The CHESS score: a simple tool for early prediction of shunt dependency after aneurysmal subarachnoid hemorrhage

Risk factors for shunt-dependent hydrocephalus after spontaneous subarachnoid hemorrhage

INTRODUCTION

Subarachnoid haemorrhage (SAH) is one of the most frequent neurosurgical emergencies, most of them due to intracranial aneurysm rupture. Hydrocephalus is a prevalent complication with a high rate of complications. The aims of this study are to identify predictors of shunt-dependent hydrocephalus following aneurysmal SAH and to quantify the complications arising from ventriculoperitoneal shunts.

METHODS

This study is about an observational retrospective analytic study of the patients with spontaneous SAH admitted to Miguel Servet Universitary Hospital between 2017 and 2022. Patients' clinical and radiological characteristics, type of treatment, diagnoses and treatment of hydrocephalus, complications of ventriculoperitoneal shunts and mortality are some of the data achieved in this study. A descriptive study of these variables has been done and, subsequently, the most relevant variables have been statistically analysed to identify patients with increasing risk of shunting for hydrocephalus. This study was authorized by the Ethics Committee prior to its elaboration.

RESULTS

A total of 359 patients with spontaneous SAH were admitted to Miguel Servet Universitary Hospital between 2017 and 2022, with an intrahospitalary death rate of 25.3%. 66.3% of the total of patients with SAH were due to intracranial aneurysm rupture (n = 238). 45.3% of the patients with aneurysmal SAH required an external ventricular drain (EVD) to treat acute hydrocephalus. 11.7% (n = 28) developed a shunt-dependent hydrocephalus. Statistical significance was found between shunt-dependent hydrocephalus and the following: high score in modified Fisher scale and placement of EVD. The mean interval from EVD to ventriculoperitoneal shunt placement was 26.1 days. The mean rate of reoperation of patients after shunt was 17.7%, mostly due to infection.

CONCLUSIONS

The most significant risk factor for shunt-dependent hydrocephalus after aneurysmal SAH was high Fisher grade and previous need of EVD. Shunt infections is the main cause of shunt reoperation. Early shunt placement in selected patients might reduce the rate of infectious complications.

Impact of thyroid hormone replacement therapy on the course and functional outcome of aneurysmal subarachnoid hemorrhage

BACKGROUND

Thyroid hormones were reported to exert neuroprotective effects after ischemic stroke by reducing the burden of brain injury and promoting post-ischemic brain remodeling.

OBJECTIVE

We aimed to analyze the value of thyroid hormone replacement therapy (THRT) due to pre-existing hypothyroidism on the clinical course and outcome of aneurysmal subarachnoid hemorrhage (SAH).

METHODS

SAH individuals treated between January 2003 and June 2016 were included. Data on baseline characteristics of patients and SAH, adverse events and functional outcome of SAH were recorded. Study endpoints were cerebral infarction, in-hospital mortality and unfavorable outcome at 6 months. Associations were adjusted for outcome-relevant confounders.

RESULTS

109 (11%) of 995 individuals had THRT before SAH. Risk of intracranial pressure- or vasospasm-related cerebrovascular events was inversely associated with presence of THRT (p = 0.047). In multivariate analysis, THRT was independently associated with lower risk of cerebral infarction (adjusted odds ratio [aOR] = 0.64, 95% confidence interval [CI] = 0.41-0.99, p = 0.045) and unfavorable outcome (aOR = 0.50, 95% CI = 0.28-0.89, p = 0.018), but not with in-hospital mortality (aOR = 0.69, 95% CI = 0.38-1.26, p = 0.227).

CONCLUSION

SAH patients with THRT show lower burden of ischemia-relevant cerebrovascular events and more favorable outcome. Further experimental and clinical studies are required to confirm our results and elaborate the mechanistic background of the effect of THRT on course and outcome of SAH.

Early prediction of ventricular peritoneal shunt dependency in aneurysmal subarachnoid haemorrhage patients by recurrent neural network-based machine learning using routine intensive care unit data

Aneurysmal subarachnoid haemorrhage (aSAH) can lead to complications such as acute hydrocephalic congestion. Treatment of this acute condition often includes establishing an external ventricular drainage (EVD). However, chronic hydrocephalus develops in some patients, who then require placement of a permanent ventriculoperitoneal (VP) shunt. The aim of this study was to employ recurrent neural network (RNN)-based machine learning techniques to identify patients who require VP shunt placement at an early stage. This retrospective single-centre study included all patients who were diagnosed with aSAH and treated in the intensive care unit (ICU) between November 2010 and May 2020 (n = 602). More than 120 parameters were analysed, including routine neurocritical care data, vital signs and blood gas analyses. Various machine learning techniques, including RNNs and gradient boosting machines, were evaluated for their ability to predict VP shunt dependency. VP-shunt dependency could be predicted using an RNN after just one day of ICU stay, with an AUC-ROC of 0.77 (CI: 0.75-0.79). The accuracy of the prediction improved after four days of observation (Day 4: AUC-ROC 0.81, CI: 0.79-0.84). At that point, the accuracy of the prediction was 76% (CI: 75.98-83.09%), with a sensitivity of 85% (CI: 83-88%) and a specificity of 74% (CI: 71-78%). RNN-based machine learning has the potential to predict VP shunt dependency on Day 4 after ictus in aSAH patients using routine data collected in the ICU. The use of machine learning may allow early identification of patients with specific therapeutic needs and accelerate the execution of required procedures.

Predictors of shunt insertion in patients with aneurysmal subarachnoid haemorrhage-a single-centre retrospective analysis

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.

Enhancing the prediction for shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage using a machine learning approach

Early and reliable prediction of shunt-dependent hydrocephalus (SDHC) after aneurysmal subarachnoid hemorrhage (aSAH) may decrease the duration of in-hospital stay and reduce the risk of catheter-associated meningitis. Machine learning (ML) may improve predictions of SDHC in comparison to traditional non-ML methods. ML models were trained for CHESS and SDASH and two combined individual feature sets with clinical, radiographic, and laboratory variables. Seven different algorithms were used including three types of generalized linear models (GLM) as well as a tree boosting (CatBoost) algorithm, a Naive Bayes (NB) classifier, and a multilayer perceptron (MLP) artificial neural net. The discrimination of the area under the curve (AUC) was classified (0.7 ≤ AUC < 0.8, acceptable; 0.8 ≤ AUC < 0.9, excellent; AUC ≥ 0.9, outstanding). Of the 292 patients included with aSAH, 28.8% (n = 84) developed SDHC. Non-ML-based prediction of SDHC produced an acceptable performance with AUC values of 0.77 (CHESS) and 0.78 (SDASH). Using combined feature sets with more complex variables included than those incorporated in the scores, the ML models NB and MLP reached excellent performances, with an AUC of 0.80, respectively. After adding the amount of CSF drained within the first 14 days as a late feature to ML-based prediction, excellent performances were reached in the MLP (AUC 0.81), NB (AUC 0.80), and tree boosting model (AUC 0.81). ML models may enable clinicians to reliably predict the risk of SDHC after aSAH based exclusively on admission data. Future ML models may help optimize the management of SDHC in aSAH by avoiding delays in clinical decision-making.

Cisternal Score: A Radiographic Score to Predict Ventriculoperitoneal Shunt Requirement in Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Persistent hydrocephalus requiring a ventriculoperitoneal shunt (VPS) can complicate the management of aneurysmal subarachnoid hemorrhage (aSAH). Identification of high-risk patients may guide external ventricular drain management.

OBJECTIVE

To identify early radiographic predictors for persistent hydrocephalus requiring VPS placement.

METHODS

In a 2-center retrospective study, we compared radiographic features on admission noncontrast head computed tomography scans of patients with aSAH requiring a VPS to those who did not, at 2 referral academic centers from 2016 through 2021. We quantified blood clot thickness in the basal cisterns including interpeduncular, ambient, crural, prepontine, interhemispheric cisterns, and bilateral Sylvian fissures. We then created the cisternal score (CISCO) using features that were significantly different between groups.

RESULTS

We included 229 survivors (mean age 55.6 years [SD 13.1]; 63% female) of whom 50 (22%) required VPS. CISCO was greater in patients who required a VPS than those who did not (median 4, IQR 3-6 vs 2, IQR 1-4; P < .001). Higher CISCO was associated with higher odds of developing persistent hydrocephalus with VPS requirement (odds ratio 1.6 per point increase, 95% CI 1.34-1.9; P < .001), independent of age, Hunt and Hess grades, and modified GRAEB scores. CISCO had higher accuracy in predicting VPS requirement (area under the curve 0.75, 95% CI 0.68-0.82) compared with other predictors present on admission.

CONCLUSION

Cisternal blood clot quantification on admission noncontrast head computed tomography scan is feasible and can be used in predicting persistent hydrocephalus with VPS requirement in patients with aSAH. Future prospective studies are recommended to further validate this tool.

Feasibility of Prompt Lumbar Drainage in Patients with Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Numerous studies have shown that continuous lumbar drainage (LD) reduces spontaneous subarachnoid hemorrhage (SAH)-related complications, decreasing the incidence of cerebral vasospasm, delayed cerebral ischemia , and hydrocephalus in patients treated with coiling or clipping, but performing LD before securing the aneurysm is still controversial. Our hospital has been implementing prompt LD for several years, and we present the results in this paper.

METHODS

Between January 2014 and December 2020, a total of 438 patients with SAH were included in this retrospective study. The indication for prompt LD was aneurysmal SAH of modified Fisher grade III or higher without dense intraventricular hemorrhage with obstructive hydrocephalus requiring extraventricular drainage or large intracranial hemorrhage requiring immediate decompression. Prompt LD was performed for 229 patients with SAH, and the control group included 209 patients. We compared in-hospital mortality and vasospasm or hydrocephalus occurrence and procedure-related complications between the two groups.

RESULTS

The in-hospital mortality rate was 7.4% for patients with prompt LD and 14.4% for patients without LD, and the difference was significant (P = 0.019). Vasospasm occurred in 10% of patients with prompt LD and 16.7% of controls (P = 0.039). Hydrocephalus requiring extraventricular drainage occurred in 10.9% of the LD group and 28.7% of the control group (P < 0.001). Rebleeding occurrence was 3.1% in the prompt LD group and 5.7% in the non-LD group (P = 0.168). Cerebrospinal fluid infection occurred in 0.4% of the prompt LD group and 1.4% of controls(P = 0.272).

CONCLUSIONS

Prompt LD is a feasible option for treating patients with selective aneurysmal SAH.

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.

Factors affecting ventriculoperitoneal shunt revision: a post hoc analysis of the British Antibiotic and Silver Impregnated Catheter Shunt multicenter randomized controlled trial

OBJECTIVE

The British Antibiotic and Silver Impregnated Catheter Shunt (BASICS) trial established level I evidence of the superiority of antibiotic-impregnated catheters in the prevention of infection of newly implanted ventriculoperitoneal shunts (VPSs). A wealth of patient, shunt, and surgery-specific data were collected from trial participants beyond that of the prespecified trial objectives.

METHODS

This post hoc analysis of the BASICS survival data explores the impact of patient age, hydrocephalus etiology, catheter type, valve type, and previous external ventricular drain on the risk of infection or mechanical failure. Time to failure was analyzed using Fine and Gray survival regression models for competing risk.

RESULTS

Among 1594 participants, 75 patients underwent revision for infection and 323 for mechanical failure. Multivariable analysis demonstrated an increased risk of shunt infection associated with patient ages < 1 month (subdistribution hazard ratio [sHR] 4.48, 95% CI 2.06-9.72; p < 0.001) and 1 month to < 1 year (sHR 2.67, 95% CI 1.27-5.59; p = 0.009), as well as for adults with posthemorrhagic hydrocephalus (sHR 2.75, 95% CI 1.21-6.26; p = 0.016). Age ≥ 65 years was found to be independently associated with reduced infection risk (sHR 0.26, 95% CI 0.10-0.69; p = 0.007). Antibiotic-impregnated catheter use was also associated with reduced infection risk (sHR 0.43, 95% CI 0.22-0.84; p = 0.014). Independent risk factors predisposing to mechanical failure were age < 1 month (sHR 1.51, 95% CI 1.03-2.21; p = 0.032) and 1 month to < 1 year (sHR 1.31, 95% CI 0.95-1.81; p = 0.046). Age ≥ 65 years was demonstrated to be the only independent protective factor against mechanical failure risk (sHR 0.64, 95% CI 0.40-0.94; p = 0.024).

CONCLUSIONS

Age is the predominant risk for VPS revision for infection and/or mechanical failure, with neonates and infants being the most vulnerable.

Predicting Shunt Dependency from the Effect of Cerebrospinal Fluid Drainage on Ventricular Size

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).

The MAI score: A novel score to early predict shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage after surgery

OBJECTIVE

As a chronic complication of aneurysmal subarachnoid hemorrhage(aSAH), Shunt dependent hydrocephalus (SDHC) often leads to severe neurological deficits. At present, risk factors of SDHC after aSAH are being refined. So this study aims to investigate independent risk factors and develop a novel score to identify early the patients who require a permanent shunt.

METHOD

Five hundred twenty-four patients treated in the first affiliated hospital of Harbin medical university from March 2019 to March 2021 were analyzed. We collected clinical and radiographic data of patients within 72 h after the ictus. The relevant factors were firstly analyzed by univariate analysis, and the significant factors (p < 0.05) were included in the multivariate logistic regression analysis to obtain the independent risk factors with statistical differences. The MAI score was established based on the contribution of different independent risk factors to the outcome. the new score was validated in another cohort (97 patients with aSAH from April and June 2021).

RESULT

We enrolled 524 aneurysm patients and 41(7.82%) patients who underwent ventriculoperitoneal shunt (VPS) after aneurysm treatment. Based on univariate and multivariate analysis, Acute Hydrocephalus (OR 6.498,:95% confidence interval (CI) 1.98-21.33, p = 0.002), Intraventricular hemorrhage (OR 3.55,:95%CI 1.189-10.599, p = 0.023) and Modified Fisher score ≥ 3 (OR 5.846, 95%CI 2.649-12.900, p = 0.001) were independent risk factors. The novel score was assigned according to the contribution of different independent risk factors to the results. The MAI score: Modified Fisher grade ≥ 3 (1 point), Acute Hydrocephalus (1 point), Intraventricular hemorrhage (1 point). In the receiver operating characteristic curve analysis, the area under the curve (AUC) for the MAI score is 0.773 (p < 0.0001, 95%CI 0.686-0.861). Patients scoring 2-3 MAI points showed a 10-fold higher risk for shunt dependency than patients scoring 0-1 MAI points (p < 0.001). We performed internal validation of the MAI scoring system. The scoring system reliably predicted SDHC after aSAH. The AUC of the internal validation was 0.950 (p ＝ 0.002, 95%CI 0.863-1.000).

CONCLUSION

We develop a novel score based on univariate and multivariate analysis. The effectiveness of the MAI score has been confirmed in this study, which can more accurately predict SDHC after aASH and can be widely used in clinical practice. Prospective studies are needed for validation in the future.

Monocyte Count on Admission Is Predictive of Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage

The authors sought to evaluate whether immunologic counts on admission were associated with shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage. A retrospective analysis of 143 consecutive patients with aneurysmal subarachnoid hemorrhage over a 9-year period was performed. A stepwise algorithm was followed for external ventricular drain weaning and determining the necessity of shunt placement. Data were compared between patients with and without shunt-dependent hydrocephalus. Overall, 11.19% of the cohort developed shunt-dependent hydrocephalus. On multivariate logistic regression analysis, acute hydrocephalus (OR: 61.027, 95% CI: 3.890–957.327; p = 0.003) and monocyte count on admission (OR: 3.362, 95% CI: 1.024–11.037; p = 0.046) were found to be independent predictors for shunt dependence. Receiver operating characteristic curve analysis for the prediction of shunt-dependent hydrocephalus confirmed that monocyte count exhibited an acceptable area under the curve (AUC = 0.737, 95% CI: 0.601–0.872; p < 0.001). The best predictive cutoff value to discriminate between successful external ventricular drain weaning and shunt-dependent hydrocephalus was identified as a monocyte count ≥0.80 × 10³/uL at initial presentation. These preliminary data demonstrate that a monocyte count ≥0.80 × 10³/uL at admission predicts shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage; however, further large-scale prospective trials and validation are necessary to confirm these findings.

Assessment of Sustained Systemic Inflammatory Response Syndrome and CSF Markers as Predictive Values Associated with Shunt-Dependent Hydrocephalus after Aneurysmal Subarachnoid Hemorrhage

Aim of the study: This study was conducted to detect incidence and risk factors of shunt-dependent hydrocephalus, including Systemic Inflammatory Response Syndrome. Patients and methods: After obtaining ethical approval from the research ethics committee of Cairo University, this study was conducted in two phases, phase I in the form of follow up study to detect the incidence of shunt dependent hydrocephalus in patients with ruptured subarachnoid aneurysm then phase II in the form of comparative one to detect the risk factors of acquisition of shunt dependent hydrocephalus and detect the predictive role of SIRS in SDH. The study included 90 patients with ruptured subarachnoid aneurysms followed up in the department of neurosurgery of Cairo university hospital from April 2018 to April 2020. Results: The incidence of shunt-dependent hydrocephalus was 28% among the studied patients with significant association with high-grade SIRS, Fisher score, Hunt and Hess score, and leukocytosis. The CSF white blood cells and protein were significantly higher in the hydrocephalus group. Also, there was significant hypernatremia among the hydrocephalic group. Conclusion: Despite the study's analytical design, we observed a link between high fisher, SIRS, hypernatremia, and shunt-dependent hydrocephalus in aneurysmal SAH patients. Serum sodium, CSF WBCs, and protein may all be used to predict HC.

Predicting Ventriculoperitoneal Shunt Dependence in High Grade Aneurysmal Subarachnoid Hemorrhage

INTRODUCTION

Aneurysmal subarachnoid hemorrhage (aSAH) commonly presents with hydrocephalus due to obstruction of cerebrospinal fluid (CSF) passage across the ventricular system in the brain. Placement of an external ventricular device (EVD) and in some cases ventriculoperitoneal shunt (VPS) are often necessary for patients requiring prolonged CSF diversion. The study aimed at evaluating critical factors that play a role in determining the need for extended extraventricular drainage.

METHODS

We performed a retrospective observational cohort study of two groups of patients with radiological imaging confirmed high grade aSAH (Hunt & Hess grades 3-5) who required VPS placement, shunt-dependent group, and who did not require long term CSF diversion, non-shunt-dependent group. We collected and analyzed data regarding the daily CSF output for 10 days following EVD placement, daily EVD height, intracranial pressure (ICP) and cerebral perfusion pressure (CPP), indicators of hydrocephalus, and CSF characteristics.

RESULTS

The cohort, comprising of 8 patients in the shunt-dependent group and 32 patients in the non-shunt-dependent group, displayed median daily CSF output of 275.1 mL/day and 193.4 mL/day, respectively (P = .0005). ROC curve for CSF drainage for the two groups showed an area under the curve (AUC) of 0.71 with a 95% confidence interval (CI) 0.65 to 0.77. Qualitative analysis of CSF characteristics revealed that the shunt-dependent group had more proteinaceous, darker red color, and greater proportion of red blood cells (RBCs) although not statistically significant.

CONCLUSIONS

Determinants of prolonged CSF drainage requirements in patients with high grade aSAH are not fully elucidated to this date and there is no standardized protocol for CSF diversion. Our study revealed potential markers that can be used in the assessment for the need for long term CSF diversion. Our limited sample size necessitates further research to establish clear correlations and cutoffs of these parameters in predicting long term CSF diversion requirements.

Cerebrospinal fluid predictors of shunt-dependent hydrocephalus after hemorrhagic stroke: a systematic review and meta-analysis

Hydrocephalus is a common complication of hemorrhagic stroke and has been reported to contribute to poor neurological outcomes. Herein, we aimed to investigate the validity of cerebrospinal fluid (CSF) data in predicting shunt-dependent hydrocephalus (SDHC) in patients with hemorrhagic stroke. PubMed, CENTRAL, and Embase databases were searched for relevant studies published through July 31, 2021. The 16 studies with 1505 patient included those in which CSF data predicted risk for SDHC and reports on CSF parameters in patients in whom SDHC or hydrocephalus that was not shunt-dependent developed following hemorrhagic stroke. We appraised the study quality using Newcastle-Ottawa Scale and conducted a meta-analysis of the pooled estimates of the CSF predictors. The meta-analysis revealed three significant CSF predictors for shunt dependency, i.e., higher protein levels (mean difference [MD] = 32.09 mg/dL, 95% confidence interval [CI] = 25.48-38.70, I² = 0%), higher levels of transforming growth factor β1 (TGF-β1; MD = 0.52 ng/mL, 95% CI = 0.42-0.62, I² = 0%), and higher ferritin levels (MD = 108.87 µg/dL, 95% CI = 56.68-161.16, I² = 36%). The red blood cell count, lactate level, and glucose level in CSF were not significant in predicting SDHC in patients with hemorrhagic stroke. Therefore, higher protein, TGF-β1, and ferritin levels in CSF are significant predictors for SDHC in patients with hemorrhagic stroke. Measuring these CSF parameters would help in the early recognition of SDHC risk in clinical care.

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.

Quantitative Modeling of External Ventricular Drain Output to Predict Shunt Dependency in Aneurysmal Subarachnoid Hemorrhage: Cohort Study

BACKGROUND

Acute hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH); however, attempts to predict shunt-dependent chronic hydrocephalus using clinical parameters have been equivocal.

METHODS

Cohort study of aSAH is treated with external ventricular drainage (EVD) placement at our institution, 2001-2016, via logistic regression. EVD-related parameters included mean/total EVD output (days 0-2), EVD days, EVD days ≤ 5 mmHg, and wean/clamp fails. aSAH outcomes assessed included ventriculoperitoneal shunt (VPS) placement, delayed cerebral ischemia (DCI), radiographic infarction (RI), symptomatic vasospasm (SV), age, and aSAH grades.

RESULTS

Two hundred and ten aSAH patients underwent EVD treatment for a median 12 days (range 1-54); 85 required VPS (40%). On univariate analysis, EVD output, total EVD days, EVD days ≤ 5 mmHg, and wean/clamp trial failures were significantly associated with VPS placement (p < 0.01 for all parameters). No EVD output parameter demonstrated a significant association with DCI, RI, or SV. On multivariate analysis, EVD output was a significant predictor of VPS placement, after adjusting for age and clinical and radiological grades; the optimal threshold for predicting VPS placement was mean daily output > 204 ml on days 0-2 (OR 2.59, 95% CI 1.31-5.07). Multiple wean failures were associated with unfavorable functional outcome, after adjusting for age, grade, and VPS placement (OR 1.65, 95% CI 1.10-2.47). We developed a score incorporating age, grade and EVD parameters (MAGE) for predicting VPS placement after aSAH.

CONCLUSIONS

EVD output parameters and wean/clamp trial failures predicted shunt dependence in an age- and grade-adjusted multivariable model. Early VPS placement may be warranted in patients with MAGE score ≥ 4, particularly following 2 failed wean trials.

Transient acute hydrocephalus after aneurysmal subarachnoid hemorrhage and aneurysm embolization: a single-center experience

PURPOSE

Acute hydrocephalus is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). It can be self-limiting or require cerebrospinal fluid diversion. We aimed to determine the transient acute hydrocephalus (TAH) rate in patients with aSAH treated endovascularly and evaluate its predictive factors.

METHODS

A retrospective review of 357 patients with aSAH who underwent endovascular treatment from March 2013 to December 2019 was performed. Clinical and radiographic data were analyzed and risk factors with potential significance for acute hydrocephalus were identified. We constructed a new risk score, the Drainage Or Transiency of Acute Hydrocephalus after Aneurysmal SAH (DOTAHAS) score, that may differentiate patients who would experience TAH from those needing surgical interventions.

RESULTS

Acute hydrocephalus occurred in 129 patients (36%), out of whom in 66 patients (51%) it was self-limiting while 63 patients (49%) required external ventricular drainage placement. As independent risk factors for acute hydrocephalus, we identified older age, poor initial clinical condition, aSAH from posterior circulation, and the extent of cisternal and intraventricular hemorrhage. The following three factors were shown to predict acute hydrocephalus transiency and therefore included in the DOTAHAS score, ranging from 0 to 7 points: Hunt and Hess grade ≥ 3 (1 point), modified Fisher grade 4 (2 points), and Ventricular Hijdra Sum Score (vHSS) ≥ 6 (4 points). Patients scoring ≥ 3 points had significantly higher risk for EVD (P < 0.0001) than other patients.

CONCLUSION

The newly developed DOTAHAS score can be useful in identifying patients with transient acute hydrocephalus. Further score evaluation is needed.

The Pathogenesis of Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage

Hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) and reportedly contributes to poor neurological outcomes. In this review, we summarize the molecular and cellular mechanisms involved in the pathogenesis of hydrocephalus following aSAH and summarize its treatment strategies. Various mechanisms have been implicated for the development of chronic hydrocephalus following aSAH, including alterations in cerebral spinal fluid (CSF) dynamics, obstruction of the arachnoid granulations by blood products, and adhesions within the ventricular system. Regarding molecular mechanisms that cause chronic hydrocephalus following aSAH, we carried out an extensive review of animal studies and clinical trials about the transforming growth factor-β/SMAD signaling pathway, upregulation of tenascin-C, inflammation-dependent hypersecretion of CSF, systemic inflammatory response syndrome, and immune dysregulation. To identify the ideal treatment strategy, we discuss the predictive factors of shunt-dependent hydrocephalus between surgical clipping and endovascular coiling groups. The efficacy and safety of other surgical interventions including the endoscopic removal of an intraventricular hemorrhage, placement of an external ventricular drain, the use of intraventricular or cisternal fibrinolysis, and an endoscopic third ventriculostomy on shunt dependency following aSAH were also assessed. However, the optimal treatment is still controversial, and it necessitates further investigations. A better understanding of the pathogenesis of acute and chronic hydrocephalus following aSAH would facilitate the development of treatments and improve the outcome.

Validation and Optimization of Barrow Neurological Institute Score in Prediction of Adverse Events and Functional Outcome After Subarachnoid Hemorrhage-Creation of the HATCH (Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus) Score

BACKGROUND

The Barrow Neurological Institute (BNI) score, measuring maximal thickness of aneurysmal subarachnoid hemorrhage (aSAH), has previously shown to predict symptomatic cerebral vasospasms (CVSs), delayed cerebral ischemia (DCI), and functional outcome.

OBJECTIVE

To validate the BNI score for prediction of above-mentioned variables and cerebral infarct and evaluate its improvement by integrating further variables which are available within the first 24 h after hemorrhage.

METHODS

We included patients from a single center. The BNI score for prediction of CVS, DCI, infarct, and functional outcome was validated in our cohort using measurements of calibration and discrimination (area under the curve [AUC]). We improved it by adding additional variables, creating a novel risk score (measure by the dichotomized Glasgow Outcome Scale) and validated it in a small independent cohort.

RESULTS

Of 646 patients, 41.5% developed symptomatic CVS, 22.9% DCI, 23.5% cerebral infarct, and 29% had an unfavorable outcome. The BNI score was associated with all outcome measurements. We improved functional outcome prediction accuracy by including age, BNI score, World Federation of Neurologic Surgeons, rebleeding, clipping, and hydrocephalus (AUC 0.84, 95% CI 0.8-0.87). Based on this model we created a risk score (HATCH-Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus), ranging 0 to 13 points. We validated it in a small independent cohort. The validated score demonstrated very good discriminative ability (AUC 0.84 [95% CI 0.72-0.96]).

CONCLUSION

We developed the HATCH score, which is a moderate predictor of DCI, but excellent predictor of functional outcome at 1 yr after aSAH.

Validation of shunt dependency prediction scores after aneurysmal spontaneous subarachnoid hemorrhage

BACKGROUND

Currently available scores for predicting shunt dependency after aneurysmal spontaneous subarachnoid hemorrhage (aSAH) are limited and not widely accepted. The key purpose of this study was to validate a recently created score for shunt dependency in aSAH (SDASH) in an independent population of aSAH patients. We compared this new SDASH score based on a combination of the Hunt and Hess grade, Barrow Neurological Institute (BNI) score, and the presence or not of acute hydrocephalus with other published predictive scores.

METHODS

The SDASH score, Hijdra score, BNI grading system, chronic hydrocephalus ensuing from SAH score (CHESS), Graeb score, and modified Graeb score (mGS) were calculated for a cohort of aSAH patients. Logistic regression analysis was used to determine the reliability of the SDASH score, and the area under the curve (AUC) of the receiver operating characteristics (ROC) curve was used to assess the discriminative ability of the model.

RESULTS

In 214 patients with aSAH, 40 (18.7%) developed shunt-dependent hydrocephalus (SDHC). The AUC for the SDASH score was 0.816. The SDASH score reliably predicted SDHC in aSAH (odds ratio: 2.93, 95% CI: 1.99-4.31; p < 0.001) with no statistically significant differences being found between the SDASH score and the CHESS score (AUC: 0.816), radiological-based Graeb score (AUC: 0.742), or modified Graeb score (AUC: 0.741). However, the Hijdra score (AUC: 0.673) and BNI grading system (AUC: 0.616) showed lower predictive values than the SDASH score.

CONCLUSIONS

Our findings support the ability of the SDASH score to predict shunt dependency after SAH in a population independent to that used to develop the score. The SDASH score may aid in the early management of hydrocephalus in aSAH, and it does not differ greatly from other predictive scores.

Beware of Nihilism: Favorable Outcome despite Poor Admission Status in Posterior Circulation Aneurysms after Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

 As shown in a previous study, aneurysm location seems to influence prognosis in patients with subarachnoid hemorrhage (SAH). We compared patients with ruptured aneurysms of anterior and posterior circulation, undergoing coil embolization, concerning differences in outcome and prognostic factors.

METHODS

 Patients with SAH were entered into a prospectively collected database. We retrospectively identified 307 patients with aneurysms of the anterior circulation (anterior cerebral artery, carotid bifurcation, and middle cerebral artery) and 244 patients with aneurysms of the posterior circulation (aneurysms of the basilar artery, posterior inferior cerebellar artery, posterior communicating artery and posterior cerebral artery). All patients underwent coil embolization. The outcome was assessed using the modified Rankin Scale (mRS; favorable [mRS 0-2] vs. unfavorable [mRS 3-6]) 6 months after SAH.

RESULTS

 In interventionally treated aneurysms of the anterior and posterior circulation, statistically significant risk factors for poor outcome were worse admission status and severe cerebral vasospasm. If compared with patients with ruptured aneurysms of the anterior circulation, patients with aneurysms of the posterior circulation had a significantly poorer admission status, and suffered significantly more often from an early hydrocephalus. Nonetheless, there were no differences in outcome or mortality rate between the two patient groups.

CONCLUSION

 Patients with a ruptured aneurysm of the posterior circulation suffer more often from an early hydrocephalus and have a significantly worse admission status, possibly related to the untreated hydrocephalus. Nonetheless, the outcome and the mortality rate were comparable between ruptured anterior and posterior circulation aneurysms, treated by coil embolisation. Therefore, despite the poorer admission status of patients with ruptured posterior circulation aneurysms, treatment of these patients should be considered.

Prognostic Nomogram of Predictors for Shunt-Dependent Hydrocephalus in Patients with Aneurysmal Subarachnoid Hemorrhage Receiving External Ventricular Drain Insertion: A Single-Center Experience and Narrative Review

OBJECTIVE

This study aimed to create a prediction model with a radiographic score, serum, and cerebrospinal fluid (CSF) values for the occurrence of shunt-dependent hydrocephalus (SDHC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) and to review and analyze literature related to the prediction of the development of SDHC.

METHODS

Sixty-three patients with aSAH who underwent external ventricular drain insertion were included and separated into 2 subgroups: non-SDHC and SDHC. Patient characteristics, computed tomography scoring system, and serum and CSF parameters were collected. Multivariate logistic regression was conducted to illustrate a nomogram for determining the predictors of SDHC. Furthermore, we sorted and summarized previous meta-analyses for predictors of SDHC.

RESULTS

The SDHC group had 42 cases. Stepwise logistic regression analysis revealed 3 independent predictive factors associated with a higher modified Graeb (mGraeb) score, lower level of estimated glomerular filtration rate group, and lower level of CSF glucose. The nomogram, based on these 3 factors, was presented with significant predictive performance (area under curve = 0.895) for SDHC development, compared with other scoring systems (AUC = 0.764-0.885). In addition, a forest plot was generated to present the 12 statistically significant predictors and odds ratio for correlations with the development of SDHC.

CONCLUSIONS

First, the development of a nomogram with combined significant factors had a good performance in estimating the risk of SDHC in primary patient evaluation and assisted in clinical decision making. Second, a narrative review, presented with a forest plot, provided the current published data on predicting SDHC.

Volumetric quantification of aneurysmal subarachnoid hemorrhage independently predicts hydrocephalus and seizures

OBJECTIVE

Hydrocephalus and seizures greatly impact outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH); however, reliable tools to predict these outcomes are lacking. The authors used a volumetric quantitative analysis tool to evaluate the association of total aSAH volume with the outcomes of shunt-dependent hydrocephalus and seizures.

METHODS

Total hemorrhage volume following aneurysm rupture was retrospectively analyzed on presentation CT imaging using a custom semiautomated computer program developed in MATLAB that employs intensity-based k-means clustering to automatically separate blood voxels from other tissues. Volume data were added to a prospectively maintained aSAH database. The association of hemorrhage volume with shunted hydrocephalus and seizures was evaluated through logistic regression analysis and the diagnostic accuracy through analysis of the area under the receiver operating characteristic curve (AUC).

RESULTS

The study population comprised 288 consecutive patients with aSAH. The mean total hemorrhage volume was 74.9 ml. Thirty-eight patients (13.2%) developed seizures. The mean hemorrhage volume in patients who developed seizures was significantly higher than that in patients with no seizures (mean difference 17.3 ml, p = 0.01). In multivariate analysis, larger hemorrhage volume on initial CT scan and hemorrhage volume > 50 ml (OR 2.81, p = 0.047, 95% CI 1.03-7.80) were predictive of seizures. Forty-eight patients (17%) developed shunt-dependent hydrocephalus. The mean hemorrhage volume in patients who developed shunt-dependent hydrocephalus was significantly higher than that in patients who did not (mean difference 17.2 ml, p = 0.006). Larger hemorrhage volume and hemorrhage volume > 50 ml (OR 2.45, p = 0.03, 95% CI 1.08-5.54) were predictive of shunt-dependent hydrocephalus. Hemorrhage volume had adequate discrimination for the development of seizures (AUC 0.635) and shunted hydrocephalus (AUC 0.629).

CONCLUSIONS

Hemorrhage volume is an independent predictor of seizures and shunt-dependent hydrocephalus in patients with aSAH. Further evaluation of aSAH quantitative volumetric analysis may complement existing scales used in clinical practice and assist in patient prognostication and management.

Development of machine learning models to prognosticate chronic shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

BACKGROUND

Shunt-dependent hydrocephalus significantly complicates subarachnoid hemorrhage (SAH), and reliable prognosis methods have been sought in recent years to reduce morbidity and costs associated with delayed treatment or neglected onset. Machine learning (ML) defines modern data analysis techniques allowing accurate subject-based risk stratifications. We aimed at developing and testing different ML models to predict shunt-dependent hydrocephalus after aneurysmal SAH.

METHODS

We consulted electronic records of patients with aneurysmal SAH treated at our institution between January 2013 and March 2019. We selected variables for the models according to the results of the previous works on this topic. We trained and tested four ML algorithms on three datasets: one containing binary variables, one considering variables associated with shunt-dependency after an explorative analysis, and one including all variables. For each model, we calculated AUROC, specificity, sensitivity, accuracy, PPV, and also, on the validation set, the NPV and the Matthews correlation coefficient (ϕ).

RESULTS

Three hundred eighty-six patients were included. Fifty patients (12.9%) developed shunt-dependency after a mean follow-up of 19.7 (± 12.6) months. Complete information was retrieved for 32 variables, used to train the models. The best models were selected based on the performances on the validation set and were achieved with a distributed random forest model considering 21 variables, with a ϕ = 0.59, AUC = 0.88; sensitivity and specificity of 0.73 (C.I.: 0.39-0.94) and 0.92 (C.I.: 0.84-0.97), respectively; PPV = 0.59 (0.38-0.77); and NPV = 0.96 (0.90-0.98). Accuracy was 0.90 (0.82-0.95).

CONCLUSIONS

Machine learning prognostic models allow accurate predictions with a large number of variables and a more subject-oriented prognosis. We identified a single best distributed random forest model, with an excellent prognostic capacity (ϕ = 0.58), which could be especially helpful in identifying low-risk patients for shunt-dependency.

External Validation of Scoring Models to Predict Shunt Insertion after Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

The current study is an external validation of 4 scoring models proposed in the literature for predicting ventriculoperitoneal shunt insertion after aneurysmal subarachnoid hemorrhage (aSAH) using retrospective patient data from Sheffield Teaching Hospital (STH).

METHODS

Data were collected on various demographics, and patients were individually scored using the 4 scoring models. Models were compared with each other using receiver-operator characteristic curves. The best model had the highest area under the curve.

RESULTS

A total of 301 aSAH patients were referred to the neurosurgery department in STH between 1 January 2014 and 31 December 2017. Scoring model 4 also had the largest area under the curve of 0.853 (P < 0.001), and scoring model 3 had the lowest area under the curve of 0.654 (P = 0.036).

CONCLUSIONS

Scoring model 4 was found to be the best scoring model out of the 4 scoring models externally validated to predict shunt dependency after an aSAH in STH patients. Scoring model 4 is less applicable in modern practice due to a higher proportion of coiling and use of the Hunt and Hess scale grade. A new scoring model is needed to predict shunt insertion in modern practice.

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?

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 15^th 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.

Risk factors of chronic shunt dependent hydrocephalus following aneurysmal subarachnoid haemorrhage

BACKGROUND

Acute and delayed hydrocephalus are common sequelae following aneurysmal subarachnoid haemorrhage.

AIMS

To identify factors that may influence cerebrospinal fluid diversion either temporarily or permanently in order to guide clinical judgement.

METHODS

Patients treated in our unit between 01/2014 until 12/2017 with aneurysmal SAH were retrospectively analysed to identify significant factors predisposing to CSF diversion.

RESULTS

242 patients were analysed (180F, 62M) with mean age 56 years over 36 months. 31 % patients had EVD inserted and 12 % received shunts. 19 patients had EVDs prior to their shunt. 11.8 % patients received serial lumbar puncture. Higher WFNS (P<0.05) and Fisher grade (P<0.05) were associated with increased rates of EVD insertion and shunting. Higher WFNS and Fisher scores were observed within posterior circulation aneurysms. Lower GCS and higher WFNS had significant correlation towards early shunting (P<0.05). EVD infection predisposes to higher rates of shunt conversion (P<0.05). Factors predisposing to post aneurysmal subarachnoid haemorrhage hydrocephalus and CSF drainage included aneurysm location in posterior circulation (P<0.05), increasing relative need of EVD insertion by 185 % and shunting by 240 %. Basilar tip aneurysms had even higher incidence of shunting (42 % of all posterior circulation aneurysms). Posterior circulation aneurysms had significantly higher risk of requiring EVD insertion, with 48 % of aneurysms in the posterior circulation compared to 25 % in the anterior circulation requiring EVDs (P<0.05). Incidence of posterior circulation aneurysms increases with age (>50(P<0.05)).

CONCLUSION

Our study demonstrated factors that may predict chronic post aneurysmal subarachnoid haemorrhage hydrocephalus (PASHH) in patients that will ultimately need timely intervention.

Review of CHESS Score in SAH Patients in Local Malaysian Population

Background  Chronic hydrocephalus caused by subarachnoid hemorrhage is a reversible and treatable condition. To date, existing clinical scores for predicting the development of posthemorrhagic hydrocephalus are few and difficult to apply in the clinical settings. Chronic hydrocephalus ensuing subarachnoid hemorrhage score (CHESS) was first published in 2016. Although it showed promising results, no external validation has been done outside Europe. We designed this study to validate the accuracy and reliability of CHESS score and to also look for other factors that may cause posthemorrhagic shunt dependent hydrocephalus.

Objectives  This study is to determine the reliability of CHESS score and to look for other parameters with predictive value in patients with shunt-dependent posthemorrhagic hydrocephalus.

Results  Thirty-one percent of the studied population developed shunt-dependent hydrocephalus ( n = 41). CHESS score showed an odds ratio (OR) of 2.184 with p -value < 0.001 and two other risk factors were found to be strongly related to develop shunt-dependent hydrocephalus, that is, early infarct in computed tomography (CT) brain (OR = 0.182; p -value = 0.004) and Fisher’s grade > 3 (OR = 1.986; p -value = 0.047). The sensitivity and specificity for CHESS score in this cohort population showed a sensitivity of 73.2% and specificity of 93.3%. The area under the curve for CHESS score in our cohort is 0.922.

Conclusion  CHESS score is a reliable tool in early prediction of shunt-dependent hydrocephalus post subarachnoid hemorrhage.

A Cohort Comparison Analysis of Fixed Pressure Ventriculoperitoneal Shunt Valves With Programmable Valves for Hydrocephalus Following Nontraumatic Subarachnoid Hemorrhage

BACKGROUND

Hydrocephalus after nontraumatic subarachnoid hemorrhage (SAH) is a common sequela that may require the placement of ventriculoperitoneal shunts (VPS). Adjustable-pressure valves (APVs) are being widely used in this situation though more expensive than differential-pressure valves (DPVs).

OBJECTIVE

To compare outcomes between APV and DPV in SAH-induced hydrocephalus.

METHODS

We performed a retrospective chart review of patients with nontraumatic SAH who underwent VPS placement for the treatment of hydrocephalus after SAH, between July 2007 and December 2016. Patients were classified according to the type of valve (APV vs DPV). We evaluated factors that could predict the type of valve used, outcomes in VPS revision/replacement rate, and complications.

RESULTS

A total of 66 patients underwent VPS placement who were equally distributed into the 2 groups of valves. VPS failure with the need for revision/replacement occurred in 13 (19.7%) cases. Ten (30.3%) patients with DPV had a VPS failure, while 3 (9.1%) patients with an APV had a similar failure with the need for revision/replacement (P = .03). VPS placement before discharge during the initial hospitalization (P = .02) was statistically significant associated with the use of a DPV, while the reason of external ventricular drain (EVD) failure (P = .03) was associated with the use of an APV.

CONCLUSION

APVs had a lower rate of surgical revisions compared to DPVs. Early placement of VPS was associated with the use of a DPV. The need for EVD replacement due to EVD infection or malfunction was associated with higher rates of APV use.

Intrathecal Fibrinolysis for Aneurysmal Subarachnoid Hemorrhage: Evidence From Randomized Controlled Trials and Cohort Studies

Background: The role of intrathecal fibrinolysis for the treatment of patients with aneurysmal subarachnoid hemorrhage (aSAH) has been widely investigated; however, the results have been contradictory. In our study, we conducted a meta-analysis to evaluate the safety and efficacy of intrathecal (intracisternal or intraventricular) fibrinolysis for aSAH.

Methods: PubMed, Web of Science, Embase, Medline, and the Cochrane library databases were searched up to February 1, 2019. The outcomes analyzed were neurologic recovery, delayed ischemic neurologic deficit (DIND), mortality, and the incidence of chronic hydrocephalus and hemorrhage.

Results: A total of 21 studies comprising 1,373 patients were analyzed, including nine randomized controlled trials (RCTs) and 12 non-RCTs. The results showed that intracisternal fibrinolysis significantly decreased poor neurologic outcomes (RR = 0.62, 95% CI = 0.50–0.76, P < 0.001) and reduced the incidence of DIND (RR = 0.52, 95% CI = 0.41–0.65, P <0.001), chronic hydrocephalus (RR = 0.59, 95% CI = 0.42–0.82, P = 0.002) and mortality (RR = 0.58, 95% CI = 0.37, 0.93, P = 0.02). There was no significant difference in the occurrence of hemorrhage. Moreover, the results of the Egger test and Begg's funnel plot showed no evidence of publication bias.

Conclusions: Current evidence suggests that intracisternal fibrinolysis has beneficial effects on the clinical outcomes of patients with aSAH. However, further well-designed randomized trials are needed to confirm the efficacy and safety of intracisternal fibrinolysis for the treatment of aSAH.

Lower Iron Levels Predict Acute Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

We tested the hypothesis that low serum iron levels are associated with acute hydrocephalus following aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

Patients presenting with ruptured intracranial aneurysms were enrolled in the prospective observational study. Age, sex, history of diabetes, hypertension and hyperlipidemia, symptom onset, Fisher grade, Hunt-Hess grade, aneurysm location, hemoglobin, and serum iron were collected. Acute hydrocephalus was determined within 72 hours after subarachnoid hemorrhage. A propensity-score matching analysis was performed to correct imbalances in patient characteristics between hydrocephalus and non-hydrocephalus groups.

RESULTS

A total of 535 patients were included. Incidence of acute hydrocephalus was 20.0%. In multivariate logistic regression analysis, lower serum iron was considered as a risk factor of acute hydrocephalus, as well as delayed ischemic neurologic deficit and lower hemoglobin (P = 0.000). After propensity-score matching, lower serum iron was considered as an independent risk factor for acute hydrocephalus, whereas hemoglobin and delayed ischemic neurologic deficit were not. The matched hydrocephalus group had lower serum iron comparing with the matched non-hydrocephalus group (10.26 ± 5.33 mmol/L vs. 13.44 ± 5.18 mmol/L; P = 0.000). The optimal cut-off value for serum iron levels as a predictor for acute hydrocephalus in patients with aSAH was determined as 13.1 mmol/L in the receiver operating characteristic curve. Furthermore, lower serum iron levels (odds ratio 0.305; 95% confidence interval, 0.178-0.524; P = 0.000) and acute hydrocephalus (odds ratio 0.372; 95% confidence interval, 0.202-0.684; P = 0.001) were predictors of poor outcome, as well as higher Hunt-Hess grade and Fisher grade.

CONCLUSIONS

Lower serum iron levels after aSAH was a predictor of acute hydrocephalus and unfavorable outcome.

Risk Factors and Preoperative Risk Scoring System for Shunt-Dependent Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage

Objective

Shunt-dependent hydrocephalus (SdHCP) is a well-known complication of aneurysmal subarachnoid hemorrhage (SAH). The risk factors for SdHCP have been widely investigated, but few risk scoring systems have been established to predict SdHCP. This study was performed to investigate the risk factors for SdHCP and devise a risk scoring system for use before aneurysm obliteration.

Methods

We reviewed the data of 301 consecutive patients who underwent aneurysm obliteration following SAH from September 2007 to December 2016. The exclusion criteria for this study were previous aneurysm obliteration, previous major cerebral infarction, the presence of a cavum septum pellucidum, a midline shift of >10 mm on initial computed tomography (CT), and in-hospital mortality. We finally recruited 254 patients and analyzed the following data according to the presence or absence of SdHCP : age, sex, history of hypertension and diabetes mellitus, Hunt-Hess grade, Fisher grade, aneurysm size and location, type of treatment, bicaudate index on initial CT, intraventricular hemorrhage, cerebrospinal fluid drainage, vasospasm, and modified Rankin scale score at discharge.

Results

In the multivariate analysis, acute HCP (bicaudate index of ≥0.2) (odds ratio [OR], 6.749; 95% confidence interval [CI], 2.843–16.021; p=0.000), Fisher grade of 4 (OR, 4.108; 95% CI, 1.044–16.169; p=0.043), and an age of ≥50 years (OR, 3.938; 95% CI, 1.375–11.275; p=0.011) were significantly associated with the occurrence of SdHCP. The risk scoring system using above parameters of acute HCP, Fisher grade, and age (AFA score) assigned 1 point to each (total score of 0–3 points). SdHCP occurred in 4.3% of patients with a score of 0, 8.5% with a score of 1, 25.5% with a score of 2, and 61.7% with a score of 3 (p=0.000). In the receiver operating characteristic curve analysis, the area under the curve (AUC) for the risk scoring system was 0.820 (p=0.080; 95% CI, 0.750–0.890). In the internal validation of the risk scoring system, the score reliably predicted SdHCP (AUC, 0.895; p=0.000; 95% CI, 0.847–0.943).

Conclusion

Our results suggest that the herein-described AFA score is a useful tool for predicting SdHCP before aneurysm obliteration. Prospective validation is needed.

Healthcare Economics of Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage in the United States

Hydrocephalus is one of the most common sequelae after aneurysmal subarachnoid hemorrhage (aSAH), and it is a large contributor to the condition's high rates of readmission and mortality. Our objective was to quantify the healthcare resource utilization (HCRU) and health economic burden incurred by the US health system due to post-aSAH hydrocephalus. The Truven Health MarketScan^® Research database was used to retrospectively quantify the prevalence and HCRU associated with hydrocephalus in aSAH patients undergoing surgical clipping or endovascular coiling from 2008 to 2015. Multivariable longitudinal analysis was conducted to model the relationship between annual cost and hydrocephalus status. In total, 2374 patients were included; hydrocephalus was diagnosed in 959 (40.4%). Those with hydrocephalus had significantly longer initial lengths of stay (median 19.0 days vs. 12.0 days, p < .001) and higher 30-day readmission rates (20.5% vs. 10.4%, p < .001). With other covariates held fixed, in the first 90 days after aSAH diagnosis, the average cost multiplier relative to annual baseline for hydrocephalus patients was 24.60 (95% CI, 20.13 to 30.06; p < .001) whereas for non-hydrocephalus patients, it was 11.52 (95% CI, 9.89 to 13.41; p < .001). The 5-year cumulative median total cost for the hydrocephalus group was $230,282.38 (IQR, 166,023.65 to 318,962.35) versus $174,897.72 (IQR, 110,474.24 to 271,404.80) for those without hydrocephalus. We characterize one of the largest cohorts of post-aSAH hydrocephalus patients in the USA. Importantly, the substantial health economic impact and long-term morbidity and costs from this condition are quantified and reviewed.

Prognostic Model for Chronic Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Patients with aneurysmal subarachnoid hemorrhage (aSAH) are at risk of the development of chronic shunt-dependent hydrocephalus. However, identification of shunt-dependent patients remains challenging. We sought to develop a prognostic model to identify patients with aSAH at risk of chronic shunt-dependent hydrocephalus. In addition to the well-known prognostic variables, blood clearance in the cerebrospinal fluid (CSF) spaces was considered.

METHODS

We retrospectively analyzed the data from 227 patients treated at our institution from January 2012 to January 2016. The outcome was ventriculoperitoneal shunt placement within 30 days after aSAH. The candidate prognostic variables were patient age, World Federation of Neurological Surgeons grade and Fisher grade, external ventricular drainage, ventricular and intracerebral hemorrhage, and interval to blood clearance in the peripheral/basal CSF spaces. Adjustment for multiple testing was performed. Multivariable logistic regression analysis was used for model development. Bootstrapping was applied for internal validation. The model performance measures included indexes for explained variance (R²), calibration (graphic plot, Hosmer-Lemeshow test), and discrimination (c-statistic).

RESULTS

Of the 227 patients, 90 (39.6%) required a ventriculoperitoneal shunt. The constructed prognostic model combined external ventricular drainage placement, the presence of ventricular blood, and the duration of blood clearance in the basal cisterns. The model performance was promising, with an R² of 33% (20% after bootstrapping), the calibration plot was adequate, the Hosmer-Lemeshow test result was not significant, and the c-statistic was 0.85 (0.84 as assessed after bootstrapping) indicating a good discriminating prognostic model.

CONCLUSIONS

Our prognostic model could help identify patients requiring permanent CSF diversion after aSAH, although additional modification and external validation are needed. Interventions aimed at accelerating the clearance of blood in the basal cisterns might have the potential to prevent the development of chronic hydrocephalus after aSAH.

Role of Cerebrospinal Fluid Markers for Predicting Shunt-Dependent Hydrocephalus in Patients with Subarachnoid Hemorrhage and External Ventricular Drain Placement

OBJECTIVE

We sought to identify potential risk factors for the development of shunt-dependent chronic hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) and external ventricular drain (EVD) insertion. In particular, the role of inflammatory markers within the cerebrospinal fluid (CSF) was assessed.

METHODS

For this single-center analysis, data were generated from consecutive patients with SAH and the need for EVD implantation treated on our neurosurgical intensive care unit between 2013 and 2015. Parameters were patient characteristics (age, sex, comorbidity), severity of SAH (according to the World Federation of Neurological Society score), imaging findings (intraventricular hemorrhage, diameter of the third ventricle, location of the ruptured aneurysm), and acute course of disease (cerebral infarction, vasospasm). Moreover, the impact of EVD drainage volume and CSF markers (total protein [_CSFTP], red blood cell count [_CSFRBC], interleukin-6 [_CSFIL-6], and glucose [_CSFGlc]) was assessed. Statistics including receiver-operating-curve with corresponding area-under-the-curve (AUC) analysis were calculated using SPSS.

RESULTS

Overall, 63 patients (21 males, mean age 55.2 years) were included. Twenty-one patients (30%) developed a shunt-dependent hydrocephalus. Significant risk factors for shunt dependency were the World Federation of Neurological Society score, cerebral infarction, and diameter of the third ventricle (P < 0.05). Moreover, CSF markers associated with shunt-dependent hydrocephalus included increased levels of _CSFTP on days 5 (AUC = 0.72)/11 (AUC = 0.97)/14 (AUC = 0.98), _CSFIL-6 on day 14 (AUC = 0.81), and _CSFRBC on day 15 (AUC = 0.83). The EVD drainage volume was not prognostic.

CONCLUSIONS

The time course of selected inflammatory markers in CSF may support management considerations in the early phase after SAH and critical impairment of CSF circulation.

Predicting factors for shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Chronic hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) is a major complication that leads to a medical burden and poor clinical outcomes. The aim of this study was to evaluate the predictive factors of shunt-dependent hydrocephalus focusing on postoperative fever and infection.

METHOD

A total of 418 patients were included in this study and the patient demographic features, radiologic findings, days of fever burden, and infection were compared between the shunt (n = 72) and no shunt group (n = 346). Days of fever burden was defined as the total number of days with the highest body temperature ≥ 38.0 °C each day from day 1 to day 14. Pneumonia, urinary tract infection (UTI), meningitis, and bacteremia were recorded in all patients.

RESULTS

The independent predictive factors for shunt-dependent hydrocephalus were older age ≥ 65, microsurgical clipping, placement of extraventricular drainage (EVD), days of fever burden, and infection. The incidence of shunt dependency was 2.4% in the no fever burden patients (n = 123), 14.9% in the 1-3 days of fever burden patients (n = 161), 27.0% in the 4-6 days of fever burden patients (n = 74), and 41.7% in the ≥ 7 days of fever burden patients with statistical significance among groups (p < 0.001).

CONCLUSION

The rate of shunt dependency increased proportionally as the days of fever burden increased. Older age (≥ 65), microsurgical clipping, placement of EVD, days of fever burden, and infection were independent predictive factors for shunt dependency. Proper postoperative care for maintaining normal body temperature and preventing infectious disease can help reduce the rate of shunt dependency and improve clinical outcomes.

A sustained systemic inflammatory response syndrome is associated with shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

OBJECTIVE

The authors sought to evaluate whether a sustained systemic inflammatory response was associated with shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage.

METHODS

A retrospective analysis of 193 consecutive patients with aneurysmal subarachnoid hemorrhage was performed. Management of hydrocephalus followed a stepwise algorithm to determine the need for external CSF drainage and subsequent shunt placement. Systemic inflammatory response syndrome (SIRS) data were collected for all patients during the first 7 days of hospitalization. Patients who met the SIRS criteria every day for the first 7 days of hospitalization were considered as having a sustained SIRS. Univariate and multivariate regression analyses were used to determine predictors of shunt dependence.

RESULTS

Sixteen percent of patients required shunt placement. Sustained SIRS was observed in 35% of shunt-dependent patients compared to 14% in non-shunt-dependent patients (p = 0.004). On multivariate logistic regression, female sex (OR 0.35, 95% CI 0.142-0.885), moderate to severe vasospasm (OR 3.78, 95% CI 1.333-10.745), acute hydrocephalus (OR 21.39, 95% CI 2.260-202.417), and sustained SIRS (OR 2.94, 95% CI 1.125-7.689) were significantly associated with shunt dependence after aneurysmal subarachnoid hemorrhage. Receiver operating characteristic analysis revealed an area under the curve of 0.83 for the final regression model.

CONCLUSIONS

Sustained SIRS was a predictor of shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage even after adjustment for potential confounding variables in a multivariate logistic regression model.

A novel score to predict shunt dependency after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Feasible clinical scores for predicting shunt-dependent hydrocephalus (SDHC) after aneurysmal subarachnoid hemorrhage (aSAH) are scarce. The chronic hydrocephalus ensuing from SAH score (CHESS) was introduced in 2015 and has a high predictive value for SDHC. Although this score is easy to calculate, several early clinical and radiological factors are required. The authors designed the retrospective analysis described here for external CHESS validation and determination of predictive values for the radiographic Barrow Neurological Institute (BNI) scoring system and a new simplified combined scoring system.

METHODS

Consecutive data of 314 patients with aSAH were retrospectively analyzed with respect to CHESS parameters and BNI score. A new score, the shunt dependency in aSAH (SDASH) score, was calculated from independent risk factors identified with multivariate analysis.

RESULTS

Two hundred twenty-five patients survived the initial phase after the hemorrhage, and 27.1% of these patients developed SDHC. The SDASH score was developed from results of multivariate analysis, which revealed acute hydrocephalus (aHP), a BNI score of ≥ 3, and a Hunt and Hess (HH) grade of ≥ 4 to be independent risk factors for SDHC (ORs 5.709 [aHP], 6.804 [BNI], and 4.122 [HH]; p < 0.001). All 3 SDHC scores tested (CHESS, BNI, and SDASH) reliably predicted chronic hydrocephalus (ORs 1.533 [CHESS], 2.021 [BNI], and 2.496 [SDASH]; p ≤ 0.001). Areas under the receiver operating curve (AUROC) for CHESS and SDASH were comparable (0.769 vs 0.785, respectively; p = 0.447), but the CHESS and SDASH scores were superior to the BNI grading system for predicting SDHC (BNI AUROC 0.649; p = 0.014 and 0.001, respectively). In contrast to CHESS and BNI scores, an increase in the SDASH score coincided with a monotonous increase in the risk of developing SDHC.

CONCLUSIONS

The newly developed SDASH score is a reliable tool for predicting SDHC. It contains fewer factors and is more intuitive than existing scores that were shown to predict SDHC. A prospective score evaluation is needed.

Risk factors for shunt dependency in patients suffering from spontaneous, non-aneurysmal subarachnoid hemorrhage

Patients presenting with spontaneous, non-aneurysmal subarachnoid hemorrhage (SAH) achieve better outcomes compared to patients with aneurysmal SAH. Nevertheless, some patients develop shunt-dependent hydrocephalus during treatment course. We therefore analyzed our neurovascular database to identify factors determining shunt dependency after non-aneurysmal SAH. From 2006 to 2016, 131 patients suffering from spontaneous, non-aneurysmal SAH were admitted to our department. Patients were stratified according to the distribution of cisternal blood into patients with perimesencephalic SAH (pSAH) versus non-perimesencephalic SAH (npSAH). Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months and stratified into favorable (mRS 0-2) versus unfavorable (mRS 3-6). A multivariate analysis was performed to identify predictors of shunt dependency in patients suffering from non-aneurysmal SAH. Overall, 18 of 131 patients suffering from non-aneurysmal SAH developed shunt dependency (14%). In detail, patients with npSAH developed significantly more often shunt dependency during treatment course, when compared to patients with pSAH (p = 0.02). Furthermore, patients with acute hydrocephalus, presence of intraventricular hemorrhage, presence of clinical vasospasm, and anticoagulation medication prior SAH developed significantly more often shunt dependency, when compared to patients without (p < 0.0001). However, "acute hydrocephalus" was the only significant and independent predictor for shunt dependency in all patients with non-aneurysmal SAH in the multivariate analysis (p < 0.0001). The present study identified acute hydrocephalus with the necessity of CSF diversion as significant and independent risk factor for the development of shunt dependency during treatment course in patients suffering from non-aneurysmal SAH.

Gradual External Ventricular Drainage Weaning Reduces The Risk of Shunt Dependency After Aneurysmal Subarachnoid Hemorrhage: A Pooled Analysis

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 &lt; .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.

Intraventricular Hemorrhage Caused by Subarachnoid Hemorrhage: Does the Severity Matter?

OBJECTIVE

Aneurysm rupture might be accompanied by intraventricular hemorrhage (IVH), which is associated with poor outcome of subarachnoid hemorrhage (SAH). The aim of this study was to analyze risk factors and clinical impact of IVH severity.

METHODS

A total of 995 consecutive patients with SAH treated at our institution between January 2003 and June 2016 were eligible for this study. Clinical and radiologic findings were correlated with the presence and severity of IVH assessed with the original Graeb score.

RESULTS

A total of 487 patients with SAH (48.9%) presented with IVH (mean IVH severity, 5.48 points [±3.5]). IVH severity correlated with poorer initial clinical condition (World Federation of Neurosurgical Societies grade >3; P < 0.001), acute hydrocephalus (P = 0.001), and poor outcome at 6 months (modified Rankin Scale score >2; P < 0.001). The location of the ruptured aneurysm in the anterior cerebral artery independently predicted the occurrence (P = 0.007) and severity of IVH (P < 0.001). In turn, aneurysm size affected only the severity of IVH (P = 0.001) but not its occurrence (P = 0.153). Early complications of SAH occurring within 72 hours after the bleeding event (cerebral infarction [P = 0.043], early mortality [P = 0.001], and primary craniectomy [P = 0.043]) were independently associated with the severity of IVH.

CONCLUSIONS

Severity of aneurysmal IVH is a strong contributor to initial severity and early complications of SAH. Patients with larger aneurysms, especially located in the anterior cerebral artery, are at particular risk of severe IVH in cases of aneurysm rupture.