Predictors of Ventriculoperitoneal Shunting after Spontaneous Intraparenchymal Hemorrhage

The Value of Machine Learning Models in Predicting Factors Associated with the Need for Permanent Shunting in Patients with Intracerebral Hemorrhage Requiring Emergency Cerebrospinal Fluid Diversion

OBJECTIVE

To assess the efficacy of machine learning models in identifying factors associated with the need for permanent ventricular shunt placement in patients experiencing intracerebral hemorrhage (ICH) who require emergency cerebrospinal fluid (CSF) diversion.

METHODS

A retrospective review was performed on patients with ICH requiring urgent CSF diversion who were admitted to our facility between July 2009 and May 2023. A binary logistic regression analysis was carried out to determine independent predictors linked to the development of shunt-dependent hydrocephalus following ICH. Five different machine learning models-random forest (RF), support vector machine (SVM), k-nearest neighbor (k-NN), logistic regression (LR), and Adaptive Boosting (AdaBoost)-were utilized to predict the need for permanent shunting in those with spontaneous ICH necessitating emergency CSF diversion. Additionally, RF techniques were applied to identify the factors affecting the need for permanent ventricular shunt placement in these patients.

RESULTS

A total of 578 patients were included in the analysis. Shunt-dependent hydrocephalus occurred in 121 individuals (20.9%). In the multivariate analysis, the Graeb Score, the length of time the external ventricular drain was in place, and an elevated intracranial pressure greater than 30 mm Hg were significant predictors for the need for permanent CSF diversion (P < 0.05). All predictive models showed commendable performance, with RF achieving the highest accuracy (0.921), followed by SVM (0.906), k-NN (0.889), LR (0.881), and AdaBoost (0.823). RF also excelled over the other models in terms of sensitivity and specificity, with a sensitivity of 0.912 and specificity of 0.892. The area under the curve values for RF, SVM, k-NN, LR, and AdaBoost were recorded at 0.903, 0.820, 0.804, 0.801, and 0.798, respectively.

CONCLUSIONS

This research demonstrates that machine learning models can effectively predict the need for permanent CSF diversion in patients with ICH who underwent external ventricular drain placement for urgent CSF diversion, offering important prognostic insights that could facilitate early intervention and lead to potential cost reductions.

Development and validation of a nomogram for predicting early acute hydrocephalus after spontaneous intracerebral hemorrhage: a single-center retrospective study

Acute hydrocephalus is a severe complication that may occur early after an intracerebral hemorrhage (ICH). However, clinical factors predicting the occurrence of acute hydrocephalus have rarely been studied. This study aimed to establish a nomogram model to predict early acute hydrocephalus after ICH. We retrospectively analyzed the data of 930 patients with ICH who were treated at our hospital between January 2017 and May 2024. Least absolute shrinkage and selection operator (LASSO) regression analysis was used to screen for risk factors for acute hydrocephalus, and stepwise logistic regression analysis was used to construct the prediction model, which was visualized using a nomogram. Data were randomly divided into training (n = 652) and test (n = 278) sets at a 7:3 ratio. A total of 930 patients were included, of whom 123 (13.2%) developed acute hydrocephalus within 6 h of being diagnosed with ICH. Univariate analysis revealed that 11 indicators were associated with acute hydrocephalus. In the training set, LASSO and stepwise logistic regression analyses identified four independent risk factors that were used to establish a prediction model. These were the modified Graeb score, age, infratentorial hemorrhage > 15 mL, and thalamic hemorrhage > 15 mL. A graphical nomogram was then developed. The area under the receiver operating characteristic (ROC) curve was 0.974 (95% confidence interval 0.961-0.987). In the Hosmer-Lemeshow test, the p-value was 0.887. The mean absolute error of the calibration plot was 0.012. The decision curve analysis (DCA) validated the fitness and clinical application value of this nomogram. Internal validation showed the test set was in good accordance with the training set. The nomogram prediction model showed good accuracy and could be used to predict the risk of early acute hydrocephalus after ICH, thereby aiding neurologist in making rapid clinical decisions.

Predictive factors for shunt dependency in patients with spontaneous intraventricular hemorrhage

Intraventricular hemorrhage (IVH) occurs in approximately 30-50% patients with spontaneous intracerebral hemorrhage (ICH), with a high 30-day mortality rate. Excess accumulation of parenchymal or ventricular blood associated with the development of acute hydrocephalus leads to poor outcomes. The prediction of shunt dependency is important to identify patients susceptible to requiring permanent shunt placement and benefit from the diversion. This retrospective analytical study aimed to establish a predictive model of shunt dependency in patients with IVH. This study included 179 patients with primary IVH with supratentorial origin or spontaneous ICH with extension into the ventricles between 2015 and 2021. Patients were grouped into "shunt required" and "shunt not required" groups. Variables, including age, sex, preexisting hypertension and diabetes, initial Glasgow Coma Scale scores, ICH location and volume, urokinase administration, modified Graeb score (mGraeb score), and bicaudate index, were analyzed. The shunt required group had significantly higher mGraeb scores (12.0 (6.5-15.0) vs. 7.0 (4.0-12.0), p = 0.001) and higher bicaudate index (0.20 (0.17-0.23) vs. 0.16 (0.13-0.18), P < 0.001) than the shunt not required group. The receiver operating characteristic curve (ROC curve) analysis revealed that a cut-off value of 0.16 of the bicaudate index was significantly related to shunt dependency. The subgroup statistical analysis revealed that neither urokinase administration (p = 0.533) nor urokinase dosage (p = 0.117) showed significant relevance in shunt dependency in patients who received external ventricular drainage. In logistic regression adjusted for the confounders, thalamic ICH (odds ratio (OR) 3.55; 95% confidence interval [(95%CI), 1.13-11.18], an mGraeb score greater than 8 (OR, 3.93; 95%CI, 1.84-8.38), and a bicaudate index greater than 0.16 (OR, 9.87; 95%CI, 3.79-25.73) were factors associated with a higher tendency for shunting. The findings of this study may help identify patients at risk for a permanent shunt after IVH.

Clinical impact of craniectomy on shunt-dependent hydrocephalus after intracerebral hemorrhage: A propensity score-matched analysis

PURPOSE

A consensus on decompressive craniectomy for intracerebral hemorrhage (ICH) has not yet been established. We aimed to investigate the development of shunt-dependent hydrocephalus based on the method of ICH surgery, with a focus on craniectomy.

METHODS

We retrospectively enrolled 458 patients with supratentorial ICH who underwent surgical hematoma evacuation between April 2005 and December 2021 at two independent stroke centers. Multivariate analyses were performed to characterize risk factors for postoperative shunt-dependent hydrocephalus. Propensity score matching (1:2) was undertaken to compensate for group-wise imbalances based on probable factors that were suspected to affect the development of hydrocephalus, and the clinical impact of craniectomy on shunt-dependent hydrocephalus was evaluated by the matched analysis.

RESULTS

Overall, 43 of the 458 participants (9.4%) underwent shunt procedures as part of the management of hydrocephalus after ICH. Multivariate analysis revealed that intraventricular hemorrhage (IVH) and craniectomy were associated with shunt-dependent hydrocephalus after surgery for ICH. After propensity score matching, there were no statistically significant intergroup differences in participant age, sex, hypertension status, diabetes mellitus status, lesion location, ICH volume, IVH occurrence, or IVH severity. The craniectomy group had a significantly higher incidence of shunt-dependent hydrocephalus than the non-craniectomy group (28.9% vs. 4.3%, p < 0.001; OR 9.1, 95% CI 3.7-22.7), craniotomy group (23.2% vs. 4.3%, p < 0.001; OR 6.6, 95% CI 2.5-17.1), and catheterization group (20.0% vs. 4.0%, p = 0.012; OR 6.0, 95% CI 1.7-21.3).

CONCLUSION

Decompressive craniectomy seems to increase shunt-dependent hydrocephalus among patients undergoing surgical ICH evacuation. The decision to perform a craniectomy for patients with ICH should be carefully individualized while considering the risk of hydrocephalus.

Predicting the need for cerebrospinal fluid shunt implantation after spontaneous intracerebral hemorrhage: a challenging task

Objectives

The development of persistent hydrocephalus in patients after spontaneous intracerebral hemorrhage (ICH) is still poorly understood, and many variables predicting the need for a cerebrospinal fluid (CSF)-shunt have been described in the literature with varying results. The aim of this study is to find predictive factors for shunt dependency.

Methods

We performed a retrospective, single-center study of 99 neurosurgically treated patients with spontaneous ICH. Variables, including age, Glasgow Coma Scale (GCS), intraventricular hemorrhage (IVH), location of hemorrhage, acute hydrocephalus, and volumetric analysis of IVH, ICH, and intraventricular CSF were compared between patients with and without CSF-shunt implantation. Furthermore, receiver operating characteristics (ROC) for ICH, IVH, and intraventricular CSF volume parameters were calculated.

Results

CSF-shunt implantation was performed significantly more often in patients after thalamic (p = 0.03) and cerebellar ICH (p = 0.04). Moreover, a lower ratio between the total hemorrhage volume and intraventricular CSF volume (p = 0.007), a higher IVH distribution in the third ventricle, and an acute hydrocephalus (p < 0.001) with an increased intraventricular CSF volume (p < 0.001) were associated with shunt dependency. Our ROC model demonstrated a sensitivity of 82% and a specificity of 65% to predict the necessity for a shunt at a cutoff value of 1.9 with an AUC of 0.835.

Conclusion

Volumetric analysis of ICH, IVH, and intraventricular CSF may improve the prediction of CSF shunt implantation in patients with spontaneous ICH.

Intraventricular Hemorrhage Score as a Robust Predictor for Shunt-Dependent Hydrocephalus After Spontaneous Supratentorial Intracerebral Hemorrhage

OBJECTIVE

Spontaneous intracerebral hemorrhage (ICH) is a common stroke subtype, and patients often develop intraventricular hemorrhage (IVH) and hydrocephalus (H). It is essential to promptly recognize factors that can predict the need for permanent cerebrospinal fluid shunt. This study aims to assess the potential of the IVH score as a predictor for shunt-dependent H in ICH patients.

METHODS

We retrospectively reviewed data from 296 patients with spontaneous supratentorial ICH. Clinical and radiographic data were analyzed. IVH scores were calculated based on initial brain computed tomography scans. A multivariable logistic regression analysis was performed to identify independent predictors of shunt-dependent H, and a receiver operating characteristic curve was generated for the IVH score.

RESULTS

Among the 296 ICH patients, 25 (8.4%) required permanent cerebrospinal fluid shunt placement. The IVH score was identified as the sole significant independent predictor of shunt-dependent H (P < 0.01), with an odds ratio of 1.13 and a 95% confidence interval between 1.04 and 1.22. With each unit increase in the IVH score, the likelihood of shunt dependence rises by 13%. The area under the curve for the IVH score as a predictor of shunt-dependent H was 0.818. With an IVH score threshold of 6.5, the sensitivity was 80.0%, and the specificity was 26.6%.

CONCLUSIONS

The IVH score is a valuable predictor of shunt-dependent H in patients with spontaneous supratentorial ICH. Its simplicity allows for easy integration into routine clinical practice, aiding in better patient risk stratification and informed decision-making regarding permanent CSF shunt placement.

Prediction of Permanent Shunt Dependency in Patients with Intraventricular Hemorrhage: Outcomes of Early External Ventricular Drainage Weaning Protocol

BACKGROUND

Hydrocephalus remains a common sequela of intraventricular hemorrhage (IVH) despite adequate drainage of the hematoma, including endoscopic surgery, intraventricular fibrinolysis, and external ventricular drainage (EVD). Moreover, the appropriate timing for conversion from EVD to ventriculoperitoneal shunt (VPS) is uncertain. This study aimed to evaluate the predictors of shunt dependency in patients with IVH based on the early EVD weaning protocol in our institution.

METHODS

We retrospectively reviewed medical records of patients who were diagnosed with primary IVH and secondary IVH from spontaneous intracerebral hemorrhage during the period 2018-2021. Predictors associated with shunt dependency were identified using a logistic regression model. The cutoff point of each variable was selected by receiver operating characteristic curve analysis. Furthermore, shunt complications were reported as a safety measure of our early EVD weaning protocol.

RESULTS

The analysis included 106 patients. After IVH treatment, 15 (14%) patients required ventriculoperitoneal shunt, whereas 91 (86%) patients were shunt-free. The diameter of posttreatment temporal horn and the degree of IVH reduction were the significant predictors of shunt dependency. Moreover, patients with IVH reduction of >45% and temporal horn diameter of <9 mm had a lower probability of shunt dependency. Shunt failure was found in 2 (13.3%) patients.

CONCLUSIONS

This study showed that a large temporal horn diameter and a lower degree of IVH removal were predictors of shunt dependency in patients with IVH. In addition, early conversion from EVD to ventriculoperitoneal shunt is safe and feasible.

Treatment of Intraventricular Hemorrhage with External Ventricular Drainage and Fibrinolysis: A Comprehensive Systematic Review and Meta-Analysis of Complications and Outcome

BACKGROUND

External ventricular drainage (EVD) is a key factor in the treatment of intraventricular hemorrhage (IVH) but associated with risks and complications. Intraventricular fibrinolysis (IVF) has been proposed to improve clinical outcome and reduce complications of EVD treatment. The following review and metaanalysis provides a comprehensive evaluation of IVH treatment with external ventricular drainage (EVD) and intraventricular fibrinolysis (IVF) with regards to complications and clinical outcomes.

METHODS

The PRISMA guidelines were followed preparing this review. Studies included in the meta-analysis were compared using forest plots and the related odds ratios.

RESULTS

After a literature search, 980 articles were identified and 65 and underwent full-text review. Forty-two articles were included in the review and meta-analysis. We found that bolted and antibiotic-coated catheters were superior to tunnelled/uncoated catheters (P < 0.001) and antibiotic- vs. silver-impregnated catheters (P < 0.001]) in preventing infection. Shunt dependency was related to the volume of blood in the ventricles but unaffected by IVF (P = 0.98). IVF promoted hematoma clearance, decreased mortality (22.4% vs. 40.9% with IVF vs. no IVF, respectively, P < 0.00001), improved good functional outcomes (47.2% [IVF] vs. 38.3% [no IVF], P = 0.03), and reduced the rate of catheter occlusion from 37.3% without IVF to 10.6% with IVF (P = 0.0003).

CONCLUSIONS

We present evidence and best practice recommendations for the treatment of IVH with EVD and intraventricular fibrinolysis. Our analysis further provides a comprehensive quantitative reference of the most relevant clinical endpoints for future studies on novel IVH technologies and treatments.

Radiographic Predictors of Shunt Dependency in Intracranial Hemorrhage With Intraventricular Extension

Background

Intracranial hemorrhage (ICH) may be complicated by intraventricular hemorrhage (IVH) and hydrocephalus, which can require the placement of a ventriculoperitoneal shunt (VPS). ICH and IVH risk scores using radiographic and clinical characteristics have been developed but utilization for assessment of future need for VPS placement is limited.

Methods

This is a single-institution retrospective review for patients with primary ICH with IVH from 2018-2020. Initial CTs and charts were analyzed to determine ICH, IVH, LeRoux and Graeb scores, Evans’ index, ICH and IVH volumes, and comorbidities. Outcomes including Glasgow coma scale (GCS), National Institute of Health Stroke Scale (NIHSS), length of stay, and shunt placement were evaluated with bivariate correlations, t-tests, chi-squared tests, and receiver operating characteristic (ROC) curves (p=0.05).

Results

A total of 130 patients were included of which 102 underwent full treatment beyond hospital day one. VPS placement was significantly associated with longer length of stay (p<0.001), discharge NIHSS (p=0.001), arrival Evans’ index (p<0.001), IVH (p=0.033), LeRoux (p=0.049), but not comorbidities, ICH score, or admission GCS. When treated beyond hospital day one, Evans’ index (p<0.001), IVH volume (p=0.029), Graeb (p=0.0029), IVH (p=0.004), Slice (p=0.015), and Leroux scores (p=0.006) were associated with shunt placement of which an Evans’ index of 0.31 or greater had highest sensitivity and specificity (area under the ROC curve (AUC) 0.81, sensitivity 81%, specificity 0.76).

Conclusions

The higher the Evans’ index, Graeb, IVH, Slice, and LeRoux scores on admission, the higher the risk of shunt dependency in patients undergoing full treatment beyond hospital day one. Admission imaging scores significantly predict the development of shunt dependence and may be considered in treatment.

Prediction of Shunt-Dependent Hydrocephalus after Primary Supratentorial Intracerebral Hemorrhage with a Focus on the Influence of Craniectomies

Objective

Hydrocephalus after intracerebral hemorrhage (ICH) is known to be related to poor prognosis and mortality. We analyzed predictors of permanent hydrocephalus in the patients with surgically treated supratentorial ICH.

Methods

From 2004 to 2019, a total of 414 patients with surgically treated primary supratentorial ICH were included. We retrospectively analyzed age, sex, preexisting hypertension and diabetes, location and volume of ICH, presence and severity of intraventricular hemorrhage (IVH), and type of surgery.

Results

Forty patients (9.7%) required shunt surgery. Concomitant IVH was higher in the 'shunt required' group (92.5%) than in the 'shunt not required' group (67.9%) (p=0.001). IVH severity was worse in the 'shunt required' group (13.5 vs. 7.5, p=0.008). Craniectomy (47.5%) was significantly high in the 'shunt required' group. According to multivariable analysis, the presence of an IVH was 8.1 times more frequent and craniectomy was 8.6 times more frequent in the 'shunt required' group. In the comparison between craniotomy and craniectomy group, the presence of an IVH was related with a 3.9 times higher (p=0.033) possibility and craniectomies rather than craniotomies with a 7-times higher possibility of shunt surgery (p<0.001). Within the craniectomy group, an increase in the craniectomy area by 1 cm2 was correlated with a 3.2% increase in the possibility of shunt surgery (odds ratio, 1.032; 95% confidence interval, 1.005-1.061; p=0.022).

Conclusion

Presence of IVH, the severity of IVH and decompressive craniectomy were related to the development of shunt dependent hydrocephalus in the patients with ICH. The increasing size of craniectomy was related with increasing rate of shunt requirement.

Subarachnoid Hemorrhage and Hydrocephalus

BACKGROUND

Hydrocephalus associated with subarachnoid hemorrhage is a common neurosurgical problem, the management of which is tailor-made to the patient. It is usually seen with an aneurysmal bleed and is independent of the primary modality of treatment.

AIM

This study aimed to provide a comprehensive overview of this important association and discuss the various available treatment modalities.

MATERIALS AND METHODS

A detailed review of the literature was done on the risk factors, pathogenesis, and treatment of hydrocephalus in the setting of subarachnoid hemorrhage.

RESULTS

Hydrocephalus occurs in 6% to 67% of subarachnoid hemorrhage (SAH). It may present as acute, subacute, or chronic at the time of presentation. Diagnosis is made with a plain computed tomography scan of the brain, and the treatment is observant, temporary, or permanent cerebrospinal fluid diversion.

CONCLUSION

Hydrocephalus associated with SAH interferes with the outcome of SAH. It prolongs the hospital stay, besides causing additional morbidity. The various risk factors, if present, should warn us to be vigilant, and management is definitely not uniform and is custom made to the patients' needs.

Endoscopic Third Ventriculostomy for Hydrocephalus Secondary to Extraventricular Obstruction in Thalamic Hemorrhage: A Case Series

BACKGROUND

Intracranial hemorrhage carries significant morbidity and mortality, particularly if associated with hydrocephalus. Management of hydrocephalus includes temporary external ventricular drainage, with or without shunting. Thalamic location is an independent predictor of mortality and increases the likelihood of shunt dependence.

OBJECTIVE

To determine whether endoscopic third ventriculostomy (ETV) can avoid the need for shunt placement and expedite recovery.

METHODS

We prospectively identified thalamic intracranial hemorrhage patients who developed acute hydrocephalus requiring cerebrospinal fluid diversion by extraventricular drain placement from November 2017 to February 2019. Patients who failed an extraventricular drain clamping trial were then evaluated for eligibility for an ETV procedure. Patients who underwent ETV were then followed up for the development of hydrocephalus, need for shunting, and length of stay in the intensive care unit.

RESULTS

Eight patients (7 males, 1 female) were prospectively enrolled. All patients underwent an ETV successfully. None of the patients required shunting. ETV was performed despite the presence of other factors that would have prevented shunt placement, including fever, leukocytosis, and gastrostomy tube placement. Seven patients who underwent ETV were evaluated at 3-mo follow-up and did not require shunting.

CONCLUSION

ETV is a safe and effective technique for the management of hydrocephalus resulting from an extraventricular obstruction in thalamic hemorrhage. It can avoid the need for permanent shunting in this patient population. Larger studies should be conducted to validate and further analyze this intervention.

Factors Impacting Hydrocephalus Incidence in Intracerebral Hemorrhage: A Retrospective Analysis

OBJECTIVE

To test which intracerebral hemorrhage (ICH) characteristics impact incidence of hydrocephalus and characterize subsequent impact on outcomes.

METHODS

A search of the electronic medical record of Sinai Grace Hospital between January 2009 and April 2018 using International Classification of Diseases, Ninth Revision and Tenth Revision codes for ICH identified 847 patients. After excluding patients with hemorrhagic conversion of stroke, subarachnoid hemorrhage, and traumatic hemorrhage, 560 patients remained for analysis. Generalized linear modeling was used to assess variance in modified Rankin Scale (mRS) score and length of stay.

RESULTS

Incidence of hydrocephalus on arrival varied with ICH volume (P < 0.001), intraventricular hemorrhage (IVH) status (P < 0.001), bleed location (P < 0.001), and external ventricular drain (EVD) status (P < 0.001). An EVD was inserted in 47% of patients presenting with IVH (n = 102/217), while 4% of patients without IVH received an EVD (n = 14/343) (P < 0.001). Hemorrhage locations had different rates of EVD placement: thalamic 43%, basal ganglia 22%, cerebellar 28%, brainstem 21%, lobar 7% (P < 0.001). Shunt dependency did not vary between bleed locations (P = 0.072). Variance in mRS score was explained by IVH, bleed location, hydrocephalus on arrival, and ICH volumes. In particular, cerebellar hemorrhage location was associated with better outcomes (mean discharge mRS score of 3.3 vs. 3.9, P < 0.001).

CONCLUSIONS

Bleed characteristics affect incidence of hydrocephalus on admission, rates of long-term shunt dependency, and outcomes. Hemorrhage location did not predict shunt dependency; however, it did predict outcomes. Specifically, cerebellar ICH was associated with a better discharge mRS score.

Comparative Analysis of the Patients with Spontaneous Thalamic Hemorrhage with Concurrent Intraventricular Hemorrhage and Those without Intraventricular Hemorrhage

BACKGROUND

This study aimed to compare the characteristics of patients with spontaneous thalamic hemorrhage (STH) accompanied by intraventricular hemorrhage (IVH) with those of patients without IVH.

METHODS

The medical records of consecutive patients with STH admitted to our institute between January 2000 and December 2018 were reviewed retrospectively. The laboratory and radiological results, mortality, and functional recovery were compared between the STH patients with IVH and those without IVH.

RESULTS

Among 2,389 patients with spontaneous intracerebral hemorrhage, 233 (9.8%) patients were included in this study. Concurrent IVH was detected in 159 (68.2%) patients with STH, and more frequently in those with body mass index ≥ 25, Glasgow Coma Scale score of 3-8, underlying disease, family history of stoke, posterior/medial/global location of hematoma, ventriculomegaly, large volume of hemorrhage, and midline shift ≥ 5 mm. The 3-month mortality was 25.8% and 8.1% (P = 0.039), the rate of good functional recovery at 6 months was 52.2% and 31.0% (P = 0.040), and incidence of delayed normal pressure hydrocephalus (NPH) at 12 months was 10.8% and 24.5% (P = 0.062) in the STH patients with IVH and those without IVH, respectively. At 12 months, delayed NPH developed in 28 of 47 (59.6%) patients who received external ventricular drainage (EVD)-based treatment, 5 of 45 (11.1%) patients who underwent endoscopic evacuation-based treatment, and 8 of 45 (17.8%) patients who underwent other surgeries.

CONCLUSION

Concurrent IVH is strongly associated with mortality in patients with STH. Delayed NPH may develop more frequently in STH patients with IVH who were treated with EVD.

Factors Associated with the Need for Ventriculoperitoneal Shunting in Patients with Spontaneous Intracerebral Hemorrhage Requiring Emergency Cerebrospinal Fluid Diversion

Introduction Intracerebral hemorrhage (ICH) is a serious medical condition that is frequently complicated by acute hydrocephalus, necessitating emergency cerebrospinal fluid (CSF) diversion in a subset of patients, ultimately requiring long-term treatment via placement of permanent ventricular shunts. The present study aimed to determine factors associated with the need for permanent ventricular shunt placement in these patients.

Methods A total of 309 consecutive patients who underwent emergent CSF diversion with external ventricular drain (EVD) as a treatment for ICH between July 2009 and July 2018 were studied retrospectively to assess the factors that might be correlated with shunt-dependent chronic hydrocephalus. A binary logistic regression model was designed to identify independent related factors of shunt-dependent hydrocephalus after ICH.

Results Of 309 patients included in this study, 102 (33.00%) required permanent ventricular CSF shunting before discharge. In univariate analysis, age,ventriculitis, ICP elevation >30 mm Hg, ICH evacuation, the Graeb score, days of EVD in place, and CSF protein levels were significantly associated with the requirement for permanent CSF diversion (p < 0.05). The age and ICH evacuation were protective variables and the ventriculoperitoneal (VP) shunt possibility was reduced by 22.6 and 63.5%, respectively.

Conclusion Our results showed that higher Graeb score, ICP elevation >30 mm Hg, more days of EVD in place, and higher CSF protein levels were associated with permanent CSF diversion in these patients. Advanced age and ICH evacuation decreased the possibility of VP shunting in our study.These factors may help in predicting which patients will need permanent CSF diversion and could ultimately lead to improvements in the management of these patients.

Third Ventricle Obstruction by Thalamic Intracerebral Hemorrhage Predicts Poor Functional Outcome Among Patients Treated with Alteplase in the CLEAR III Trial

INTRODUCTION

The Clot Lysis: Evaluating Accelerated Resolution of IVH trial examined whether irrigating the ventricular system with alteplase improved functional outcomes in patients with small intracerebral hemorrhage (ICH) and large intraventricular hemorrhage (IVH). Thalamic ICH location was common and was associated with poor outcome. One possible explanation is thalamic ICH-associated mass effect obstructing the third ventricle. We hypothesized that patients with thalamic ICH obstructing the third ventricle would have worse functional outcomes compared to patients without obstructing lesions.

METHODS

ICH obstruction of third ventricle was defined as third ventricle compression on 1 or more axial computed tomography slices visually impeding cerebral spinal fluid flow. If the third ventricle was casted with IVH, it was scored as such. Multivariable logistic regression analyses were used to determine whether obstruction of the third ventricle predicts poor functional outcomes defined as modified Rankin score (mRS) 4-6, higher mRS, and mortality at 180 days. Models were adjusted for thalamic ICH location, ICH volume, IVH volume, age, hydrocephalus, baseline Glasgow coma scale, and percentage of low cerebral perfusion pressures during treatment.

RESULTS

Among saline-treated patients, obstruction of the third ventricle by IVH was a significant predictor of higher mRS at 180 days (OR 1.87, CI 1.01-3.47) and mortality at 180 days (OR 2.73, CI 1.27-5.87) while obstruction by ICH was not. In contrast, among alteplase-treated patients, obstruction by ICH was a significant predictor of mRS 4-6 (OR 3.20, CI 1.30-7.88) and higher mRS at 180 days (OR 2.33, CI 1.24-4.35), while obstruction by IVH was not.

CONCLUSIONS

Poor outcomes were associated with mass-related obstruction of the third ventricle from thalamic ICH in alteplase-treated patients and from IVH in saline-treated patients. Once the ventricular system is cleared with alteplase, obstruction of cerebral spinal fluid flow from thalamic ICH might become important in functional recovery.

Prediction of Shunt Dependency After Intracerebral Hemorrhage and Intraventricular Hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage is a disease with high morbidity and mortality. Extension of the hemorrhage into the ventricles is associated with the development of acute hydrocephalus and a poor outcome. Although it can be managed by external ventricular drainage (EVD), a subset of these patients require placement of permanent ventricular shunts. This study aimed to examine the factors on admission that can predict shunt dependency after EVD management.

METHODS

Seventy-two patients who underwent EVD were included in this study. Seventeen of these patients underwent placement of a ventriculoperitoneal shunt. Variables analyzed included age, intraventricular hemorrhage (IVH) score, bicaudate index, acute hydrocephalus, initial Glasgow Coma Scale scores, and blood volume in each ventricle.

RESULTS

In univariate analysis, IVH score (p = 0.020), bicaudate index (p < 0.001), blood volume in lateral ventricles (p = 0.025), blood volume in the fourth ventricle (p = 0.038), and the ratio of blood volume in lateral ventricles to that in third and fourth ventricles (p = 0.003) were significantly associated with persistent hydrocephalus. The best multiple logistic regression model included blood volume parameters and bicaudate index as predictors with the area under a receiver operating characteristic curve of 0.849. The variance inflation factor (VIF) showed that collinearity was not found among predictors. Patients diagnosed with acute hydrocephalus had less blood volume in the lateral ventricles (OR = 0.910) and had more blood volume in the third ventricle (OR = 3.174) and fourth ventricle (OR = 2.126).

CONCLUSIONS

These findings may promote more aggressive monitoring and earlier interventions for persistent hydrocephalus after intraventricular hemorrhage in patients at risk.

Smartphone-assisted endoscopic surgery via Kocher's point for intraventricular hemorrhage caused by thalamic hemorrhage: A comparison with external ventricular drainage

The aim of the present study was to investigate the efficacy of endoscopic surgery via a Kocher point approach for intraventricular hemorrhage (IVH) caused by thalamic hemorrhage (TH), in comparison with external ventricular drainage (EVD). Between January 2016 and August 2017, a total of 40 patients with IVH caused by TH were enrolled. The patients were assigned to an EVD group and an endoscopic surgery group in a non-randomized manner. The pre-operative characteristics recorded included age, pre-operative Glasgow Coma Scale (GCS) score, hemorrhage volume, length of neuro-intensive care unit stay and Graeb score of IVH. Outcomes included the GCS score at 2 weeks after surgery, 30-day and 90-day mortality rates, modified Rankin scale at 6 months after ictus and ventriculo-peritoneal (VP) shunt rate. The baseline characteristics were not significantly different between the two groups. The VP shunt rate in the EVD group was significantly higher compared with that in the endoscopic surgery group (50.0 vs. 15.0%; P=0.02; odds ratio, 5.7). In conclusion, smartphone-assisted endoscopic surgery via Kocher's point is feasible and safe, and significantly reduces permanent shunt dependency for IVH caused by TH.

Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial

OBJECTIVE

To study factors associated with permanent CSF diversion and the relationship between shunting and functional outcomes in spontaneous intraventricular hemorrhage (IVH).

METHODS

Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III), a randomized, multicenter, double-blind, placebo-controlled trial, was conducted to determine if pragmatically employed external ventricular drainage (EVD) plus intraventricular alteplase improved outcome, in comparison to EVD plus saline. Outcome measures were predictors of shunting and blinded assessment of mortality and modified Rankin Scale at 180 days.

RESULTS

Among the 500 patients with IVH, CSF shunting was performed in 90 (18%) patients at a median of 18 (interquartile range [IQR] 13-30) days. Patient demographics and IVH characteristics were similar among patients with and without shunts. In the multivariate analysis, black race (odds ratio [OR] 1.98; 95% confidence interval [CI] 1.18-3.34), duration of EVD (OR 1.10; CI 1.05-1.15), placement of more than one EVD (OR 1.93; CI 1.13-3.31), daily drainage CSF per 10 mL (OR 1.07; CI 1.04-1.10), and intracranial pressure >30 mm Hg (OR 1.70; CI 1.09-2.88) were associated with higher odds of permanent CSF shunting. Patients who had CSF shunts had similar odds of 180-day mortality, while survivors with shunts had increased odds of poor functional outcome, compared to survivors without shunts.

CONCLUSIONS

Among patients with spontaneous IVH requiring emergency CSF diversion, those with early elevated intracranial pressure, high CSF output, and placement of more than one EVD are at increased odds of permanent ventricular shunting. Administration of intraventricular alteplase, early radiographic findings, and CSF measures were not useful predictors of permanent CSF diversion.

Intracranial pressure and cerebral perfusion pressure monitoring in non-TBI patients: special considerations

The effect of intracranial pressure (ICP) and the role of ICP monitoring are best studied in traumatic brain injury (TBI). However, a variety of acute neurologic illnesses e.g., subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, meningitis/encephalitis, and select metabolic disorders, e.g., liver failure and malignant, brain tumors can affect ICP. The purpose of this paper is to review the literature about ICP monitoring in conditions other than TBI and to provide recommendations how the technique may be used in patient management. A PubMed search between 1980 and September 2013 identified 989 articles; 225 of which were reviewed in detail. The technique used to monitor ICP in non-TBI conditions is similar to that used in TBI; however, indications for ICP monitoring often are intertwined with the presence of obstructive hydrocephalus and hence the use of ventricular catheters is more frequent. Increased ICP can adversely affect outcome, particularly when it fails to respond to treatment. However, patients with elevated ICP can still have favorable outcomes. Although the influence of ICP-based care on outcome in non-TBI conditions appears less robust than in TBI, monitoring ICP and cerebral perfusion pressure can play a role in guiding therapy in select patients.

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

BACKGROUND

Acute hydrocephalus is a well-known sequela of aneurysmal subarachnoid hemorrhage (SAH). Controversy exists about whether open microsurgical methods serve to reduce shunt dependency compared with endovascular techniques.

OBJECTIVE

To determine predictors of shunt-dependent hydrocephalus and functional outcomes after aneurysmal SAH.

METHODS

A total of 471 patients who were part of a prospective, randomized, controlled trial from 2003 to 2007 were retrospectively reviewed. All variables including demographic data, medical history, treatment, imaging, and functional outcomes were included as part of the trial. No additional variables were retrospectively collected.

RESULTS

Ultimately, 147 patients (31.2%) required a ventriculoperitoneal shunt (VPS) in our series. Age, dissecting aneurysm type, ruptured vertebrobasilar aneurysm, Fisher grade, Hunt and Hess grade, admission intraventricular hemorrhage, admission intraparenchymal hemorrhage, blood in the fourth ventricle on admission, perioperative ventriculostomy, and hemicraniectomy were significant risk factors (P < .05) associated with shunt-dependent hydrocephalus on univariate analysis. On multivariate analysis, intraventricular hemorrhage and intraparenchymal hemorrhage were independent risk factors for shunt dependency (P < .05). Clipping vs coiling treatment was not statistically associated with VPS after SAH on both univariate and multivariate analyses. Patients who did not receive a VPS at discharge had higher Glasgow Outcome Scale and Barthel Index scores and were more likely to be functionally independent and to return to work 72 months after surgery (P < .05).

CONCLUSION

There is no difference in shunt dependency after SAH among patients treated by endovascular or microsurgical means. Patients in whom shunt-dependent hydrocephalus does not develop after SAH tend to have improved long-term functional outcomes.

Risk factors associated with infections and need for permanent cerebrospinal fluid diversion in pediatric intensive care patients with externalized ventricular drains

BACKGROUND

Externalized ventricular drains (EVDs) are commonly used in pediatric intensive care units (PICU) but few data are available regarding infection rates, infection risks, or factors associated with conversion to permanent cerebrospinal fluid (CSF) diversion.

METHODS

Retrospective observational study of patients managed with EVDs admitted to a tertiary care PICU from January 2005 to December 2009.

RESULTS

Three hundred eighty patients were identified. Neurologic diagnostic groups were externalization of existing shunt in 196 patients (52 %), brain tumor in 122 patients (32 %), intracranial hemorrhage in 23 patients (6 %), traumatic brain injury in 17 patients (5 %), meningitis in 9 patients (2 %), or other in 13 patients (3 %). Six percent of all patients (24/380) had new infections associated with EVD management for an infection rate of 8.6 per 1,000 catheter days. The median time to positive cultures was 7 days (interquartile range 4.75, 9) after EVD placement. Patients with EVD infections had significantly longer EVD duration 6 versus 11.5 days (p = 0.0001), and higher maximum EVD outputs 1.9 versus 1.5 mL/kg/h (p = 0.0017). Need for permanent CSF diversion was associated with higher maximum EVD drainage (1.3 vs. 1.6 mL/kg/h p < 0.0001), longer EVD duration (5 vs. 4 days, p < 0.005), and younger age (4.5 vs. 8 years, p < 0.02) but not intracranial hypertension (72 vs. 82 % of patients, p = 0.4).

CONCLUSIONS

In our large pediatric cohort, EVD infections were associated with longer EVD duration and higher maximum EVD output. Permanent CSF diversion was more likely in patients with higher maximum EVD drainage, longer EVD duration, and younger age.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Progress in translational research on intracerebral hemorrhage: is there an end in sight?

Intracerebral hemorrhage (ICH) is a common and often fatal stroke subtype for which specific therapies and treatments remain elusive. To address this, many recent experimental and translational studies of ICH have been conducted, and these have led to several ongoing clinical trials. This review focuses on the progress of translational studies of ICH including those of the underlying causes and natural history of ICH, animal models of the condition, and effects of ICH on the immune and cardiac systems, among others. Current and potential clinical trials also are discussed for both ICH alone and with intraventricular extension.

Predictors of long-term shunt-dependent hydrocephalus in patients with intracerebral hemorrhage requiring emergency cerebrospinal fluid diversion

Object

Intracerebral hemorrhage (ICH) is frequently complicated by acute hydrocephalus, necessitating emergency CSF diversion with a subset of patients, ultimately requiring long-term treatment via placement of permanent ventricular shunts. It is unclear what factors may predict the need for ventricular shunt placement in this patient population.

Methods

The authors performed a retrospective analysis of a prospective database (ICH Outcomes Project) containing patients with nontraumatic ICH admitted to the neurological ICU at Columbia University Medical Center between January 2009 and September 2011. A multiple logistic regression model was developed to identify independent predictors of shunt-dependent hydrocephalus after ICH. The following variables were included: patient age, admission Glasgow Coma Scale score, temporal horn diameter on admission CT imaging, bicaudate index, admission ICH volume and location, intraventricular hemorrhage volume, Graeb score, LeRoux score, third or fourth ventricle hemorrhage, and intracranial pressure (ICP) and ventriculitis during hospital stay.

Results

Of 210 patients prospectively enrolled in the ICH Outcomes Project, 64 required emergency CSF diversion via placement of an external ventricular drain and were included in the final cohort. Thirteen of these patients underwent permanent ventricular CSF shunting prior to discharge. In univariate analysis, only thalamic hemorrhage and elevated ICP were significantly associated with the requirement for permanent CSF diversion, with p values of 0.008 and 0.033, respectively. Each remained significant in a multiple logistic regression model in which both variables were present.

Conclusions

Of patients with ICH requiring emergency CSF diversion, those with persistently elevated ICP and thalamic location of their hemorrhage are at increased odds of developing persistent hydrocephalus, necessitating permanent ventricular shunt placement. These factors may assist in predicting which patients will require permanent CSF diversion and could ultimately lead to improvements in the management of this disorder and the outcome in patients with ICH.

Intraventricular fibrinolysis versus external ventricular drainage alone in intraventricular hemorrhage: a meta-analysis

BACKGROUND AND PURPOSE

The purpose of this study was to analyze the effect of intraventricular fibrinolysis (IVF) compared with external ventricular drainage alone on mortality and functional outcome in the management of intraventricular hemorrhage secondary to spontaneous supratentorial intracerebral hemorrhage.

METHODS

The authors conducted a systematic review and performed a meta-analysis. They reviewed the PubMed, Cochrane Library, and Liliacs databases. In addition, they conducted a manual review of article bibliographies.

RESULTS

Using a prespecified search strategy, 4 randomized and 8 observational studies were included in a meta-analysis. These studies involved a total of 316 patients with intraventricular hemorrhage at baseline, of whom 167 had IVF (52.8%). Pooled odds ratios of the impact of IVF on patient mortality, functional outcomes, and complications were calculated. The overall mortality risk decreased from 46.7% in the external ventricular drainage alone group to 22.7% in the external ventricular drainage+IVF group, corresponding to an overall pooled Peto OR of 0.32 (95% CI, 0.19 to 0.52). This result was highly significant with urokinase, not with recombinant tissue-type plasminogen activator. IVF was also associated with an increase in good functional outcome. There was no difference between the 2 groups in terms of shunt dependence and complications.

CONCLUSIONS

The combination of IVF and external ventricular drainage in the management of severe intraventricular hemorrhage secondary to small intracerebral hemorrhage in young patients was associated with better survival and functional outcome results. Urokinase and recombinant tissue-type plasminogen activator could not have the same therapeutic effects. Well-designed randomized trials with special considerations to the fibrinolytic agents are needed.