Risk of hemorrhagic complication associated with ventriculoperitoneal shunt placement in aneurysmal subarachnoid hemorrhage patients on dual antiplatelet therapy

Mahaney, Kelly B.; Chalouhi, Nohra; Viljoen, Stephanus; Smietana, Janel; Kung, David; Jabbour, Pascal; Bulsara, Ketan R.; Howard, Matthew A.; Hasan, David

doi:10.3171/2013.5.jns122494

Cited by 71 publications

(53 citation statements)

References 20 publications

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“…However, this can complicate the inpatient management of attendant procedures for patients with SAH, especially EVD placement and removal, shunt placement, and decompressive craniectomy. Ventriculoperitoneal shunt-related ICH rates of up to 71% have been reported in patients concomitantly treated with dual antiplatelet agents after stent-assisted aneurysm coiling, 13,18 and a significantly increased risk of fatal hemorrhagic complications was reported with respect to dual antiplatelet therapy during stent-assisted aneurysm coiling by Mocco et al, who found a 12% risk of mortality in an SAH cohort relative to a 0.8% mortality in the unruptured aneurysm cohort. 21 All previously reported blister aneurysm flow-diversion treatment series described dual antiplatelet pretreatment prior to flow-diverter placement; similarly, all patients in our series also underwent preloading with aspirin and clopidogrel.…”

Section: Discussionmentioning

confidence: 99%

Pipeline flow diversion of ruptured blister aneurysms of the supraclinoid carotid artery using a single-device strategy

Ryan

Khan

Barco

et al. 2017

Neurosurgical Focus

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OBJECTIVERuptured blister aneurysms remain challenging lesions for treatment due to their broad, shallow anatomy and thin, fragile wall. Historical challenges with both open microsurgical approaches and intrasaccular endovascular approaches have led to increased use of flow diversion for management of these aneurysms. However, the optimum paradigm, including timing of treatment, use of dual antiplatelet therapy, and number of flow-diverter devices to use remains unknown. The authors describe their experience with ruptured blister aneurysms treated with flow diversion at their institution, and discuss rates of rebleeding and number of devices used.METHODSAll patients presenting with subarachnoid hemorrhage from a ruptured blister aneurysm and treated with Pipeline flow diversion were identified. Patient demographic data, clinical status and course, need for external ventricular drain (EVD), timing of treatment, and angiographic details and follow-up were recorded.RESULTSThere were 13 patients identified (11 women and 2 men), and 4 had multiple aneurysms. Two aneurysms were treated on initial angiography, with average time to treatment of 3.1 days for the remainder, after discussion with the family and institution of dual antiplatelet therapy. Device placement was technically successful in all patients, with 2 patients receiving 2 devices and the remainder receiving 1 device. There was 1 intraoperative complication, of a wire perforation causing intracerebral hemorrhage requiring decompressive craniectomy. Three patients had required EVD placement for management of hydrocephalus. There was no rebleeding from the target lesion; however, one patient had worsening intraventricular hemorrhage and another had rupture of an unrecognized additional aneurysm, and both died. Of the other 11 patients, 10 made a good recovery, with 1 remaining in a vegetative state. Nine underwent follow-up angiography, with 5 achieving complete occlusion, 2 with reduced aneurysm size, and 2 requiring retreatment for aneurysm persistence or enlargement. There were no episodes of delayed rupture.CONCLUSIONSPipeline flow diversion is a technically feasible and effective treatment for ruptured blister aneurysms, particularly in good-grade patients without hydrocephalus. Patients with a worse grade on presentation and requiring EVDs may have higher risk for bleeding complications and poor outcome. There was no rebleeding from the target lesion with use of a single device in this series.

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Section: Discussionmentioning

confidence: 99%

Pipeline flow diversion of ruptured blister aneurysms of the supraclinoid carotid artery using a single-device strategy

Ryan

Khan

Barco

et al. 2017

Neurosurgical Focus

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“…13,14 However, perioperative antiplatelet treatment is mandatory to prevent in-stent thrombosis, which is a major concern in patients with acute SAH. 6,7,15 For this reason, stent placement is generally used only as a rescue technique in acutely ruptured aneurysms. In a recent systematic review of 339 patients with ruptured aneurysms who were treated acutely with SAC, clinically significant intracranial hemorrhagic complications occurred in 8% and clinically significant thromboembolic events occurred in 6%.…”

Section: Discussionmentioning

confidence: 99%

Temporary Solitaire Stent-Assisted Coiling: A Technique for the Treatment of Acutely Ruptured Wide-Neck Intracranial Aneurysms

Signorelli

Gory

Turjman

2013

American Journal of Neuroradiology

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BACKGROUND AND PURPOSE:Wide-neck intracranial aneurysms in patients with acute SAH are often challenging lesions to treat by neurosurgical and endovascular approaches. The aim of this study was to investigate the feasibility, safety, and efficacy of the use of temporary Solitaire AB stent-assisted technique with coiling for the treatment of acutely ruptured wide-neck aneurysms without perioperative antiplatelet therapy.

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“…2 Intracerebral hemorrhage rarely occurs after shunt insertions (4% of cases) and is usually subclinical. 13,16 Around 8%-10% of shunts become infected, requiring lengthy hospitalization for intravenous antibiotics, temporary ventriculostomy placement, and shunt revision. 9,11 In a cohort of patients undergoing VPS placement after SAH, up to 29.6% required a subsequent revision procedure (usually within 6 months).…”

Section: Discussionmentioning

confidence: 99%

Comparison of techniques for ventriculoperitoneal shunting in 523 patients with subarachnoid hemorrhage

Chalouhi

Whiting

Anderson

et al. 2014

JNS

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A cute hydrocephalus occurs in up to two-thirds of patients with subarachnoid hemorrhage (SAH), and its treatment involves the placement of a ventriculostomy catheter. 7,10,12,14 Around 6%-37% of patients ultimately require permanent CSF diversion usually treated through ventriculoperitoneal shunt (VPS) placement because of the development of chronic hydrocephalus. [3][4][5]14 It is common practice to use a new contralateral bur hole for placement of the VPS in SAH patients with an existing ventriculostomy. The classic reasoning behind this practice is that the potential, subclinical contamination of the ventriculostomy site may increase the risk of shunt infection. At Thomas Jefferson University and Jefferson Hospital for Neuroscience, we have primarily used the same ventriculostomy site for placement of the VPS. This technique provides atraumatic insertion of the ventricular catheter without the stylet through an existing track while potentially decreasing the risk of catheter-related hemorrhage or malpositioning and reducing the operative time.Practice in this respect, both in the US and abroad, has largely been driven by operator preference and experience, as little has been published about the optimal shunting technique. We present the results of the first study comparing the safety of the 2 VPS techniques (same site vs contralateral site) in patients with SAH. Object. It is common practice to use a new contralateral bur hole for ventriculoperitoneal shunt (VPS) placement in subarachnoid hemorrhage (SAH) patients with an existing ventriculostomy. At Thomas Jefferson University and Jefferson Hospital for Neuroscience, the authors have primarily used the ventriculostomy site for the VPS. The purpose of this study was to compare the safety of the 2 techniques in patients with SAH.Methods. The rates of VPS-related hemorrhage, infection, and proximal revision were compared between the 2 techniques in 523 patients undergoing VPS placement (same site in 464 and contralateral site in 59 patients).Results. The rate of new VPS-related hemorrhage was significantly higher in the contralateral-site group (1.7%) than in the same-site group (0%; p = 0.006). The rate of VPS infection did not differ between the 2 groups (6.4% for same site vs 5.1% for contralateral site; p = 0.7). In multivariate analysis, higher Hunt and Hess grades (p = 0.05) and open versus endovascular treatment (p = 0.04) predicted shunt infection, but the VPS technique was not a predictive factor (p = 0.9). The rate of proximal shunt revision was 6% in the same-site group versus 8.5% in the contralateralsite group (p = 0.4). In multivariate analysis, open surgery was the only factor predicting proximal VPS revision (p = 0.05).Conclusions. The results of this study suggest that the use of the ventriculostomy site for VPS placement may be feasible and safe and may not add morbidity (infection or need for revision) compared with the use of a fresh contralateral site. This rapid and simple technique also was associated with a lower risk of shunt-related h...

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Risk of hemorrhagic complication associated with ventriculoperitoneal shunt placement in aneurysmal subarachnoid hemorrhage patients on dual antiplatelet therapy

Cited by 71 publications

References 20 publications

Pipeline flow diversion of ruptured blister aneurysms of the supraclinoid carotid artery using a single-device strategy

Pipeline flow diversion of ruptured blister aneurysms of the supraclinoid carotid artery using a single-device strategy

Temporary Solitaire Stent-Assisted Coiling: A Technique for the Treatment of Acutely Ruptured Wide-Neck Intracranial Aneurysms

Comparison of techniques for ventriculoperitoneal shunting in 523 patients with subarachnoid hemorrhage

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