Timing of Permanent Ventricular Shunt Placement Following External Ventricular Drain Placement in Primary Intracerebral Hemorrhage

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.

Assessment of Sustained Systemic Inflammatory Response Syndrome and CSF Markers as Predictive Values Associated with Shunt-Dependent Hydrocephalus after Aneurysmal Subarachnoid Hemorrhage

Aim of the study: This study was conducted to detect incidence and risk factors of shunt-dependent hydrocephalus, including Systemic Inflammatory Response Syndrome. Patients and methods: After obtaining ethical approval from the research ethics committee of Cairo University, this study was conducted in two phases, phase I in the form of follow up study to detect the incidence of shunt dependent hydrocephalus in patients with ruptured subarachnoid aneurysm then phase II in the form of comparative one to detect the risk factors of acquisition of shunt dependent hydrocephalus and detect the predictive role of SIRS in SDH. The study included 90 patients with ruptured subarachnoid aneurysms followed up in the department of neurosurgery of Cairo university hospital from April 2018 to April 2020. Results: The incidence of shunt-dependent hydrocephalus was 28% among the studied patients with significant association with high-grade SIRS, Fisher score, Hunt and Hess score, and leukocytosis. The CSF white blood cells and protein were significantly higher in the hydrocephalus group. Also, there was significant hypernatremia among the hydrocephalic group. Conclusion: Despite the study's analytical design, we observed a link between high fisher, SIRS, hypernatremia, and shunt-dependent hydrocephalus in aneurysmal SAH patients. Serum sodium, CSF WBCs, and protein may all be used to predict HC.

Prognostic Nomogram of Predictors for Shunt-Dependent Hydrocephalus in Patients with Aneurysmal Subarachnoid Hemorrhage Receiving External Ventricular Drain Insertion: A Single-Center Experience and Narrative Review

OBJECTIVE

This study aimed to create a prediction model with a radiographic score, serum, and cerebrospinal fluid (CSF) values for the occurrence of shunt-dependent hydrocephalus (SDHC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) and to review and analyze literature related to the prediction of the development of SDHC.

METHODS

Sixty-three patients with aSAH who underwent external ventricular drain insertion were included and separated into 2 subgroups: non-SDHC and SDHC. Patient characteristics, computed tomography scoring system, and serum and CSF parameters were collected. Multivariate logistic regression was conducted to illustrate a nomogram for determining the predictors of SDHC. Furthermore, we sorted and summarized previous meta-analyses for predictors of SDHC.

RESULTS

The SDHC group had 42 cases. Stepwise logistic regression analysis revealed 3 independent predictive factors associated with a higher modified Graeb (mGraeb) score, lower level of estimated glomerular filtration rate group, and lower level of CSF glucose. The nomogram, based on these 3 factors, was presented with significant predictive performance (area under curve = 0.895) for SDHC development, compared with other scoring systems (AUC = 0.764-0.885). In addition, a forest plot was generated to present the 12 statistically significant predictors and odds ratio for correlations with the development of SDHC.

CONCLUSIONS

First, the development of a nomogram with combined significant factors had a good performance in estimating the risk of SDHC in primary patient evaluation and assisted in clinical decision making. Second, a narrative review, presented with a forest plot, provided the current published data on predicting SDHC.

Role of Cerebrospinal Fluid Markers for Predicting Shunt-Dependent Hydrocephalus in Patients with Subarachnoid Hemorrhage and External Ventricular Drain Placement

OBJECTIVE

We sought to identify potential risk factors for the development of shunt-dependent chronic hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) and external ventricular drain (EVD) insertion. In particular, the role of inflammatory markers within the cerebrospinal fluid (CSF) was assessed.

METHODS

For this single-center analysis, data were generated from consecutive patients with SAH and the need for EVD implantation treated on our neurosurgical intensive care unit between 2013 and 2015. Parameters were patient characteristics (age, sex, comorbidity), severity of SAH (according to the World Federation of Neurological Society score), imaging findings (intraventricular hemorrhage, diameter of the third ventricle, location of the ruptured aneurysm), and acute course of disease (cerebral infarction, vasospasm). Moreover, the impact of EVD drainage volume and CSF markers (total protein [_CSFTP], red blood cell count [_CSFRBC], interleukin-6 [_CSFIL-6], and glucose [_CSFGlc]) was assessed. Statistics including receiver-operating-curve with corresponding area-under-the-curve (AUC) analysis were calculated using SPSS.

RESULTS

Overall, 63 patients (21 males, mean age 55.2 years) were included. Twenty-one patients (30%) developed a shunt-dependent hydrocephalus. Significant risk factors for shunt dependency were the World Federation of Neurological Society score, cerebral infarction, and diameter of the third ventricle (P < 0.05). Moreover, CSF markers associated with shunt-dependent hydrocephalus included increased levels of _CSFTP on days 5 (AUC = 0.72)/11 (AUC = 0.97)/14 (AUC = 0.98), _CSFIL-6 on day 14 (AUC = 0.81), and _CSFRBC on day 15 (AUC = 0.83). The EVD drainage volume was not prognostic.

CONCLUSIONS

The time course of selected inflammatory markers in CSF may support management considerations in the early phase after SAH and critical impairment of CSF circulation.