Predictors of long-term shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

Rincón, Fred; Gordon, Errol; Starke, Robert M.; Buitrago, Manuel M.; Fernandez, Andres; Schmidt, J. Michael; Claassen, Jan; Wartenberg, Katja E.; Frontera, Jennifer A.; Seder, David B.; Palestrant, David; Connolly, E. Sander; Lee, Ki-Won; Mayer, Stephan A.; Badjatia, Neeraj

doi:10.3171/2010.2.jns09376

Cited by 105 publications

(97 citation statements)

References 26 publications

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“…5 A prior inves tigation found no association between shuntdependent hydrocephalus and admission neurological status in pa tients with SAH, in agreement with previous ICH cohort data as well as results from our univariate analysis. 23 Interestingly, development of shuntdependent hy drocephalus was more likely in those patients with a tha lamic hemorrhage, but independent of other hemorrhage locations or IVH volume, despite the fact that IVH is known to predict worse outcomes in patients with ICH in a volumedependent manner. 18,25 Given the anatomical relationship of thalamic hemorrhages to the third ven tricle and the foramen of Monro, it is intuitive that he matoma formation in this location more easily results in obstruction of CSF flow independent of IVH volume than in hemorrhages occurring in other locations.…”

Section: Discussionmentioning

confidence: 99%

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

Zacharia¹,

Vaughan²,

Hickman³

et al. 2012

FOC

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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.

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Section: Discussionmentioning

confidence: 99%

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

Zacharia¹,

Vaughan²,

Hickman³

et al. 2012

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“…[3][4][5][6][7]11,12,16,18,23 On the basis of the evidence of an association between the severity of SAH and the prevalence of subsequent sNPH, many neurosurgeons have believed that several surgical manipulations for facilitating CSF dynamics, such as hematoma evacuation, widening the opening of the cisterns, and fenestration of the lamina terminalis, might help to reduce the subsequent occurrence of sNPH after the surgical treatment of SAH. However, the authors of a recent meta-analysis of 11 nonrandomized studies in which data from 1973 patients were pooled concluded that there was no significant difference in the prevalence of sNPH between the 975 patients who had undergone fenestration of the lamina terminalis and the 998 who had not (p = 0.09).…”

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confidence: 99%

“…[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. [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.…”

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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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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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“…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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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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Predictors of long-term shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

Cited by 105 publications

References 26 publications

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

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

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

Risk of Shunting After Aneurysmal Subarachnoid Hemorrhage

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