Predisposing Factors Related to Shunt-Dependent Chronic Hydrocephalus after Aneurysmal Subarachnoid Hemorrhage

Kwon, Jae-Hyun; Sung, Soon Ki; Song, Young‐Jin; Choi, Hyu-Jin; Huh, Jae-Taeck; Kim, Hyung-Dong

doi:10.3340/jkns.2008.43.4.177

Cited by 54 publications

(62 citation statements)

References 30 publications

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“…3,17,23 Previous studies have shown advanced age to be an independent risk factor for SDHCP after aSAH. 3,12,21,25,33 Our analysis demonstrated increased age to be associated with a higher risk of receiving a shunt after aSAH. van Gijn et al 9 have demonstrated a quantitative correlation between increasing age and higher bicaudate indices; therefore, it could be that hydrocephalus is diagnosed more frequently with increasing age.…”

Section: Discussionmentioning

confidence: 88%

“…It has been suggested that meningeal infection causes CSF flow disturbances, 4,17 ependymal cell dysfunction, and CSF barrier cell inflammation that lead to increased secretion of CSF 32 resulting in chronic hydrocephalus. It has been described that meningitis is associated with the duration of EVD, 33 as CSF sampling from EVD can increase the risk of meningitis. 34 Meningitis is a risk factor that could, in principle, be prevented with comprehensive management and therefore should be the focus of prevention efforts to minimize the patient's risk for shunting.…”

Section: Discussionmentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 88%

Section: Discussionmentioning

confidence: 99%

Risk of Shunting After Aneurysmal Subarachnoid Hemorrhage

Adams

Ban

Leinonen

et al. 2016

Stroke

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“…13 Large thirdventricle diameter (approximately 7 mm), high CSF protein levels, higher Hunt and Hess grade, and the presence of intraventricular blood have all been shown to be predictors of shunt dependency in patients with SAH who have developed hydrocephalus. 5,24 Post-SAH hydrocephalus is unique because of the variability in intracranial pressure (ICP).…”

Section: Discussionmentioning

confidence: 99%

Use of programmable versus nonprogrammable shunts in the management of hydrocephalus secondary to aneurysmal subarachnoid hemorrhage: a retrospective study with cost-benefit analysis

Lee¹,

King²,

Kumar³

et al. 2014

JNS

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Object. The choice of programmable or nonprogrammable shunts for the management of hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) remains undefined. Variable intracranial pressures make optimal management difficult. Programmable shunts have been shown to reduce problems with drainage, but at 3 times the cost of nonprogrammable shunts.Methods. All patients who underwent insertion of a ventriculoperitoneal shunt for hydrocephalus after aneurysmal SAH between 2006 and 2012 were included. Patients were divided into those in whom nonprogrammable shunts and those in whom programmable shunts were inserted. The rates of shunt revisions, the reasons for adjustments of shunt settings in patients with programmable devices, and the effectiveness of the adjustments were analyzed. A cost-benefit analysis was also conducted to determine if the overall cost for programmable shunts was more than for nonprogrammable shunts.Results. Ninety-four patients underwent insertion of shunts for hydrocephalus secondary to SAH. In 37 of these patients, nonprogrammable shunts were inserted, whereas in 57 programmable shunts were inserted. Four (7%) of 57 patients with programmable devices underwent shunt revision, whereas 8 (21.6%) of 37 patients with nonprogrammable shunts underwent shunt revision (p = 0.0413), and 4 of these patients had programmable shunts inserted during shunt revision. In 33 of 57 patients with programmable shunts, adjustments were made. The adjustments were for a trial of functional improvement (n = 21), overdrainage (n = 5), underdrainage (n = 6), or overly sunken skull defect (n = 1). Of these 33 patients, 24 showed neurological improvements (p = 0.012). Cost-benefit analysis showed $646.60 savings (US dollars) per patient if programmable shunts were used, because the cost of shunt revision is a lot higher than the cost of the shunt.Conclusions. The rate of shunt revision is lower in patients with programmable devices, and these are therefore more cost-effective. In addition, the shunt adjustments made for patients with programmable devices also resulted in better neurological outcomes.

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“…11 Furthermore, it has been shown in patients with subarachnoid hemorrhage that malresorptive hydrocephalus may be caused by blood products clogging the arachnoid villi. 9,18 In this study, we sought to determine patient variables predicting the occurrence of true postoperative hydrocephalus.…”

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confidence: 99%

Predicting postoperative hydrocephalus in 227 patients with skull base meningioma

Burkhardt

Zinn

Graenicher

et al. 2011

FOC

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Object Some patients develop communicating hydrocephalus after meningioma surgery, and this can develop into a serious clinical condition. However, this has rarely been addressed in the literature. Therefore, the authors sought to determine predictive patient variables for the occurrence of postoperative hydrocephalus following skull base meningioma surgery. Methods For this purpose, the authors retrospectively analyzed all patients who underwent resection of intracranial meningiomas between 1998 and 2009 at the Department of Neurosurgery, University Hospital Zurich, Switzerland. Of 594 patients with meningioma, 227 (38%) had a lesion located at the skull base, and thus were included for analysis. The following patient variables were examined: demographic data (age and sex); tumor number (solitary vs multiple); tumor side and localization within the skull base region (anterior, medial, posterior); infiltration of the cavernous sinus; compression of the optic channel/optic nerve; tumor volume; preoperative embolization (yes/no); duration of surgery; Simpson grade of resection; histopathological features (WHO grade); number of surgeries (single vs multiple); preoperative embolization; duration of hospital stay; tumor recurrence; use of an artificial dural substitute; postoperative infection rate; and clinical outcome (Glasgow Outcome Scale score at discharge and at 3 months, and vital status at last follow-up). Hierarchical clustering, factor analysis, and stepwise regression models revealed a ranking list for the top predictive variables for the occurrence of postoperative hydrocephalus. Results A total of 35 patients (5.9%) of the cohort of 594 developed communicating postoperative hydrocephalus, with no patient manifesting obstructive hydrocephalus. Of these 35 patients, 18 had a meningioma located at the skull base (18 [7.9%] of 227), in contrast to 17 patients with meningiomas in other locations (17 [4.6%] of 367). The following patient variables correlated with the occurrence of hydrocephalus, as defined by factor analysis: age, duration of surgery, duration of hospital stay, tumor volume, postoperative infection, and preoperative embolization. A stepwise regression analysis of the latter variables identified 2 variables as significantly predictive: age (p = 0.0012) and duration of surgery (p = 0.0013). Conclusions In this study, the incidence of communicating postoperative hydrocephalus was almost twice as high in patients with skull base lesions as in patients with meningiomas in other locations. Patient age, duration of surgery, duration of hospital stay, tumor volume, postoperative infection, and preoperative embolization were associated with the occurrence of hydrocephalus. In the statistical prediction model, patient age and duration of surgery were the most significant predictors of postoperative hydrocephalus after skull base meningioma surgery.

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Predisposing Factors Related to Shunt-Dependent Chronic Hydrocephalus after Aneurysmal Subarachnoid Hemorrhage

Abstract: Hydrocephalus after aneurysmal SAH seems to have a multifactorial etiology. Understanding predisposing factors related to the shunt-dependent chronic hydrocephalus may help to guide neurosurgeons for better treatment outcomes.

Cited by 54 publications

References 30 publications

Risk of Shunting After Aneurysmal Subarachnoid Hemorrhage

Risk of Shunting After Aneurysmal Subarachnoid Hemorrhage

Use of programmable versus nonprogrammable shunts in the management of hydrocephalus secondary to aneurysmal subarachnoid hemorrhage: a retrospective study with cost-benefit analysis

Predicting postoperative hydrocephalus in 227 patients with skull base meningioma

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