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Kothari SA, Siddiq MS, Rahimi S, Vale F, Shah M, Garcia KA. Standardized Criteria to Initiate External Ventricular Drain (EVD) Weaning in a Neurological Intensive Care Unit to Increase the Safety of EVD Discontinuation and Reduce the Need for a Shunt. Cureus 2024; 16:e58362. [PMID: 38756294 PMCID: PMC11096804 DOI: 10.7759/cureus.58362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction Patients with subarachnoid hemorrhages (SAH) with external ventricular drains (EVD) can develop chronic hydrocephalus (HCP), requiring permanent cerebrospinal fluid (CSF) diversion via an external shunt. Two different strategies have been used to assess for dependence on EVD: 1) prompt closure, and 2) gradual weaning. Gradual weaning of EVDs is performed by increasing drainage resistance to outflow over days. However, when to start one strategy or the other is up to the physician. No uniform guidelines exist raising a question: Are standardized criteria necessary to initiate the EVD weaning process for SAH patients to increase the safety of EVD discontinuation and reduce the need for a shunt? This study shares criteria used to initiate EVD weaning that displayed increased safety of EVD discontinuation for patients with subarachnoid hemorrhage requiring EVD, particularly with regards to length of hospital stay (LOS), hospital-acquired infection rates, and ventriculoperitoneal shunt/endoscopic third ventriculostomy (VPS/ETV) placement. Methods One hundred and fifty-one SAH patients from January 2016 to January 2019 were analyzed. 60 aneurysmal SAH (aSAH) and 18 non-aneurysmal nontraumatic SAH (naSAH) patients required EVD placement. A gradual EVD weaning protocol was initiated if patients met the following criteria: 1. The reason for EVD placement has resolved or is resolving, 2. The quantity of CSF output is <250mL over 24 hours, 3. Quality of CSF is nonbloody, 4. Intracranial Pressure (ICP) must be within normal limits, and 5. The patient must be neurologically stable. It was acceptable to initiate the weaning process when the patient had mild cerebral vasospasm, but not moderate to severe cerebral vasospasm. EVD weaning was performed by increasing the drain (chamber) height by 5 millimeters of mercury every 24 hours if the criteria were met. Charts were reviewed for LOS, infection rates, and rate of VPS/ETV. Gender, age, race, wean failure incidence, Hunt-Hess scores, modified Fisher scores, and syndrome of inappropriate antidiuretic hormone/cerebral salt wasting (SIADH/CSW) rates were obtained. Results The average LOS for aSAH patients with EVD was 20.35 days. The incidence of VPS/ETV was 11%. A chi-square analysis revealed that aSAH patients had higher rates of VPS/ETV placement (p<0.001) and EVD wean failures (p<0.001) than naSAH patients. aSAH patients had a lower incidence of VPS/ETV placement of 11% compared to 21% nationally. Conclusions Standardized criteria to initiate EVD weaning provided a reduction in VPS/ETV placement among aSAH patients compared to national averages and provided a uniform approach to EVD management. Comparable infection rates and LOS for SAH patients requiring EVDs compared to national averages were found.
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Affiliation(s)
| | - Mevish S Siddiq
- Neurology, Columbia University Irving Medical Center, New York, USA
| | - Scott Rahimi
- Neurosurgery, Augusta University Medical College of Georgia, Augusta, USA
| | - Fernando Vale
- Neurosurgery, Augusta University Medical College of Georgia, Augusta, USA
| | - Manan Shah
- Neurology, Augusta University Medical College of Georgia, Augusta, USA
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Capion T, Lilja-Cyron A, Olsen MH, Møller K, Juhler M, Mathiesen T. Predictors of shunt insertion in patients with aneurysmal subarachnoid haemorrhage-a single-centre retrospective analysis. Acta Neurochir (Wien) 2024; 166:24. [PMID: 38240848 PMCID: PMC10799140 DOI: 10.1007/s00701-024-05926-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/23/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND No standard has been established regarding timing and choice of strategy for discontinuation of external ventricular drainage (EVD) in patients with aneurysmal subarachnoid haemorrhage (aSAH), and little is known about the importance of clinical variables. A proportion of the patients who initially pass their discontinuation attempt return with delayed hydrocephalus and the need of a permanent shunt. Early differentiation between patients who need a shunt and those who do not would facilitate care. We conducted a retrospective analysis on patients with aSAH and an EVD to search significant differences in treatment and clinical variables between patients who received a permanent shunt during initial hospitalization or after readmission, and those who never received a shunt. METHODS We included 183 patients with aSAH who received an EVD over a 4-year period between 2015 and 2018 and divided them into three groups: those who received a shunt during primary admission, those who were readmitted for delayed hydrocephalus and received a shunt, and those who never needed a shunt. Between these groups, we compared selected clinical variables as well as outcome at discharge and after 6 months. Additionally, we assessed the ability of a shunt dependency score (SDASH) to predict the need for permanent drainage in the patients. RESULTS Of 183 included patients, 108 (59%) ultimately received a ventriculoperitoneal (VP) shunt. Of these, 89 (82%) failed discontinuation during the primary admission and received a permanent shunt before discharge from the neurosurgical department. The remaining 19 (18%) were discharged after successful discontinuation, but subsequently developed delayed hydrocephalus and were admitted for shunt placement a median of 39 (range: 18-235) days after ictus. Ninety-four patients were discharged after successful discontinuation of the EVD, consisting of those who never developed the need for a permanent shunt and the 19 who were readmitted with delayed hydrocephalus, corresponding to a 20% (19/94) readmittance rate. Clinical variables such as drainage volume or discontinuation strategy did not differ across the three groups of patients. The SDASH score failed to provide any clinically useful information regarding prediction of shunt placement. CONCLUSION In this study, clinical variables including use of the predictive score SDASH predicted neither the overall need for nor the timing of shunt placement after aSAH. The homogeneous distribution of data between the three different groups renders strong independent clinical predictive factors unlikely. Thus, attempts to predict a permanent shunt requirement from these variables may be futile in these patients.
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Affiliation(s)
- Tenna Capion
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
| | - Alexander Lilja-Cyron
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Tiit Mathiesen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Darshan HR, Sudhir BJ, Singh A, Sreenath R, Easwer HV, Krishnakumar K, Nair P. Analysis of Evolution of Hydrocephalus in Posterior Fossa Tumors and Validation Study of the Modified Canadian Preoperative Prediction Rule for Hydrocephalus in Children and Frankfurt Grading System for Prediction of Cerebrospinal Fluid Diversion in Adults with Posterior Fossa Tumors. World Neurosurg 2023; 180:e91-e98. [PMID: 37683926 DOI: 10.1016/j.wneu.2023.08.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023]
Abstract
OBJECTIVE We sought to analyze the evolution of hydrocephalus and enumerate its predictive factors in posterior fossa tumors in children and adults. We also validated the modified Canadian Preoperative Prediction Rule for Hydrocephalus (mCPPRH) and Frankfurt grading systems as tools to predict cerebrospinal fluid (CSF) diversion in children and adults, respectively. METHODS A retrospective review of patients with posterior fossa tumors operated between 2012 and 2019 was performed. Clinical, radiologic, and operative data were obtained. Validation was performed for both scores via receiver operating characteristic (ROC) curves and evaluation of the area under the curve (AUC). RESULTS We included 116 children and 343 adults in the study. Of the adults, 141 patients had intraaxial tumors and 172 had extraaxial tumors. The insertion of external ventricular drain (EVD), its duration, papilledema was noted to have significant influence on the need for permanent CSF diversion (P < 0.05) in children. The ROC for mCPPRH score was 0.659 (0.501-0.816), Age- 0.496 (0.334-0.658) and Evans index- 0.788 (0.654-0.922). In adults- Intraaxial tumours Age, Frankfurt score, duration of EVD, Diagnosis, Extent of resection and periventricular capping significant predictors and ROC age AUC 0.300 (0.193-0.407), Evans index 0.939 (0.888-0.990), and Frankfurt score 0.908 (0.853-0.964) (P < 0.05), whereas in extraaxial tumors Frankfurt grading, sex, duration of EVD, presence of perilesional edema and extent of resection (P < 0.05) ROC age AUC 0.439 (0.344-0.534), Evans index 0.941 (0.906-0.977), and Frankfurt score 0.847 (0.782-0.912). CONCLUSIONS This is the first external validation study for the 2 predictive systems in use. mCPPRH demonstrated poor predictive accuracy, and Frankfurt grading system demonstrated good accuracy. EVD insertion and its duration was significantly predictive of the need for permanent CSF diversion.
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Affiliation(s)
- Hirisave Ravikumar Darshan
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Bhanu Jayanand Sudhir
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India.
| | - Ajit Singh
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Rajeev Sreenath
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Hariharan Venkat Easwer
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Kesavapisharady Krishnakumar
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Prakash Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
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Ebel F, Lichter E, Mariani L, Guzman R, Soleman J. Rapid Versus Gradual Weaning of External Ventricular Drain: A Systematic Literature Review and Meta-analysis. Neurocrit Care 2023; 39:250-259. [PMID: 37308728 PMCID: PMC10499951 DOI: 10.1007/s12028-023-01766-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/19/2023] [Indexed: 06/14/2023]
Abstract
The insertion of an external ventricular drain (EVD) is one of the most common neurosurgical procedures. Whether the weaning method (gradual or rapid) influences the ventriculoperitoneal shunt (VPS) insertion rate has not been conclusively established. The aim of this study is to provide a systematic literature review and conduct a meta-analysis of studies comparing gradual with rapid EVD weaning regarding VPS insertion rate. Articles were identified by searching the Pubmed/Medline, Embase, and Web of Science databases throughout October 2022. Two independent researchers assessed the studies for inclusion and quality. We included randomized trials, prospective cohort studies, and retrospective cohort studies, which compared gradual and rapid EVD weaning. The primary outcome was VPS insertion rate, whereas secondary outcomes were EVD-associated infection (EVDAI) rate and length of stay in the hospital and intensive care unit (ICU). Four studies directly comparing rapid versus gradual EVD weaning, with 1337 patients suffering from subarachnoid hemorrhage, were identified and included in the meta-analysis. VPS insertion rate was 28.1% and 32.1% in patients with gradual and rapid EVD weaning, respectively (relative risk 0.85, 95% confidence interval 0.49-1.46, p = 0.56). Further, the EVDAI rate was comparable between the groups (gradual group 11.2%, rapid group 11.5%, relative risk 0.67, 95% confidence interval 0.24-1.89, p = 0.45), whereas length of stay in the ICU and hospital were significantly shorter in the rapid weaning group (2.7 and 3.6 days, respectively; p < 0.01). Rapid EVD weaning seems comparable to gradual EVD weaning concerning VPS insertion rates and EVDAI, whereas hospital and ICU length of stay is significantly reduced.
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Affiliation(s)
- Florian Ebel
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Eric Lichter
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland
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Rubinos C, Kwon SB, Megjhani M, Terilli K, Wong B, Cespedes L, Ford J, Reyes R, Kirsch H, Alkhachroum A, Velazquez A, Roh D, Agarwal S, Claassen J, Connolly ES, Park S. Predicting Shunt Dependency from the Effect of Cerebrospinal Fluid Drainage on Ventricular Size. Neurocrit Care 2022; 37:670-677. [PMID: 35750930 PMCID: PMC9847349 DOI: 10.1007/s12028-022-01538-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/19/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Prolonged external ventricular drainage (EVD) in patients with subarachnoid hemorrhage (SAH) leads to morbidity, whereas early removal can have untoward effects related to recurrent hydrocephalus. A metric to help determine the optimal time for EVD removal or ventriculoperitoneal shunt (VPS) placement would be beneficial in preventing the prolonged, unnecessary use of EVD. This study aimed to identify whether dynamics of cerebrospinal fluid (CSF) biometrics can temporally predict VPS dependency after SAH. METHODS This was a retrospective analysis of a prospective, single-center, observational study of patients with aneurysmal SAH who required EVD placement for hydrocephalus. Patients were divided into VPS-dependent (VPS+) and non-VPS dependent groups. We measured the bicaudate index (BCI) on all available computed tomography scans and calculated the change over time (ΔBCI). We analyzed the relationship of ΔBCI with CSF output by using Pearson's correlation. A k-nearest neighbor model of the relationship between ΔBCI and CSF output was computed to classify VPS. RESULTS Fifty-eight patients met inclusion criteria. CSF output was significantly higher in the VPS+ group in the 7 days post EVD placement. There was a negative correlation between delta BCI and CSF output in the VPS+ group (negative delta BCI means ventricles become smaller) and a positive correlation in the VPS- group starting from days four to six after EVD placement (p < 0.05). A weighted k-nearest neighbor model for classification had a sensitivity of 0.75, a specificity of 0.70, and an area under the receiver operating characteristic curve of 0.80. CONCLUSIONS The correlation of ΔBCI and CSF output is a reliable intraindividual biometric for VPS dependency after SAH as early as days four to six after EVD placement. Our machine learning model leverages this relationship between ΔBCI and cumulative CSF output to predict VPS dependency. Early knowledge of VPS dependency could be studied to reduce EVD duration in many centers (intensive care unit length of stay).
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Affiliation(s)
- Clio Rubinos
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Soon Bin Kwon
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, NY, USA
| | - Murad Megjhani
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, NY, USA
| | - Kalijah Terilli
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, NY, USA
| | - Brenda Wong
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Lizbeth Cespedes
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Jenna Ford
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Renz Reyes
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Hannah Kirsch
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Ayham Alkhachroum
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Angela Velazquez
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - David Roh
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - E Sander Connolly
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
- Department of Neurosurgery, Columbia University, New York, NY, USA
| | - Soojin Park
- Department of Neurology, Columbia University, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, NY, USA.
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA.
- Department of Biomedical Informatics, Columbia University, New York, NY, USA.
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Ronsley R, Bouffet E, Dirks P, Drake J, Kulkarni A, Bartels U. Successful management of symptomatic hydrocephalus using a temporary external ventricular drain with or without endoscopic third ventriculostomy in pediatric patients with germinoma. J Neurosurg 2022; 137:807-812. [PMID: 35238528 DOI: 10.3171/2021.8.jns211443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to describe the management of hydrocephalus in a cohort of pediatric patients with germinoma. METHODS The authors conducted a retrospective chart review of patients with germinoma and symptomatic hydrocephalus treated at the Hospital for Sick Children between 2002 and 2020. Descriptive data included tumor location, CSF diversion procedure (external ventricular drain [EVD], endoscopic third ventriculostomy [ETV], ventriculoperitoneal [VP] shunt) and outcomes. The frontooccipital horn ratio (FOR) method was used to determine the presence of ventriculomegaly. RESULTS Of 39 patients with germinoma, 22 (73% male) had symptomatic hydrocephalus at diagnosis (11 pineal, 4 suprasellar, and 7 bifocal). Management of hydrocephalus included EVD (n = 5, 22.7%), ETV (n = 5, 22.7%), and combination ETV and EVD (n = 7, 31.8%), whereas 5 patients (22.7%) did not undergo surgical intervention. The median FOR at diagnosis was 0.42 (range 0.38-0.58), which correlated with moderate to severe ventriculomegaly. Carboplatin and etoposide-based chemotherapy induced fast tumor shrinkage, avoiding CSF diversion (n = 5) and resolving hydrocephalus with a transient EVD (n = 5). The median duration until EVD removal was 7 days (range 2-10 days). Two of 12 patients with EVD ultimately required a VP shunt. Kaplan-Meier overall survival was 100% and progression-free survival was 96.4% at a median follow-up of 10.4 years. CONCLUSIONS Timely initiation of chemotherapy is imperative to rapidly reduce tumor bulk in children with germinoma and limits the need for VP shunt insertions. In children in whom CSF diversion is required, hydrocephalus may be successfully managed with a temporary EVD ± ETV.
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Affiliation(s)
- Rebecca Ronsley
- 1Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia
| | - Eric Bouffet
- 2Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario; and
| | - Peter Dirks
- 3Pediatric Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - James Drake
- 3Pediatric Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Abhaya Kulkarni
- 3Pediatric Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Ute Bartels
- 2Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario; and
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Wahood W, Breeding T, Mohamed Z, Haider AS, Lanzino G, Brinjikji W, Rabinstein AA. Trends in Utilization of Temporary and Permanent Cerebrospinal Fluid Diversion and Catheter Cerebral Angiography for Patients with Aneurysmal Subarachnoid Hemorrhage in the United States. World Neurosurg 2022; 164:e1161-e1178. [PMID: 35660669 DOI: 10.1016/j.wneu.2022.05.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION We sought to analyze the rate of utilization of methods of cerebrospinal fluid diversion over time in a nationally representative cohort of patients admitted with aneurysmal subarachnoid hemorrhage (aSAH). METHODS The Nationwide Inpatient Sample was queried for patients admitted with aSAH from 2006 to 2018. Patients who received external ventricular drainage (EVD), lumbar drainage, ventriculoperitoneal shunt (VPS), and cerebral angiography were then identified. A Cochrane-Armitage test was conducted to assess the linear trend of proportions of EVD, lumbar drains, VPS, and mean cerebral angiograms per admission. Four regression analyses were conducted to infer the association of baseline variables to EVD, lumbar drain, VPS, and mean number of cerebral angiographies. RESULTS A total of 133,567 admissions were identified from 2006-2018 involving aSAH. Of these, 41.82% received EVD, 6.22% received lumbar drainage, 10.58% received VPS, and 75.03% had cerebral angiograms. There was an average upward trend of 1.57% in annual EVD utilization, downward trend of -0.28% in utilization of lumbar drainage, no changes in VPS utilization, and an upward trend of 0.04 angiograms per year (P < 0.001). There was a higher proportion of Black patients treated with EVD and VPS in both urban teaching hospitals and large hospitals. CONCLUSIONS Our results show the temporal trends in utilization of temporary and permanent methods of cerebrospinal fluid diversion and catheter cerebral angiography among patients with aSAH in the United States. The underutilization of VPS following EVD and the differences in EVD and VPS utilization depending on race and hospital size deserve further exploration.
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Affiliation(s)
- Waseem Wahood
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, Florida, USA.
| | - Tessa Breeding
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, Florida, USA
| | - Zayn Mohamed
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Ali S Haider
- Texas A&M University College of Medicine, Bryan, Texas, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Waleed Brinjikji
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Kamal A, Ahmed KM, Venkatachalam AM, Osman M, Aoun SG, Aiyagari V, Schneider N, Hasan-Washington H, Stutzman SE, Olson DM. Pilot Study of Neurologic Pupil Index as A Predictor of External Ventricular Drain Clamp Trial Failure After Subarachnoid Hemorrhage. World Neurosurg 2022; 164:2-7. [PMID: 35525437 DOI: 10.1016/j.wneu.2022.04.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND External ventricular drains (EVDs) provide a temporary egress for cerebrospinal fluid (CSF) in patients with symptomatic hydrocephalus following aneurysmal subarachnoid hemorrhage. Before EVD removal, a wean trial, which involves clamping the EVD, is typically attempted to ensure that CSF self-regulation is achieved. Automated infrared pupillometry (AIP) has been shown to detect early neurologic decline. We sought to explore the use of AIP to detect early EVD clamping trial failure. METHODS This prospective observational pilot study enrolled aneurysmal subarachnoid hemorrhage patients before an EVD clamp trial. On initiating the clamp trial, nurses included hourly AIP assessment in documentation. Clamp trial outcome was based on neurologic examination and neuroimaging. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) models were constructed to explore computed tomography (CT) versus AIP as predictors of clamp trial outcome. RESULTS Among the 30 subjects enrolled, there were 38 clamping trials and 22 successful EVD removals. CT scan as a predictor of clamp trial was found to have a sensitivity of 68.8% and specificity of 89.5% (PPV = 84.6%, NPV = 77.3%). AIP assessment as a predictor of wean trial outcome was found to have a sensitivity of 58.3% and specificity of 100% (PPV = 100%, NPV = 63.2%). CONCLUSIONS The pilot study data support that Neurological Pupil index <3 is a potential indicator of early clamp trial failure, but a CT scan has a higher sensitivity and NPV for predicting successful EVD removal. This finding suggests the benefits of including AIP assessments during clamping trials.
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Affiliation(s)
- Abdulkadir Kamal
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA
| | - Khalid M Ahmed
- University of Texas Houston McGovern Medical School, Department of Pulmonary and Critical Care Medicine, Houston, Texas, USA
| | - Aardhra M Venkatachalam
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA; Ross University School of Medicine, Miramar, Florida, USA
| | - Mohamed Osman
- Texas Health Harris Methodist, Fort Worth, Texas, USA
| | - Salah G Aoun
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA
| | - Venkatesh Aiyagari
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA
| | - Nathan Schneider
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA
| | - Heather Hasan-Washington
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA
| | - Sonja E Stutzman
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA
| | - DaiWai M Olson
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA.
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9
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Zaranek M, Arshad R, Zheng K, Harris CA. Response of Astrocytes to Blood Exposure due to Shunt Insertion in vitro. AIChE J 2021; 67. [PMID: 35497642 DOI: 10.1002/aic.17485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The breakdown of the ventricular zone (VZ) with the presence of blood in cerebrospinal fluid (CSF) has been shown to increase shunt catheter obstruction in the treatment of hydrocephalus, but the mechanisms by which this occurs are generally unknown. Using a custom-built incubation chamber, we immunofluorescently assayed cell attachment and morphology on shunt catheters with and without blood after 14 days. Samples exposed to blood showed significantly increased cell attachment (average total cell count 392.0±317.1 versus control of 94.7±44.5, P<0.0001). Analysis of the glial fibrillary acidic protein (GFAP) expression showed similar trends (854.4±450.7 versus control of 174.3±116.5, P<0.0001). An in vitro model was developed to represent the exposure of astrocytes to blood following an increase in BBB permeability. Exposure of astrocytes to blood increases the number of cells and their spread on the shunt.
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Affiliation(s)
- Mira Zaranek
- Wayne State University Dept. of Chemical Engineering and Materials Science, 6135 Woodward Avenue, Detroit, MI 48202
| | - Rooshan Arshad
- Wayne State University Dept. of Chemical Engineering and Materials Science, 6135 Woodward Avenue, Detroit, MI 48202
| | - Kevin Zheng
- Wayne State University Dept. of Chemical Engineering and Materials Science, 6135 Woodward Avenue, Detroit, MI 48202
| | - Carolyn A Harris
- Wayne State University Dept. of Chemical Engineering and Materials Science, 6135 Woodward Avenue, Detroit, MI 48202
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Palasz J, D'Antona L, Farrell S, Elborady MA, Watkins LD, Toma AK. External ventricular drain management in subarachnoid haemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2021; 45:365-373. [PMID: 34448080 DOI: 10.1007/s10143-021-01627-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 07/14/2021] [Accepted: 08/12/2021] [Indexed: 01/15/2023]
Abstract
External ventricular drainage (EVD) is one of the most commonly performed neurosurgical procedures. Despite this, the optimal drainage and weaning strategies are still unknown. This PRISMA-compliant systematic review and meta-analysis analysed the outcomes of patients undergoing EVD procedures, comparing continuous versus intermittent drainage and rapid versus gradual weaning. Four databases were searched from inception to 01/10/2020. Articles reporting at least 10 patients treated for hydrocephalus secondary to subarachnoid haemorrhage were included. Other inclusion criteria were the description of the EVD drainage and weaning strategies used and a comparison of continuous versus intermittent drainage or rapid versus gradual weaning within the study. Random effect meta-analyses were used to compare functional outcomes, incidence of complications and hospital length of stay. Intermittent external CSF drainage was associated with lower incidence of EVD-related infections (RR = 0.20, 95% CI 0.05-0.72, I-squared = 0%) and EVD blockages compared to continuous CSF drainage (RR = 0.45, 95% CI 0.27-0.74, I-squared = 0%). There was no clear advantage in using gradual EVD weaning strategies compared to rapid EVD weaning; however, patients who underwent rapid EVD weaning had a shorter hospital length of stay (SMD = 0.34, 95% CI 0.22-0.47, I-squared = 0%). Intermittent external CSF drainage after SAH is associated with lower incidence of EVD-related infections and EVD blockages compared to continuous CSF drainage. Patients who underwent rapid EVD weaning had a shorter hospital length of stay and there was no clear clinical advantage in using gradual weaning.
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Affiliation(s)
- Joanna Palasz
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, Box 32, London, WC1N 3BG, UK.
| | - Linda D'Antona
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, Box 32, London, WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
| | - Sarah Farrell
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, Box 32, London, WC1N 3BG, UK
- Royal Free Hospital, Pond St, Hampstead, London, UK
| | - Mohamed A Elborady
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, Box 32, London, WC1N 3BG, UK
| | - Laurence D Watkins
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, Box 32, London, WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
| | - Ahmed K Toma
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, Box 32, London, WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, London, UK
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11
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Croci DM, Dalolio M, Aghlmandi S, Taub E, Rychen J, Chiappini A, Zumofen D, Guzman R, Mariani L, Roethlisberger M. Early permanent cerebrospinal fluid diversion in aneurysmal subarachnoid hemorrhage: does a lower rate of nosocomial meningitis outweigh the risk of delayed cerebral vasospasm related morbidity? Neurol Res 2020; 43:40-53. [PMID: 33106124 DOI: 10.1080/01616412.2020.1819091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective: Early permanent cerebrospinal fluid (CSF) diversion for hydrocephalus during the first 2 weeks after aneurysmal subarachnoid hemorrhage (aSAH) shortens the duration of external ventricular drainage (EVD) and reduces EVD-associated infections (EVDAI). The objective of this study was to detect any association with symptomatic delayed cerebral vasospasm (DCVS), or delayed cerebral ischemia (DCI) by the time of hospital discharge. Methods: We used a single-center dataset of aSAH patients who had received a permanent CSF diversion. We compared an 'early group' in which the procedure was performed up to 14 days after the ictus, to a 'late group' in which it was performed from the 15th day onward. Results: Among 274 consecutive aSAH patients, 39 (14%) had a permanent CSF diversion procedure with a silver-coated EVD. While the blood clot burden was similarly distributed, patients with early permanent CSF diversion (20 out of 39; 51%) had higher levels of consciousness on admission. Early permanent CSF diversion was associated with less colonized catheter, a shorter duration of extracorporeal CSF diversion (OR 0.73, 95%CI 0.58-0.92 per EVD day), and a lower rate of EVDAI (OR 0.08, 95%CI 0.01-0.80). The occurrence of CSF diversion device obstruction, the rate of symptomatic DCVS or detected DCI on computed tomography and the likelihood of a poor outcome at discharge did not differ between the two groups. Discussion: Early permanent CSF diversion lowers the occurrence of catheter colonization and infectious complication without affecting DCVS-related morbidity in good-grade aSAH patients. These findings need confirmation in larger prospective multicenter cohorts. Abbreviations: aSAH: aneurysmal subarachnoid hemorrhage; BNI: Barrow Neurological Institute Scale; CSF: Cerebrospinal fluid; DCVS: Delayed Cerebral Vasospasm; DCI: Delayed Cortical Ischemia; EKNZ: Ethik-Kommission Nordwest Schweiz; EVD: External ventricular drain; EVDAI: External ventricular drain-associated infections; GCS: Glasgow Coma Scale; IRB: Institutional Review Board; IVH: Inraventricular hemorrhage; mRS: Modified Rankin Scale; SOS: Swiss Study of Subarachnoid Hemorrhage Registry; WFNS: World Federation Neurological-Surgeon Scale.
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Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, University Hospital Basel, University of Basel , Basel, Switzerland.,Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano , Lugano, Switzerland
| | - Martina Dalolio
- Department of Neurosurgery, University Hospital Basel, University of Basel , Basel, Switzerland.,Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano , Lugano, Switzerland
| | - Soheila Aghlmandi
- Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel , Basel, Switzerland
| | - Ethan Taub
- Department of Neurosurgery, University Hospital Basel, University of Basel , Basel, Switzerland
| | - Jonathan Rychen
- Department of Neurosurgery, University Hospital Basel, University of Basel , Basel, Switzerland
| | - Alessio Chiappini
- Department of Neurosurgery, University Hospital Basel, University of Basel , Basel, Switzerland.,Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano , Lugano, Switzerland
| | - Daniel Zumofen
- Department of Neurosurgery, University Hospital Basel, University of Basel , Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital Basel, University of Basel , Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital Basel, University of Basel , Basel, Switzerland
| | - Michel Roethlisberger
- Department of Neurosurgery, University Hospital Basel, University of Basel , Basel, Switzerland.,Department of Neurosurgery, University Malaya Specialist Centre, University of Malaya , Kuala Lumpur, Malaysia
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12
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Association of Dexamethasone with Shunt Requirement, Early Disability, and Medical Complications in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2020; 34:760-768. [PMID: 32851604 DOI: 10.1007/s12028-020-01059-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/21/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND PURPOSE Current guidelines do not support the routine use of corticosteroids in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, corticosteroids use in aSAH has been practiced at some centers by convention. The aim of the study was to determine the incidence of hydrocephalus requiring ventriculoperitoneal shunt (VPS) placement as well as functional outcome on discharge and adverse events attributed to corticosteroids in patients with aSAH treated with different dexamethasone (DXM) treatment schemes. METHODS We retrospectively analyzed 206 patients with aSAH stratified to three groups based on the DXM treatment scheme: no corticosteroids, short course of DXM (S-DXM; 4 mg every 6 h for 1 day followed by a daily total dose reduction by 25% and then by 50% on last day), and long course of DXM (L-DXM; 4 mg every 6 h for 5-7 days followed by reduction by 50% every other day). The primary outcome measure was the placement of a VPS, and the secondary outcome was a good functional outcome [modified Rankin Scale (mRS) 0-3] at hospital discharge. Safety measures were the incidence of infection (pneumonia, urinary tract infection, ventriculitis, meningitis), presence of delirium, and hyperglycemia. RESULTS There was no difference in the rate of external ventricular drain (EVD) (p = 0.164) and VPS placement (p = 0.792), nor in the rate of good outcome (p = 0.928) among three defined treatment regimens. Moreover, the median duration of treatment with EVD did not differ between subjects treated with no corticosteroids, S-DXM, and L-DXM (p = 0.905), and the probability of EVD removal was similar when stratified according to treatment regimens (log-rank; p = 0.256). Patients who received L-DXM had significantly more complications as compared to patients, who received no corticosteroids or S-DXM (78.4% vs. 58.6%; p = 0.005). After adjustment, L-DXM remained independently associated with increased risk of combined adverse events (OR = 2.72; 95%CI, 1.30-5.72; p = 0.008), infection (OR = 3.45; 95%CI, 1.63-7.30; p = 0.001) and hyperglycemia (OR = 2.05; 95%CI, 1.04-4.04; p = 0.039). CONCLUSIONS DXM use among patients with aSAH did not relate to the rate of EVD and VPS placement, duration of EVD treatment, and functional disability at discharge but increased the risk of medical complications.
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13
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Intracranial Pressure during External Ventricular Drainage Weaning Is an Outcome Predictor of Traumatic Brain Injury. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8379134. [PMID: 32695822 PMCID: PMC7368209 DOI: 10.1155/2020/8379134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/18/2020] [Indexed: 11/18/2022]
Abstract
External ventricular drainage (EVD) is widely used in patients with a traumatic brain injury (TBI). However, the EVD weaning trial protocol varies and insufficient studies focus on the intracranial pressure (ICP) during the weaning trial. We aimed to establish the relationship between ICP during an EVD weaning trial and the outcomes of TBI. We enrolled 37 patients with a TBI with an EVD from July 2018 to September 2019. Among them, 26 were allocated to the favorable outcome group and 11 to the unfavorable outcome group (death, post-traumatic hydrocephalus, persistent vegetative state, and severe disability). Groups were well matched for sex, pupil reactivity, admission Glasgow Coma Scale score, Marshall computed tomography score, modified Fisher score, intraventricular hemorrhage, EVD days, cerebrospinal fluid output before the weaning trial, and the complications. Before and during the weaning trial, we recorded the ICP at 1-hour intervals to calculate the mean ICP, delta ICP, and ICP burden, which was defined as the area under the ICP curve. There were significant between-group differences in the age, surgery types, and intensive care unit days (p = 0.045, p = 0.028, and p = 0.004, respectively). During the weaning trial, 28 (75.7%) patients had an increased ICP. Although there was no significant difference in the mean ICP before and during the weaning trial, the delta ICP was higher in the unfavorable outcome group (p = 0.001). Moreover, patients who experienced death and hydrocephalus had a higher ICP burden, which was above 20 mmHg (p = 0.016). Receiver operating characteristic analyses demonstrated the predictive ability of these variables (area under the curve [AUC] = 0.818 [p = 0.002] for delta ICP and AUC = 0.758 [p = 0.038] for ICP burden > 20 mmHg). ICP elevation is common during EVD weaning trials in patients with TBI. ICP-related parameters, including delta ICP and ICP burden, are significant outcome predictors. There is a need for larger prospective studies to further explore the relationship between ICP during EVD weaning trials and TBI outcomes.
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14
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Winkler EA, Burkhardt JK, Rutledge WC, Rick JW, Partow CP, Yue JK, Birk H, Bach AM, Raygor KP, Lawton MT. Reduction of shunt dependency rates following aneurysmal subarachnoid hemorrhage by tandem fenestration of the lamina terminalis and membrane of Liliequist during microsurgical aneurysm repair. J Neurosurg 2019; 129:1166-1172. [PMID: 29243978 DOI: 10.3171/2017.5.jns163271] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 05/30/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEShunt-dependent hydrocephalus is an important cause of morbidity following aneurysmal subarachnoid hemorrhage (aSAH) in excess of 20% of cases. Hydrocephalus leads to prolonged hospital and ICU stays, well as to repeated surgical interventions, readmissions, and complications associated with ventriculoperitoneal (VP) shunts, including shunt failure and infection. Whether variations in surgical technique at the time of aneurysm treatment may modify rates of shunt dependency remains a matter of debate. Here, the authors report on their experience with tandem fenestration of the lamina terminalis (LT) and membrane of Liliequist (MoL) at the time of open microsurgical repair of the ruptured aneurysm.METHODSThe authors conducted a retrospective review of 663 consecutive patients with aSAH treated from 2005 to 2015 by open microsurgery via a pterional or orbitozygomatic craniotomy by the senior author (M.T.L.). Data collected from review of the electronic medical record included age, Hunt and Hess grade, Fisher grade, need for an external ventricular drain, and opening pressure. Patients were stratified into those undergoing no fenestration and those undergoing tandem fenestration of the LT and MoL at the time of surgical repair. Outcome variables, including VP shunt placement and timing of shunt placement, were recorded and statistically analyzed.RESULTSIn total, shunt-dependent hydrocephalus was observed in 15.8% of patients undergoing open surgical repair following aSAH. Tandem microsurgical fenestration of the LT and MoL was associated with a statistically significant reduction in shunt dependency (17.9% vs 3.2%, p < 0.01). This effect was confirmed with multivariate analysis of collected variables (multivariate OR 0.09, 95% CI 0.03-0.30). Number-needed-to-treat analysis demonstrated that tandem fenestration was required in approximately 6.8 patients to prevent a single VP shunt placement. A statistically significant prolongation in days to VP shunt surgery was also observed in patients treated with tandem fenestration (26.6 ± 19.4 days vs 54.0 ± 36.5 days, p < 0.05).CONCLUSIONSTandem fenestration of the LT and MoL at the time of open microsurgical clipping and/or bypass to secure ruptured anterior and posterior circulation aneurysms is associated with reductions in shunt-dependent hydrocephalus following aSAH. Future prospective randomized multicenter studies are needed to confirm this result.
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15
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Abstract
External ventricular drains (EVD) are essential in the early management of hydrocephalus and elevated intracranial pressure after subarachnoid hemorrhage (SAH). Once in place, management of the EVD is thought to influence long-term patient outcomes, rates of ventriculitis, incidence of delayed cerebral ischemia, need for a ventriculoperitoneal shunt, and intensive care unit (ICU) and hospital length of stay. The available evidence supports adopting early clamp trials and intermittent cerebrospinal fluid (CSF) drainage. However, a recent survey demonstrated that most neurological ICUs employ the opposite approach of continuously open EVDs and gradual weaning. In this article, we review the literature and arguments for and against the different EVD approaches. We conclude that an early clamp trial and intermittent CSF drainage can be safe and result in fewer EVD complications and shorter length of stay. Given the discrepancy between the available evidence and current practice, more studies on the optimal management of EVDs are warranted with the greatest need for multicenter prospective studies.
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16
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Faried A, Kurniawan CB, Halim D, Arifin MZ. A rare case of depressed skull fractures at the anterior cranial fossa associated with communicating hydrocephalus resulting a progressive vision loss. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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17
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Jabbarli R, Pierscianek D, RÖlz R, Reinhard M, Darkwah Oppong M, Scheiwe C, Dammann P, Kaier K, Wrede KH, Shah M, Zentner J, Sure U. Gradual External Ventricular Drainage Weaning Reduces The Risk of Shunt Dependency After Aneurysmal Subarachnoid Hemorrhage: A Pooled Analysis. Oper Neurosurg (Hagerstown) 2018; 15:498-504. [DOI: 10.1093/ons/opy009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/12/2018] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Chronic posthemorrhagic hydrocephalus necessitating shunt placement is a common complication of subarachnoid hemorrhage (SAH).
OBJECTIVE
To evaluate the role of external ventricular drainage (EVD) weaning on risk of shunt dependency after SAH.
METHODS
Two German university hospitals with different EVD management regimes (rapid weaning [RW] vs gradual weaning [GW]) pooled the data of their observational cohorts containing altogether 1171 consecutive SAH patients treated between January 2005 and December 2012. Development and timing of shunt dependency in SAH survivals were the endpoints of the study.
RESULTS
The final cohort consisted of 455 and 510 SAH survivors treated in the centers with RW and GW, respectively. Mortality rates, as well as baseline demographic, clinical, and radiographic parameters, showed no differences between the centers. Patients with GW were less likely to develop shunt dependency (27.5% vs 34.7%, P = .018), Multivariate analysis confirmed independent association between RW regime and shunt dependency (P = .026). Shunt-dependent SAH patients undergoing GW required significantly longer time until shunting (mean 29.8 vs 21.7 d, P < .001) and hospital stay (mean 39 vs 34.4 d, P = .03). In addition, patients with GW were at higher risk for secondary shunt placement after successful initial weaning (P = .001). The risk of cerebrospinal fluid infection was not associated with the weaning regime (15.3% vs 12.9%, P = .307).
CONCLUSION
At the expense of longer treatment, GW may decrease the risk of shunt dependency after SAH without an additional risk for infections. Due to the risk of secondary shunt dependency, SAH patients with GW require proper posthospital neurological care.
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Affiliation(s)
- Ramazan Jabbarli
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
- Department of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | | | - Roland RÖlz
- Department of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Matthias Reinhard
- Department of Neurology, University Medical Center Freiburg, Frieburg, Germany
- Department of Neurology and Clinical Neurophysiology, Klinikum Esslingen, Esslingen, Germany
| | | | - Christian Scheiwe
- Department of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Philipp Dammann
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Medical Informatics, University Medical Center Freiburg, Freiburg, Germany
| | - Karsten H Wrede
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Mukesch Shah
- Department of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Josef Zentner
- Department of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
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18
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Multani JS, Oermann EK, Titano J, Mascitelli J, Nicol K, Feng R, Skovrlj B, Pain M, Mocco JD, Bederson JB, Costa A, Shrivastava R. Quantitative Computed Tomography Ventriculography for Assessment and Monitoring of Hydrocephalus: A Pilot Study and Description of Method in Subarachnoid Hemorrhage. World Neurosurg 2017; 104:136-141. [PMID: 28456742 DOI: 10.1016/j.wneu.2017.04.107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 04/15/2017] [Accepted: 04/17/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is no facile quantitative method for monitoring hydrocephalus (HCP). We propose quantitative computed tomography (CT) ventriculography (qCTV) as a novel computer vision tool for empirically assessing HCP in patients with subarachnoid hemorrhage (SAH). METHODS Twenty patients with SAH who were evaluated for ventriculoperitoneal shunt (VPS) placement were selected for inclusion. Ten patients with normal head computed tomography (CTH) findings were analyzed as negative controls. CTH scans were segmented both manually and automatically (by qCTV) to generate measures of ventricular volume. RESULTS The median manually calculated ventricular volume was 36.1 cm3 (interquartile range [IQR], 30-115 cm3), which was similar to the median qCTV measured volume of 37.5 cm3 (IQR, 32-118 cm3) (P = 0.796). Patients undergoing VPS placement demonstrated an increase in median ventricular volume on qCTV from 21 cm3 to 40 cm3 on day T-2 and to 51 cm3 by day 0, a change of 144%. This is in contrast to patients who did not require shunting, in whom median ventricular volume decreased from 16 cm3 to 14 cm3 on day T-2 and to 13 cm3 by day 0, with an average overall volume decrease 19% (P = 0.001). The average change in ventricular volume predicted which patients would require VPS placement, successfully identifying 7 of 10 patients (P = 0.004). Using an optimized cutoff of a change in ventricular volume of 2.5 cm3 identified all patients who went on to require VPS placement (10 of 10; P = 0.011). CONCLUSIONS qCTV is a reliable means of quantifying ventricular volume and hydrocephalus. This technique offers a new tool for monitoring neurosurgical patients for hydrocephalus, and may be beneficial for use in future research studies, as well as in the routine care of patients with hydrocephalus.
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Affiliation(s)
- Jasjit Singh Multani
- Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA
| | - Eric Karl Oermann
- Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA
| | - Joseph Titano
- Department of Radiology, Mount Sinai Health System, New York, New York, USA
| | - Justin Mascitelli
- Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA
| | - Kelly Nicol
- Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA
| | - Rui Feng
- Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA.
| | - Branko Skovrlj
- Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA
| | - Margaret Pain
- Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA
| | - J D Mocco
- Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA
| | - Joshua B Bederson
- Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA
| | - Anthony Costa
- Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA
| | - Raj Shrivastava
- Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA
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19
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Predictors of Shunt Insertion in Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 98:421-426. [DOI: 10.1016/j.wneu.2016.11.092] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/15/2016] [Accepted: 11/16/2016] [Indexed: 11/20/2022]
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20
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Jabbarli R, Müller O. Authors' reply. Eur J Neurol 2016; 23:e42-3. [DOI: 10.1111/ene.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 04/04/2016] [Indexed: 11/30/2022]
Affiliation(s)
- R. Jabbarli
- Department of Neurosurgery; University Hospital Essen; Essen Germany
| | - O. Müller
- Department of Neurosurgery; University Hospital Essen; Essen Germany
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21
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Wilson CD, Safavi-Abbasi S, Sun H, Kalani MYS, Zhao YD, Levitt MR, Hanel RA, Sauvageau E, Mapstone TB, Albuquerque FC, McDougall CG, Nakaji P, Spetzler RF. Meta-analysis and systematic review of risk factors for shunt dependency after aneurysmal subarachnoid hemorrhage. J Neurosurg 2016; 126:586-595. [PMID: 27035169 DOI: 10.3171/2015.11.jns152094] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) may be complicated by hydrocephalus in 6.5%-67% of cases. Some patients with aSAH develop shunt dependency, which is often managed by ventriculoperitoneal shunt placement. The objectives of this study were to review published risk factors for shunt dependency in patients with aSAH, determine the level of evidence for each factor, and calculate the magnitude of each risk factor to better guide patient management. METHODS The authors searched PubMed and MEDLINE databases for Level A and Level B articles published through December 31, 2014, that describe factors affecting shunt dependency after aSAH and performed a systematic review and meta-analysis, stratifying the existing data according to level of evidence. RESULTS On the basis of the results of the meta-analysis, risk factors for shunt dependency included high Fisher grade (OR 7.74, 95% CI 4.47-13.41), acute hydrocephalus (OR 5.67, 95% CI 3.96-8.12), in-hospital complications (OR 4.91, 95% CI 2.79-8.64), presence of intraventricular blood (OR 3.93, 95% CI 2.80-5.52), high Hunt and Hess Scale score (OR 3.25, 95% CI 2.51-4.21), rehemorrhage (OR 2.21, 95% CI 1.24-3.95), posterior circulation location of the aneurysm (OR 1.85, 95% CI 1.35-2.53), and age ≥ 60 years (OR 1.81, 95% CI 1.50-2.19). The only risk factor included in the meta-analysis that did not reach statistical significance was female sex (OR 1.13, 95% CI 0.77-1.65). CONCLUSIONS The authors identified several risk factors for shunt dependency in aSAH patients that help predict which patients are likely to require a permanent shunt. Although some of these risk factors are not independent of each other, this information assists clinicians in identifying at-risk patients and managing their treatment.
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Affiliation(s)
| | - Sam Safavi-Abbasi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Hai Sun
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - M Yashar S Kalani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Yan D Zhao
- Biostatistics and Epidemiology, University of Oklahoma, Oklahoma City, Oklahoma
| | - Michael R Levitt
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Hospital, Jacksonville, Florida
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Hospital, Jacksonville, Florida
| | | | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Cameron G McDougall
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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22
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Tso MK, Ibrahim GM, Macdonald RL. Predictors of Shunt-Dependent Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2015; 86:226-32. [PMID: 26428322 DOI: 10.1016/j.wneu.2015.09.056] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/16/2015] [Accepted: 09/16/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Shunt-dependent hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH). There is a need to identify patients who require ventriculoperitoneal shunt (VPS) insertion so that any modifiable risk factors can be addressed early after aSAH. METHODS Exploratory analysis was performed on 413 patients enrolled in CONSCIOUS-1, a prospective randomized controlled trial of patients with aSAH treated with clazosentan. The association between clinical and neuroimaging covariates and VPS placement was first determined by univariate analysis. Covariates with P < 0.15 on univariate analysis were then analyzed in a multivariate logistic regression model. Receiver operating characteristic curve analysis was used to define optimal predictive thresholds. The published literature was reviewed to determine the overall rate of VPS insertion after aSAH. RESULTS Overall, 17.2% (71/413) of patients required VPS insertion. Multivariate analysis demonstrated that insertion of an external ventricular drain (odds ratio, 6.21; 95% confidence interval, 2.51-16.91) and increasing volume of cerebrospinal fluid (CSF) drainage per day (odds ratio, 1.004; 95% confidence interval, 1.000-1.009) were associated with VPS insertion. Receiver operating characteristic curve analysis revealed an optimal daily CSF output threshold of 78 mL was predictive of VPS insertion. Among 41,789 patients with aSAH from 66 published studies, the overall VPS insertion rate was 12.7%. CONCLUSIONS The presence of an external ventricular drain and increased daily CSF output (above 78 mL/day) seems to be predictive of subsequent VPS insertion after aSAH. Although we could not identify modifiable risk factors for needing a VPS, nevertheless, these findings identify patients at greatest risk of VPS placement and inform treatment decisions as well as patient expectations.
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Affiliation(s)
- Michael K Tso
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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23
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Daily drained CSF volume is a predictor for shunt dependence - A retrospective study. Clin Neurol Neurosurg 2015; 138:147-50. [PMID: 26342208 DOI: 10.1016/j.clineuro.2015.08.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 08/19/2015] [Accepted: 08/22/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Acute hydrocephalus ensues from various intracranial processes and is usually treated using external ventricular drainage (EVD). After the acute phase, a clamp trial is usually performed to identify patients requiring permanent CSF shunting. The aim of our study was to identify simple and clinically accessible factors that can help predict the result of the EVD clamp trial. METHODS 86 patients were selected for this retrospective analysis. Average CSF drained volume over 3 days given a constant EVD pressure level of 15 cm H2O and other clinical and laboratory parameters were statistically compared with the result of an EVD clamp trial. RESULTS The univariate analysis identified significant differences between the groups of patients who failed or passed the EVD clamp trial for the mean daily drained volume over 3 days (Mann-Whitney U-test, p<0.01). In the multivariate logistic regression, the average daily CSF output over 3 days was also significant (p=0.02), no other significant factors could be identified. Using hierarchical clustering, the best threshold daily value for EVD clamp trial failure was found at 130 ml (mean daily drained CSF volume) with the sensitivity of 64.5% and specificity of 83.6% (chi-square 20.6, p<0.01). CONCLUSION We have identified a simple, clinically available factor for identifying patients who are likely to fail the EVD clamp trial.
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