and unruptured aneurysms.

METHODS

Hospitalizations for clipping and coiling of ruptured and unruptured aneurysms from 2002 to 2007 were collected from the NIS by cross-matching International Classification of Diseases-9 codes for diagnoses of subarachnoid hemorrhage or unruptured cerebral aneurysm with procedure codes for clipping or coiling. The incidence of ventricular shunt placement for hydrocephalus after clipping and coiling was compared using generalized linear models with generalized estimating equations (GEE) to adjust for patient- and hospital-specific factors and correlation between admissions.

RESULTS

Of 10,899 ruptured aneurysm patients (6593 clipping, 4306 coiling), clipping had a similar incidence of ventricular shunt placement (9.3%) compared to coiling (10.5%) (odds ratio = 0.984; 95% confidence interval = 0.85, -1.14; P value = 0.833 after adjustment for patient-specific and hospital-specific factors). Likewise, of 9686 unruptured aneurysm patients (4483 clipping, 5203 coiling), clipping had similar incidence of ventricular shunt placement (0.4%) compared to coiling (0.5%) (odds ratio = 0.763; 95% confidence interval = 0.37, -1.58; P value = 0.465 after adjustment for patient-specific and hospital-specific factors). Predictors of shunt placement in ruptured aneurysm patients were age, comorbidity score, admission type, payer, and hospital aneurysm volume. Predictors of shunt placement in unruptured aneurysm patients were comorbidity score and admission type.

CONCLUSIONS

In an observational study, clipping and coiling of ruptured and unruptured cerebral aneurysms are associated with similar incidences of ventricular shunt placement for hydrocephalus.

Permanent cerebrospinal fluid diversion in subarachnoid hemorrhage: Influence of physician practice style

Background:

Acute hydrocephalus (HCP) after aneurysmal subarachnoid hemorrhage (SAH) often persists. Our previous study described factors that singly and combined in a formula correlate with permanent CSF diversion. We now aimed to determine whether the same parameters are applicable at an institution with different HCP management practice.

Methods:

We reviewed records of 181 consecutive patients who presented with SAH and received an external ventricular drain (EVD) for acute HCP. After exclusion and inclusion criteria were met, 71 patients were analyzed. Data included admission Fisher and Hunt and Hess grades, aneurysm location, treatment modality, ventricle size, CSF cell counts and protein levels, length of stay (LOS) in the hospital, and the presence of craniectomy. Outcome measures were: (1) initial EVD challenge outcome; (2) shunting within 3 months; and (3) LOS.

Results:

Shunting correlated with Hunt and Hess grade, CSF protein, and the presence of craniectomy. The formula derived in our previous study demonstrated a weaker correlation with initial EVD challenge failure. Several parameters that correlated with shunting in the previous study were instead associated with LOS in this study.

Conclusions:

The decision to shunt depends on management choices in the context of a disease process that may improve over time. Based on the treatment strategy, the shunting rate may be lowered but LOS increased. Markers of disease severity in patients with HCP after SAH correlate with both shunt placement and LOS. This is the first study to directly evaluate the effect of different practice styles on the shunting rate. Differences in HCP management practices should inform the design of prospective studies.

THIRD VENTRICULOSTOMY THROUGH THE FENESTRATED LAMINA TERMINALIS DURING MICRONEUROSURGICAL CLIPPING OF INTRACRANIAL ANEURYSMS

OBJECTIVE

Fenestration of the lamina terminalis (LT) is an alternative means of cerebrospinal fluid (CSF) drainage during acute or emergency surgery of ruptured intracranial aneurysms in patients with high-grade subarachnoid hemorrhage. External ventricular drainage allows drainage of CSF and also measurement of intracranial pressure after the surgery. Catheterization of the third ventricle via the fenestrated LT after clipping the aneurysm is an alternative to conventional ventriculostomies. This method has been used by the senior author (JAH) since 2001. The authors describe their experience with this technique, which can be used safely in selected cases of high-grade subarachnoid hemorrhage.

METHODS

Seventy-eight patients with aneurysmal subarachnoid hemorrhage underwent third ventriculostomy via the LT between March 2001 and December 2005. Clinical and radiological data of these consecutive patients were retrospectively reviewed.

RESULTS

There were no procedure-related complications. Eight patients (10%) later required a conventional ventriculostomy, 7 because of catheter occlusion and 1 because of catheter displacement. In 7 patients (9%), a positive CSF culture was found.

CONCLUSION

Ventriculostomy via the fenestrated LT performed during aneurysm surgery is a practical way for later CSF removal and intracranial pressure monitoring. The catheter can be applied via the same craniotomy without the need for an additional intervention. No procedure-related complications were observed in the present series. This technique can be suggested as a safe alternative to a classical ventriculostomy.

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.

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 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.

The effects of fenestration of the interpeduncular cistern membrane arousted to the opening of lamina terminalis in patients with ruptured ACoA aneurysms: a prospective, comparative study

BACKGROUND

The incidence of chronic hydrocephalus requiring shunt placement is a well-known and common complication of aneurysmal subarachnoid hemorrhage (aSAH). It was suggested that fenestration of the lamina terminalis (LT) during microsurgery for aSAH may be associated with a reduced rate of shunt-dependent chronic hydrocephalus (SDCH). We analyzed that, fenestrations of the LT and Liliequist membrane (LM) would reduce rate of SDCH and improve rate of favorable outcome.

METHODS

145 patients who were analyzed in the study were treated in our department with ruptured anterior communicating artery (ACoA) aneurysms. We compared the rate of shunting and clinical outcome in patients in whom only fenestration of the LT (Group 1) was performed with that in patients in whom fenestrations of both the LT and LM (Group 2) were performed.

RESULTS

Chronic hydrocephalus requiring shunting amounted to 9.8% (7 patients) in Group 1 and 4% (3 patients) in Group 2 (p=0.203). Also, there were no differences in the rate of shunt dependent hydrocephalus between the two groups in patients with Fisher's CT grades 3 (p=0.343) and 4 (p=0.667), and HH grades 4 (p=0.306) and 5 (p=0.361). Favorable clinical outcomes were observed with rates of 74.6% in Group 1 and 79.7% in Group 2 (p=0.693). Also there were no differences in the rates of favorable clinical outcome between the two groups in patients with Fisher's CT grades 3-4, HH grades 4-5.

CONCLUSIONS

Our study shows that fenestration of the LM coupled with the opening of the LT reduced-relatively-the incidence of SDCH; this however was not significant. This positive effect was particularly noticeable in patients in whom a cisternal "overflow" was observed at surgery when opening the LM. This corresponded to cases with ventricular dilatation and a IVth ventricle with clots.

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.

Hydrocephalus: comparison of clipping and embolization in aneurysm treatment

OBJECT

In this retrospective study conducted at Atkinson Morley's Hospital and Middlesbrough General Hospital, the authors analyzed 100 matched patients who had suffered subarachnoid hemorrhage (SAH) to determine whether the technical procedure by which aneurysms are treated affects the development of chronic hydrocephalus.

METHODS

Four hundred seventy-five patients presented with SAH between 1995 and 1998. Exclusion criteria included posterior circulation aneurysms, multiple aneurysms, electively clipped or embolized aneurysms, angiographically undetected SAH, patients who died within 1 month of neurosurgical intervention, and patients with the same aneurysm location but a different Fisher grade. The authors matched 50 patients who underwent embolization of their aneurysms with another 50 who had similar Fisher grades and aneurysm types and underwent clipping of their aneurysms. The maximum incidence of ruptured aneurysms occurred in patients who were between 41 and 60 years of age, with women preponderant in both study groups. In each group, 27 patients had anterior communicating artery aneurysm, 13 had posterior communicating artery aneurysm, seven had middle cerebral artery aneurysm, and three had internal carotid artery aneurysm. The lesions in three patients in each group were Fisher Grade I, in 23 patients they were Fisher Grade II, in 14 they were Fisher Grade III, and 10 patients had Fisher Grade IV SAH. Nine patients among those with clipped aneurysms and eight of the patients who underwent embolization had hydrocephalus for which they needed intervention. These interventions included lumbar puncture, ventricular drainage, and ventriculoperitoneal (VP) shunt placement; three patients in each group needed VP shunt placement.

CONCLUSIONS

The technical procedure used to treat aneurysms, whether clipping or embolization, does not significantly affect the development of chronic hydrocephalus. However, a larger sample of patients is needed for accurate comparisons and stronger conclusions.

Chronic hydrocephalus in elderly patients following subarachnoid hemorrhage

BACKGROUND

With the aging of the population, surgery for ruptured intracranial aneurysms is increasing among the elderly. We sought to clarify the characteristics of chronic hydrocephalus following aneurysmal subarachnoid hemorrhage (SAH) in elderly patients.

METHODS

Of the 576 surgically treated patients, 289 were aged 59 years or younger, 169 were 60 to 69, and 118 were 70 years or older. The relationship between chronic hydrocephalus and the causative factors was analyzed for each age group.

RESULTS

Of the 576 patients, chronic hydrocephalus was observed in 215 (37%), with the incidence increasing significantly with age (p < 0.001) and being the highest in the oldest age group. In elderly patients, the incidence of chronic hydrocephalus was relatively high, even after mild SAH. The incidence of chronic hydrocephalus was high regardless of age in patients with severe SAH, such as in those with H&H grades III-IV, SAH grades III-IV, acute hydrocephalus, symptomatic vasospasm, and intraventricular hemorrhage, and in those with vertebro-basilar artery aneurysms.

CONCLUSION

In the elderly, the incidence of chronic hydrocephalus following SAH was significantly higher than in younger patients, even after mild SAH. In elderly patients, careful observation and individualized treatment are necessary even if SAH is mild.

Factors associated with hydrocephalus after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Associations among various factors and the occurrence of hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) were evaluated retrospectively in 897 patients enrolled in the North American study of tirilazad mesylate.

METHODS

Patients were assessed for hydrocephalus in a blinded fashion. Assessment of hydrocephalus was made on the basis of 3-month follow-up computed tomographic studies or, for those without a 3-month follow-up scan, on the basis of the latest computed tomographic studies obtained at least 10 days after SAH. Criteria indicating the occurrence of hydrocephalus were the presence of significantly enlarged temporal horns or prior placement of a ventricular shunt. Univariate analysis was performed to assess relationships among various factors and hydrocephalus. Factors statistically associated with the occurrence of hydrocephalus were analyzed further using logistic regression analysis.

RESULTS

Overall, 25.9% of the 897 patients developed hydrocephalus. Statistically significant associations among the following factors and hydrocephalus were observed (P value; risk coefficient): 1) severity of 3-month post-SAH Glasgow Outcome Scale (0.0001; 2.00); 2) increased ventricular size at admission (0.0001; 2.78); 3) neurological grade severity at admission (0.0274; 1.26); 4) preexisting hypertension (0.0284; 1.66); 5) alcoholism (0.0066; 2.30); 6) female sex (0.0056; 0.49); 7) increased aneurysm size (0.0239; 0.56); 8) pneumonia (0.0299; 1.78); 9) meningitis (0.0290; 5.86); and 10) intraventricular hemorrhage at admission (0.0414; 1.64).

CONCLUSION

Hydrocephalus seems to have a multifactorial etiology. Knowledge of risk factors related to the occurrence of hydrocephalus may help guide neurosurgeons in the long-term care of patients who have experienced aneurysmal SAH.

Increase of collagen synthesis and deposition in the arachnoid and the dura following subarachnoid hemorrhage in the rat

Arachnoidal fibrosis following subarachnoid hemorrhage (SAH) has been suggested to play a pathogenic role in the development of late post-hemorrhagic hydrocephalus in humans. The purpose of this study was to investigate the rate of collagen synthesis in the arachnoid and the dura in the rat under normal conditions and to study the time schedule and the localization of the increased collagen synthesis following an experimental SAH. We found that the activity of prolyl 4-hydroxylase, a key enzyme in collagen synthesis, was 3-fold higher in the dura than that in the arachnoid and was similar to the activity in the skin. We then induced SAH in rats by injecting autologous arterial blood into cisterna magna. After SAH, we observed an increase in prolyl 4-hydroxylase activity of the arachnoid and the dura at 1 week. At this time point the enzyme activity in both tissues was 1.7-1.8-fold compared to that in the controls and after this time point the activities declined but remained slightly elevated at least till week 4. The rate of collagen synthesis was measured in vitro by labeling the tissues with [(3)H]proline. The rate increased to be 1.7-fold at 1 to 2 weeks after the SAH in both of the tissues. Immunohistochemically we observed a deposition of type I collagen in the meninges at 3 weeks after the SAH. SAH is followed by a transient increase in the rate of collagen synthesis in the arachnoid and, surprisingly, also the dura. Increased synthesis also resulted in an accumulation of type I collagen in the meningeal tissue, suggesting that the meninges are a potential site for fibrosis. The time schedule of these biochemical and histological events suggest that meningeal fibrosis may be involved in the pathogenesis of late post-hemorrhagic hydrocephalus.

Development of obstructive hydrocephalus with lumboperitoneal shunting following subarachnoid hemorrhage

Hydrocephalus is a frequent complication of subarachnoid hemorrhage (SAH). The optimum method of treating hydrocephalus in this setting has not been determined. We review our experience with patients developing communicating hydrocephalus secondary to SAH and subsequently treated with lumboperitoneal (LP) shunts. Following hospitalization for the treatment of SAH, patients who developed clinical symptoms and radiologic signs of hydrocephalus were treated with (ventriculoperitoneal) VP or LP shunting. Eighteen patients received an LP shunt, of which seven (28%) developed a non-communicating or obstructive hydrocephalus. These seven patients underwent replacement with a VP shunt and have not had further complications. In the setting of post-SAH communicating hydrocephalus, obstructive hydrocephalus may develop after LP shunt placement. Patients who develop this complication and have their LP shunts converted to VP shunts have a favorable prognosis.

Ruptured intracranial aneurysms: acute endovascular treatment with electrolytically detachable coils--a prospective randomized study

PURPOSE

To compare the use of electrolytically detachable coils versus surgical ligation for the management of acutely ruptured intracranial aneurysm.

MATERIALS AND METHODS

A prospective randomized study included 109 patients with acute (< 72 hours) subarachnoid hemorrhage caused by a ruptured aneurysm (Hunt and Hess grade I-II [n = 67], grade III [n = 26], or grade IV-V [n = 16]). All patients were suitable candidates for both endovascular and surgical treatment and were randomly assigned to undergo coil embolization (n = 52) or surgical ligation (n = 57).

RESULTS

Significantly better primary angiographic results were achieved after surgery in patients with anterior cerebral artery aneurysm (n = 55, P = .005) and after endovascular treatment in those with posterior circulation aneurysm (n = 11, P = .045). No significant differences were seen in middle cerebral artery (n = 19) or internal carotid artery (n = 24) aneurysms. Early rebleeding occurred in one patient after incomplete coil embolization. The technique-related mortality rate was 4% in the surgical group and 2% in the endovascular group. Clinical outcome (Glasgow Outcome Scale score) at 3 months was not significantly different between treatment groups in terms of intended treatment modality. No late rebleedings had occurred at the time of this writing.

CONCLUSION

In selected patients with a recently ruptured intracranial aneurysm, favorable results were achieved by using endovascular treatment. Subsequent acute or late open surgery was sometimes required. The clinical outcome at 3 months was comparable in the endovascular and surgical treatment groups.

The possible role of CSF hydrodynamic parameters following in management of SAH patients

It is suggested that reduced intracranial compliance may be present even when measured ICP is normal and may precede clinical deterioration. Our findings reflect a decompensation of hydrodynamic parameters more pronounced 4-7 postictal days, when compliance is reduced not only in patients with poor clinical condition, but also in patients with Hunt-Hess grade I-III. Increased CSF outflow resistance in the first few days is not surprising; it is thought to be due to the blockage of flow of CSF through the basal subarachnoid cisterns and clogging of the arachnoid villi with erythrocytes and fibrin. Enlargement of ventricles seen on CT scan at the same time suggests the development of acute hydrocephalus. During the first days after SAH, our data reflects evidence of ventricular enlargement in patients presenting with both poor and better clinical condition. We conclude that the monitoring of ICP and dynamic measuring of CSF hydrodynamic parameters is important for longer than the generally accepted few days for selected cases after SAH.