Clipping or Coiling of Ruptured Cerebral Aneurysms and Shunt-Dependent Hydrocephalus

Varelas, Panayiotis N.; Helms, Ann; Sinson, Grant; Spanaki, Marianna V.; Hacein‐Bey, Lotfi

doi:10.1385/ncc:4:3:223

Cited by 73 publications

(46 citation statements)

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“…Several Risk of Shunt Dependent Hydrocephalus : Clipping vs. Coiling | KH Nam, et al studies have compared the incidence of SDHC according to treatment modality. Most reports revealed that endovascular coiling could be attributed to an increased rate of SDHC 4,5,19) . However, Gruber et al 8) reported that the endovascular treatment group did not suffer SDHC more frequently than the surgical treatment group.…”

Section: Discussionmentioning

confidence: 99%

“…Whether or not incidence of SDHC differs significantly between surgical clipping and endovascular coiling is currently unknown. However, several authors have reported results that demonstrated fewer occurrences of SDHC in the surgical treatment group [3][4][5]19) Another study revealed no difference between the two groups 8) . Early evacuation of cisternal clots during surgery is a possible mechanism for lowering SDHC in the surgical group 8) ; however, this is hypothesized only under thick hemorrhagic conditions.…”

Section: Introductionmentioning

confidence: 97%

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Risk of Shunt Dependent Hydrocephalus after Treatment of Ruptured Intracranial Aneurysms : Surgical Clipping versus Endovascular Coiling According to Fisher Grading System

Nam

Hamm

Kang

et al. 2010

J Korean Neurosurg Soc

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Objective :The amount of hemorrhage observed on a brain computed tomography scan, or a patient's Fisher grade (FG), is a powerful risk factor for development of shunt dependent hydrocephlaus (SDHC). However, the influence of treatment modality (clipping versus coiling) on the rate of SDHC development has not been thoroughly investigated. Therefore, we compared the risk of SDHC in both treatment groups according to the amount of subarachnoid hemorrhage (SAH). Methods : We retrospectively reviewed 839 patients with aneurysmal SAH for a 5-year-period. Incidence of chronic SDHC was analyzed using each treatment modality according to the FG system. In addition, other well known risk factors for SDHC were also evaluated. Results : According to our data, Hunt-Hess grade, FG, acute hydrocephalus, and intraventricular hemorrhage were significant risk factors for development of chronic SDHC. Coiling group showed lower incidence of SDHC in FG 2 patients, and clipping groups revealed a significantly lower rate in FG 4 patients. Conclusion : Based on our data, treatment modality might have an influence on the incidence of SDHC. In FG 4 patients, the clipping group showed lower incidence of SDHC, and the coiling group showed lower incidence in FG 2 patients. We suggest that these findings could be a considerable factor when deciding on a treatment modality for aneurysmal SAH patients, particularly when the ruptured aneurysm can be occluded by either clipping or coiling.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 97%

Risk of Shunt Dependent Hydrocephalus after Treatment of Ruptured Intracranial Aneurysms : Surgical Clipping versus Endovascular Coiling According to Fisher Grading System

Nam

Hamm

Kang

et al. 2010

J Korean Neurosurg Soc

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“…Also, recognition of predictive variables and identifying patients at risk for shunt-dependent hydrocephalus (SDHCP) could lead to optimized management with avoidance of increased neurological morbidity, impaired functional outcome and quality of life, and extended hospital stays associated with chronic hydrocephalus. 3,9,14,15 The few published series on shunting after aSAH had short follow-up times, 2,4,[16][17][18] small samples, 2,3,5,6,[15][16][17][18][19][20] or used administrative databases, 12,[21][22][23] where there was an inherent problem of selection bias and uncontrollable factors that could influence the reported rate of shunt requirement. Case series are especially vulnerable to selection bias; studies that report on a series drawn from their patients from a particular population (eg, a hospital or clinic) may not appropriately represent the proportions in the wider population.…”

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confidence: 99%

Risk of Shunting After Aneurysmal Subarachnoid Hemorrhage

Adams

Ban

Leinonen

et al. 2016

Stroke

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A cute aneurysmal subarachnoid hemorrhage (aSAH) is a critical systemic condition, and survivors of the primary bleed require multidisciplinary neurointensive care. 1 People who survive aSAH carry an increased risk for various complications including epilepsy, depression, cognitive impairment, shunt requirement for hydrocephalus, and shunt complications. 1Hydrocephalus after aSAH has been reported to occur in 6% to 67% of the cases.2-6 The acute phase can be self-limiting in some patients, whereas others will require external ventricular drainage (EVD) to alleviate hydrocephalus symptoms. 7Whereas mechanisms of hydrocephalus development have not been fully elucidated, studies have suggested deterioration of the cerebrospinal fluid (CSF) dynamics, 3,8 obstructive mechanisms because of blood products, 3,9 disrupted absorption at the arachnoid granulations level, 3,10 or inflammation 11 as possible causes. For some patients, this will continue to develop into a chronic condition requiring permanent CSF diversion, 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-receiveroperating 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. The onlin...

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“…The prevalence of sNPH has been reported to be 8.9%-48% in patients with SAH. [1][2][3][4][5][6][7]11,12,16,18,22,23 Acute hydrocephalus coexisting with SAH is known to be one of the most important predictors for sNPH. [3][4][5][6]11,16 Previous studies have shown that severe symptoms at SAH onset and a large amount of subarachnoid blood seen on admission CT images are associated with the development of sNPH.…”

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confidence: 99%

“…[3][4][5][6][7][8][9][10][11]12,16,18,23 A posterior circulation location of the ruptured aneurysm and endovascular coil embolization have been reported to be significantly associated with sNPH. 1,[4][5][6][7]12,15,16,22 However, this relationship is controversial, because SAH caused by a posterior circulation aneurysm frequently occurs with severe initial symptoms and acute hydrocephalus, compared to SAH caused by a ruptured anterior circulation aneurysm, which is known to occur with mild symptoms and/or no acute hydrocephalus. 14 In addition, most ruptured posterior circulation aneurysms have been treated with endovascular coil embolization.…”

mentioning

confidence: 99%

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

Yamada¹,

Ishikawa²,

Yamamoto³

et al. 2015

JNS

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abbreviatioNs ACA = anterior cerebral artery; ICA = internal carotid artery; MCA = middle cerebral artery; NPH = normal-pressure hydrocephalus; SAH = subarachnoid hemorrhage; sNPH = secondary NPH; WFNS = World Federation of Neurological Societies. submitted December 5, 2014. accepted January 21, 2015. iNclude wheN citiNg Published online July 31, 2015; DOI: 10.3171/2015.1.JNS142761. disclosure Dr. Ishikawa has received honoraria from Medtronic Japan Co., Ltd. (Japan). Dr. Yamada declares no disclosures and no conflicts of interest. Drs. Yamamoto, Ino, Kimura, and Kobayashi report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. All authors have made substantial contributions to the intellectual content of the paper, have approved the final manuscript, and agree with submission to this journal. Dr. Yamada is the corresponding author for this study and the principal investigator. He takes responsibility for data management, accuracy of statistical analysis, conduct of the research, and drafting of the manuscript. The following grants funded this study: " 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 emboli...

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Clipping or Coiling of Ruptured Cerebral Aneurysms and Shunt-Dependent Hydrocephalus

Abstract: One-third of patients admitted with aneurysmal SAH require temporary or permanent CSF diversion. Permanent shunting was found to be associated with coiling in our patient population.

Cited by 73 publications

References 23 publications

Risk of Shunt Dependent Hydrocephalus after Treatment of Ruptured Intracranial Aneurysms : Surgical Clipping versus Endovascular Coiling According to Fisher Grading System

Risk of Shunt Dependent Hydrocephalus after Treatment of Ruptured Intracranial Aneurysms : Surgical Clipping versus Endovascular Coiling According to Fisher Grading System

Risk of Shunting After Aneurysmal Subarachnoid Hemorrhage

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

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