Shunt performance in 349 patients with hydrocephalus after aneurysmal subarachnoid hemorrhage

First insights into the utilisation of the M.BLUE® device for post-haemorrhagic hydrocephalus treatment

BACKGROUND/OBJECTIVES

Gravitational shunt systems reduce the risk of over-drainage in aneurysmal subarachnoid hemorrhage-associated hydrocephalus (aSAH-aH). The Miethke M.BLUE® valve, initially designed for pediatric use, has been scarcely studied in adults. This study assesses its safety and effectiveness in managing aSAH-aH.

METHODS

A retrospective study was conducted on 17 adult patients treated with the M.BLUE® valve for aSAH-aH. Outcomes included radiological assessment (Evans' Index, callosal-marginal angle), clinical improvement (gait, urinary, cognitive functions), and post-operative valve adjustments.

RESULTS

The Evans' Index decreased by 14.9 ± 12.2% (P < .001), and the callosal-marginal angle increased by 27.3 ± 21% (P < .001). One case of over-drainage and three of under-drainage required post-operative adjustment. Three non-device-related mechanical complications were recorded (ventricular catheter malposition, peritoneal catheter migration, infection). No valve dysfunctions were reported. Clinical improvements were observed in gait (15/15), cognition (14/15, P < .001), and urinary function (12/13, P < .001).

CONCLUSIONS

.The M.BLUE® device appears to be a safe and effective option for treating aSAH-aH in adults. It achieved positive radiological changes with limited post-operative adjustments and demonstrated significant clinical improvements.

Chronic, Shunt-Dependent Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage: Incidence, Risk Factors, Clinical Phenotypes, and Outcome

OBJECTIVE

The main aim was to determine the incidence, risk factors, clinical phenotypes, and response to shunt surgery in chronic, shunt-dependent hydrocephalus (SDHC) after aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

In this observational, single-center study, 849 aSAH patients treated at Uppsala University Hospital between 2008-2018 were included. Variables on demography, injury severity, treatments, chronic hydrocephalus presentation, and outcome were evaluated.

RESULTS

In total, 107 (13%) patients were treated with a shunt due to SDHC. In multivariate logistic regressions, risk factors for SDHC were worse neurologic (World Federation of Neurosurgical Societies) grade, larger ventricles (Evans index) at admission, the need to insert an external ventricular drain (EVD), decompressive craniectomy, and complications with meningitis. Six different SDHC phenotypes were identified: impeded neurological recovery (55%), Hakim-Adams syndrome (17%), high-pressure symptoms (13%), failed EVD removal (8%), external brain herniation after decompressive craniectomy (DC; 6%), and subdural hygroma (1%). The former 3 groups significantly improved in modified Rankin Scale (mRS) and 87%-100% exhibited subjective symptomatic relief. There was no significant change in mRS for the latter 3 groups, but 60%-100% experienced some subjective relief postoperatively.

CONCLUSIONS

Chronic SDHC was a common complication after aSAH, particularly in patients with severe primary brain injury, acute hydrocephalus, and treatment-related factors. The condition presents with distinct clinical phenotypes, which may influence treatment response. Recognizing these phenotypes could aid in optimizing patient selection and expectations for shunt surgery outcomes.

Risk factors for shunt-dependent hydrocephalus after spontaneous subarachnoid hemorrhage

INTRODUCTION

Subarachnoid haemorrhage (SAH) is one of the most frequent neurosurgical emergencies, most of them due to intracranial aneurysm rupture. Hydrocephalus is a prevalent complication with a high rate of complications. The aims of this study are to identify predictors of shunt-dependent hydrocephalus following aneurysmal SAH and to quantify the complications arising from ventriculoperitoneal shunts.

METHODS

This study is about an observational retrospective analytic study of the patients with spontaneous SAH admitted to Miguel Servet Universitary Hospital between 2017 and 2022. Patients' clinical and radiological characteristics, type of treatment, diagnoses and treatment of hydrocephalus, complications of ventriculoperitoneal shunts and mortality are some of the data achieved in this study. A descriptive study of these variables has been done and, subsequently, the most relevant variables have been statistically analysed to identify patients with increasing risk of shunting for hydrocephalus. This study was authorized by the Ethics Committee prior to its elaboration.

RESULTS

A total of 359 patients with spontaneous SAH were admitted to Miguel Servet Universitary Hospital between 2017 and 2022, with an intrahospitalary death rate of 25.3%. 66.3% of the total of patients with SAH were due to intracranial aneurysm rupture (n = 238). 45.3% of the patients with aneurysmal SAH required an external ventricular drain (EVD) to treat acute hydrocephalus. 11.7% (n = 28) developed a shunt-dependent hydrocephalus. Statistical significance was found between shunt-dependent hydrocephalus and the following: high score in modified Fisher scale and placement of EVD. The mean interval from EVD to ventriculoperitoneal shunt placement was 26.1 days. The mean rate of reoperation of patients after shunt was 17.7%, mostly due to infection.

CONCLUSIONS

The most significant risk factor for shunt-dependent hydrocephalus after aneurysmal SAH was high Fisher grade and previous need of EVD. Shunt infections is the main cause of shunt reoperation. Early shunt placement in selected patients might reduce the rate of infectious complications.

Acute evacuation of 54 intracerebral hematomas (aICH) during the microsurgical clipping of a ruptured middle cerebral artery bifurcation aneurysm-illustration of the individual clinical courses and outcomes with a serial brain CT/MRI panel until 12 months

PURPOSE

In aneurysmal intracerebral hemorrhage (aICH), our review showed the lack of the patient's individual (i) timeline panels and (ii) serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome.

METHODS

Our retrospective cohort consists of 54 consecutive aICH patients from a defined population who acutely underwent the clipping of a middle cerebral artery bifurcation saccular aneurysm (Mbif sIA) with the aICH evacuation at Kuopio University Hospital (KUH) from 2010 to 2019. We constructed the patient's individual timeline panels since the emergency call and serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome. The patients were indicated by numbers (1.-54.) in the pseudonymized panels, tables, results, and discussion.

RESULTS

The aICH volumes on KUH admission (median 46 cm3) plotted against the time from the emergency call to the evacuation (median 8 hours) associated significantly with the rebleeds (n=25) and the deaths (n=12). The serial CT/MRI slice panels illustrated the aICHs, intraventricular hemorrhages (aIVHs), residuals after the aICH evacuations, perihematomal edema (PHE), delayed cerebral injury (DCI), and in the 42 survivors, the clinical outcome (mRS) and the brain tissue outcome.

CONCLUSIONS

Regarding aICH evacuations, serial brain CT/MRI panels present more information than words, figures, and graphs. Re-bleeds associated with larger aICH volumes and worse outcomes. Swift logistics until the sIA occlusion with aICH evacuation is required, also in duty hours and weekends. Intraoperative CT is needed to illustrate the degree of aICH evacuation. PHE may evoke uncontrollable intracranial pressure (ICP) in spite of the acute aICH volume reduction.

Should individual timeline and serial CT/MRI panels of all patients be presented in acute brain insult cohorts? A pilot study of 45 patients with decompressive craniectomy after aneurysmal subarachnoid hemorrhage

PURPOSE

Our review of acute brain insult articles indicated that the patients' individual (i) timeline panels with the defined time points since the emergency call and (ii) serial brain CT/MRI slice panels through the neurointensive care until death or final brain tissue outcome at 12 months or later are not presented.

METHODS

We retrospectively constructed such panels for the 45 aneurysmal subarachnoid hemorrhage (aSAH) patients with a secondary decompressive craniectomy (DC) after the acute admission to neurointensive care at Kuopio University Hospital (KUH) from a defined population from 2005 to 2018. The patients were indicated by numbers (1.-45.) in the pseudonymized panels, tables, results, and discussion. The timelines contained up to ten defined time points on a logarithmic time axis until death ([Formula: see text]; 56%) or 3 years ([Formula: see text]; 44%). The brain CT/MRI panels contained a representative slice from the following time points: SAH diagnosis, after aneurysm closure, after DC, at about 12 months (20 survivors).

RESULTS

The timelines indicated re-bleeds and allowed to compare the times elapsed between any two time points, in terms of workflow swiftness. The serial CT/MRI slices illustrated the presence and course of intracerebral hemorrhage (ICH), perihematomal edema, intraventricular hemorrhage (IVH), hydrocephalus, delayed brain injury, and, in the 20 (44%) survivors, the brain tissue outcome.

CONCLUSIONS

The pseudonymized timeline panels and serial brain imaging panels, indicating the patients by numbers, allowed the presentation and comparison of individual clinical courses. An obvious application would be the quality control in acute or elective medicine for timely and equal access to clinical care.

Failure of Internal Cerebrospinal Fluid Shunt: A Systematic Review and Meta-Analysis of the Overall Prevalence in Adults

OBJECTIVE

Reported rates of failures of internal cerebrospinal fluid shunt (ICSFS) vary greatly from less than 5% to more than 50% and no meta-analysis to assess the overall prevalence has been performed. We estimated the failure rate after ICSFS insertion and searched for associated factors.

METHODS

Six databases were searched from January 1990 to February 2022. Only original articles reporting the rate of adult shunt failure were included. Random-effects meta-analysis with a generalized linear mixed model method and logit transformation was used to compute the overall failure prevalence. Subgroup analysis and meta-regression were implemented to search for associated factors.

RESULTS

Of 1763 identified articles, 46 were selected, comprising 70,859 ICSFS implantations and 13,603 shunt failures, suggesting an accumulated incidence of 19.2%. However, the calculated pooled prevalence value and its 95% confidence interval (CI) were 22.7% (95% CI, 19.8-5.8). The CI of the different estimates did not overlap, indicating a strong heterogeneity confirmed by a high I² of 97.5% (95% CI, 97.1-97.8; P < 0.001; τ² = 0.3). Ninety-five percent prediction interval of shunt failure prevalence ranged from 8.75% to 47.36%. A meta-regression of prevalence of publication found a barely significant decreasing failure rate of about 2% per year (-2.11; 95% CI, -4.02 to -0.2; P = 0.031).

CONCLUSIONS

Despite being a simple neurosurgical procedure, ICSFS insertion has one of the highest risk of complications, with failure prevalence involving more than 1 patient of 5. Nonetheless, all efforts to lower this high level of shunt failure seem to be effective.

Gastrostomy and internal cerebrospinal fluid shunt in adults. A systematic review and meta-analysis of the risk of infection

BACKGROUND

Hydrocephalus is a frequent neurological condition, commonly treated by ventriculoperitoneal shunting (VPS), a neurosurgical procedure with significant risk of infection. Some severely brain-injured hydrocephalic patients with swallowing dysfunction may require percutaneous endoscopic gastrostomy (PEG). There are few data on the safety of PEG in patients with VPS, with contradictory results reported.

OBJECTIVE

The aim of this systematic review and meta-analysis was to determine the rate of VPS infection in the setting of PEG.

METHODS

Six databases were searched for the period January 1990 to June 2022. Only original articles reporting the rate of shunt infection in the setting of PEG in adults were included. Random-effects meta-analysis was used to assess the rate of infection.

RESULTS

Fifteen of the 1,703 identified articles were selected, reporting 701 internal cerebrospinal fluid shunts, with 63 infections. The pooled rate of infection in patients with both PEG and VPS was 7.41% (95% CI [3.67-14.38]). There was a significantly higher risk of VPS infection in the PEG group vs. the control group with VPS without PEG: relative risk (RR)=2.33 (95% CI [1.11-4.89]). On the other hand, the risk of infection was the same whether the PEG was placed before or after the VPS surgery: RR=1.05 (95% CI [0.57-1.92]).

CONCLUSION

Gastrostomy tube placement is a significant risk factor for VPS infection. However, onset of infection was not related to the sequence of or interval between VPS and PEG.

TRIAL REGISTRATION

This meta-analysis is registered in https://www.crd.york.ac.uk/PROSPERO/, PROSPERO ID: CRDCRD42022326774.

Non-adjustable gravitational valves or adjustable valves in the treatment of hydrocephalus after aneurysmal subarachnoid hemorrhage patients?

PURPOSE

Hydrocephalus requiring permanent CSF shunting after aneurysmal subarachnoid hemorrhage (aSAH) is frequent. It is unknown which type of valve is optimal. This study evaluates if the revision rate of gravitational differential pressure valves (G-DPVs, GAV® system (B Braun)) (G-DPV) is comparable to adjustable pressure valves (Codman Medos Hakim) (APV) in the treatment of post-aSAH hydrocephalus.

METHODS

The use of a gravitational differential pressure valve is placed in direct comparison with an adjustable pressure valve system. A retrospective chart review is performed to compare the revision rates for the two valve systems.

RESULTS

Within the registry from Radboud University Medical Center, 641 patients with a SAH could be identified from 1 January 2013 until 1 January 2019, whereas at the Heinrich Heine University, 617 patients were identified, totaling 1258 patients who suffered from aSAH. At Radboud University Medical Center, a gravitational differential pressure valve is used, whereas at the Heinrich Heine University, an adjustable pressure valve system is used. One hundred sixty-six (13%) patients required permanent ventricular peritoneal or atrial shunting. Shunt dysfunction occurred in 36 patients: 13 patients of the 53 (25%) of the gravitational shunt cohort, and in 23 of the 113 (20%) patients with an adjustable shunt (p = 0.54). Revision was performed at a mean time of 3.2 months after implantation with the gravitational system and 8.2 months with the adjustable shunt system. Combined rates of over- and underdrainage leading to revision were 7.5% (4/53) for the gravitational and 3.5% (4/113) for the adjustable valve system (p = 0 .27).

CONCLUSION

The current study does not show a benefit of a gravitational pressure valve (GAV® system) over an adjustable pressure valve (CODMAN ® HAKIM®) in the treatment of post-aSAH hydrocephalus. The overall need for revision is high and warrants further improvements in care.