Quantitative versus qualitative blood amount assessment as a predictor for shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage

Abstract

OBJECTIVEReliable tools are lacking to predict shunt-dependent hydrocephalus (SDHC) development after aneurysmal subarachnoid hemorrhage (aSAH). Quantitative volumetric measurement of hemorrhagic blood is a good predictor of SDHC but might be impractical in the clinical setting. Qualitative assessment performed using scales such as the modified Fisher scale (mFisher) and the original Graeb scale (oGraeb) is easier to conduct but provides limited predictive power. In between, the modified Graeb scale (mGraeb) keeps the simplicity of the qualitative scales yet adds assessment of acute hydrocephalus, which might improve SDHC-predicting capabilities. In this study the authors investigated the likely capabilities of the mGraeb and compared them with previously validated methods. This research also aimed to define a tailored mGraeb cutoff point for SDHC prediction.METHODSThe authors performed retrospective analysis of patients admitted to their institution with the diagnosis of aSAH between May 2013 and April 2016. Out of 168 patients, 78 were included for analysis after the application of predefined exclusion criteria. Univariate and multivariate analyses were conducted to evaluate the use of all 4 methods (quantitative volumetric assessment and the mFisher, oGraeb, and mGraeb scales) to predict the likelihood of SDHC development based on clinical data and blood amount assessment on initial CT scans.RESULTSThe mGraeb scale was demonstrated to be the most robust predictor of SDHC, with an area under the curve (AUC) of 0.848 (95% CI 0.763–0.933). According to the AUC results, the performance of the mGraeb scale was significantly better than that of the oGraeb scale (χ2 = 4.49; p = 0.034) and mFisher scale (χ2 = 7.21; p = 0.007). No statistical difference was found between the AUCs of the mGraeb and the quantitative volumetric measurement models (χ2 = 12.76; p = 0.23), but mGraeb proved to be the simplest model since it showed the lowest Akaike information criterion (66.4), the lowest Bayesian information criterion (71.2), and the highest R2Nagelkerke coefficient (39.7%). The initial mGraeb showed more than 85% specificity for predicting the development of SDHC in patients presenting with a score of 12 or more points.CONCLUSIONSAccording to the authors’ data, the mGraeb scale is the simplest model that correlates well with SDHC development. Due to limited scientific evidence of treatments aimed at SDHC prevention, we propose an mGraeb score higher than 12 to identify patients at risk with high specificity. This mGraeb cutoff point might also serve as a useful prognostic tool since patients with SDHC after aSAH have worse functional outcomes.

The risk factors of shunt-dependent hydrocephalus after subarachnoid space hemorrhage of intracranial aneurysms

“…Moreover, too much blood can deposit in the CSF circulation and cause mal-absorption. [30] Additionally, posterior aneurysms are more likely to cause intraventricular hemorrhage than anterior aneurysms, which again confirmed the relationship between posterior aneurysms and hydrocephalus. According to our results, more attention should be paid to patients with extensive subarachnoid hemorrhage than intracerebral hematoma for potential hydrocephalus.…”

The Pathogenesis of Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage

“…The clearance of blood clots from the ventricles has therefore become a major therapeutic goal. The modified Graeb scale, the qualitative measurement of IVH and acute hydrocephalus, is reportedly the simplest model that correlates well with shunt dependency following aSAH; a modified Graeb score higher than 12 identifies patients at risk with high specificity (85%) [ 100 ]. EVD has been recommended for IVH cases with acute hydrocephalus but is characterized by frequent clot obstruction and infection risks associated with prolonged drainage [ 101 ].…”

Volumetric quantification of aneurysmal subarachnoid hemorrhage independently predicts hydrocephalus and seizures

“…Based on the existing literature, certain scores have been formulated in an attempt to predict shunt-dependent hydrocephalus, including the Barrow Neurological Institute (BNI) score, which evaluates the thickness of the subarachnoid blood clot measured perpendicular to a cistern or fissure; 40 the shunt dependency in aSAH (SDASH) score, which combines the BNI score, the Hunt and Hess grade, and the presence of acute hydrocephalus; 29 the CHESS (Chronic Hydrocephalus Ensuing from SAH Score), which takes into account the Hunt and Hess grade, aneurysm location, presence of acute hy-drocephalus, presence of IVH, and early cerebral infarction; 41 and the Graeb and LeRoux scores, which qualitatively evaluate the amount and location of intraventricular blood. 30,42 To date, these scores have not gained wide clinical use and are limited by their qualitative nature. So far, none of these prognostic models considered the influence of the quantified hemorrhage volume on the development of shunt-dependent hydrocephalus.…”