III. Ventricle diameter increase during ventricular drainage challenge - A predictor of shunt dependency after subarachnoid hemorrhage

The value of ventricular measurements in the prediction of shunt dependency after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Chronic hydrocephalus requiring shunt placement is a common complication of aneurysmal subarachnoid hemorrhage (SAH). Different risk factors and prediction scores for post-SAH shunt dependency have been evaluated so far. We analyzed the value of ventricle measurements for prediction of the need for shunt placement in SAH patients.

METHODS

Eligible SAH cases treated between 01/2003 and 06/2016 were included. Initial computed tomography scans were reviewed to measure ventricle indices (bifrontal, bicaudate, Evans', ventricular, Huckman's, and third ventricle ratio). Previously introduced CHESS and SDASH scores for shunt dependency were calculated. Receiver operating characteristic analyses were performed for diagnostic accuracy of the ventricle indices and to identify the clinically relevant cut-offs.

RESULTS

Shunt placement followed in 221 (36.5%) of 606 patients. In univariate analyses, all ventricular indices were associated with shunting (all: p<0.0001). The area under the curve (AUC) ranged between 0.622 and 0.662. In multivariate analyses, only Huckman's index was associated with shunt dependency (cut-off at ≥6.0cm, p<0.0001) independent of the CHESS score as baseline prediction model. A combined score (0-10 points) containing the CHESS score components (0-8 points) and Huckman's index (+2 points) showed better diagnostic accuracy (AUC=0.751) than the CHESS (AUC=0.713) and SDASH (AUC=0.693) scores and the highest overall model quality (0.71 vs. 0.65 and 0.67), respectively.

CONCLUSIONS

Ventricle measurements are feasible for early prediction of shunt placement after SAH. The combined prediction model containing the CHESS score and Huckman's index showed remarkable diagnostic accuracy regarding identification of SAH individuals requiring shunt placement. External validation of the presented combined CHESS-Huckman score is mandatory.

Morphometric Study of the Initial Ventricular Indices to Predict the Complications and Outcome of Aneurysmal Subarachnoid Hemorrhage

Objective: Acute hydrocephalus is a common complication in patients with aneurysmal subarachnoid hemorrhage (SAH). Several ventricular indices have been introduced to enable measurements of ventricular morphology. Previously, researchers have showed their diagnostic value for various neurological disorders. In this study, we evaluated the association between ventricular indices and the clinical course, occurrence of complications and outcome of SAH. Methods: A total of 745 SAH patients with available early admission computed tomography scans were included in the analyses. Six ventricular indices (bifrontal, bicaudate, ventricular and third ventricle ratios and Evans’ and Huckman’s indices) were measured. Primary endpoints included the occurrence of cerebral infarctions, in-hospital mortality and a poor outcome at 6 months. Secondary endpoints included different adverse events in the course of SAH. Clinically relevant cut-offs for the indices were determined using receiver operating curves. Univariate analyses were performed. Multivariate analyses were conducted on significant findings in a stepwise backward regression model. Results: The higher the values of the ventricular indices were and the older the patient was, the higher the WFNS and Fisher’s scores were, and the lower the SEBES score was at admission. Patients with larger ventricles showed a shorter duration of intracranial pressure increase > 20 mmHg and required decompressive craniectomy less frequently. Ventricular indices were independently associated with the parameters of inflammatory response after SAH (C-reactive protein in serum and interleukin-6 in cerebrospinal fluid and fever). Finally, there were independent correlations between larger ventricles and all the primary endpoints. Conclusions: The lower risk of intracranial pressure increase and absence of an association with vasospasm or systemic infections during SAH, and the poorer outcome in individuals with larger ventricles might be related to a more pronounced neuroinflammatory response after aneurysmal bleeding. These observations might be helpful in the development of specific medical and surgical treatment strategies for SAH patients depending on the initial ventricle measurements.

High-Quality Nursing Combined with the Whole-Course Responsibility Nursing Intervention Reduces the Incidence of Complications in Severe Aneurysmal Subarachnoid Hemorrhage

Objective

The aim of this study is to study the influence of whole-course responsibility nursing combined with high-quality nursing intervention on the level of life and complications of severe aneurysmal subarachnoid hemorrhage patients with postoperative coma.

Methods

From December 2018 to December 2020, 90 severe aneurysmal subarachnoid hemorrhage patients with postoperative coma were selected and were divided into two groups, the experimental group and the control group, with 45 cases in each group. The control group adopted conventional nursing care, and the experimental group received whole-course responsibility nursing combined with high-quality nursing intervention. The nursing effect, degree of coma, coma recovery, and incidence of complications between all groups were compared.

Results

Compared with the control group, the experimental group yielded more favorable achievement in terms of the nursing effect (P < 0.05). Superior levels of the Glasgow Coma Scale (GCS) score, Coma Recovery Scale-Revised (CRS-R) score, GQOLI-74 score, and BI score of the experimental group were obtained and compared with the control group (all P < 0.05). The experimental group witnessed a lower complication rate, as compared to the other group (P < 0.05).

Conclusion

The whole-course responsibility nursing combined with high-quality nursing intervention is applied to severe aneurysmal subarachnoid hemorrhage patients with postoperative coma, which can substantially optimize the nursing efficiency, improve the degree of coma, help recover consciousness, ameliorate the mental state and the quality of life, and reduce the incidence of complications, which is worthy of clinical application.

Ventricular Volume Change as a Predictor of Shunt-Dependent Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) that often requires acute placement of an external ventricular drain (EVD). The current systems available for determining which patients will require long-term cerebrospinal fluid diversion remain subjective. We investigated the ventricular volume change (ΔVV) after EVD clamping as an objective predictor of shunt dependence in patients with aSAH.

METHODS

We performed a retrospective medical record review and image analysis of patients treated for aSAH at a single academic institution who had required EVD placement for acute hydrocephalus and had undergone 1 EVD weaning trial. Head computed tomography (CT) scans obtained before and after EVD clamping were analyzed using a custom semiautomated MATLAB program (MathWorks, Natick, Massachusetts, USA), which segments each CT scan into 5 tissue types using k-means clustering. Differences in the pre- and postclamp ventricular volumes were calculated.

RESULTS

A total of 34 patients with an indwelling shunt met the inclusion criteria and were sex- and age-matched to 34 controls without a shunt. The mean ΔVV was 19.8 mL in the shunt patients and 3.8 mL in the nonshunt patients (P < 0.0001). The area under the receiver operating characteristic curve was 0.84. The optimal ΔVV threshold was 11.4 mL, with a sensitivity of 76.5% and specificity of 88.2% for predicting shunt dependence. The mean ΔVV was significantly greater for the patients readmitted for shunt placement compared with the patients not requiring cerebrospinal fluid diversion (18.69 mL vs. 3.84 mL; P = 0.005). Finally, 70% of the patients with delayed shunt dependence had ΔVV greater than the identified threshold.

CONCLUSIONS

The ΔVV volume between head CT scans taken before and after EVD clamping was predictive of early and delayed shunt dependence.