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Chen L, Meng Y, Xue Q, Zhao Y, Zhou X, Hu K, He H. Risk factors of shunt-dependent hydrocephalus after subarachnoid hemorrhage: a systematic review and meta-analysis based on observational cohort studies. Neurosurg Rev 2024; 47:421. [PMID: 39134896 PMCID: PMC11319414 DOI: 10.1007/s10143-024-02589-5] [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: 05/06/2024] [Revised: 07/03/2024] [Accepted: 07/09/2024] [Indexed: 08/15/2024]
Abstract
Shunt dependent hydrocephalus (SDHC) is a common sequel after aneurysmal subarachnoid hemorrhage (aSAH) and factors contributing to the development of SDHC remain obscure. The aim of this study was to identify predictors of SDHC following aSAH. We conducted a systematic review based on the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We searched electronic databases including Pubmed, Embase, and Cochrane databases from 1980 through August 2019 for studies on the risk factors of SDHC after aSAH. Inclusion criteria were: (1) SAH and hydrocephalus confirmed by CT or magnetic resonance imaging findings; (2) the odds ratios (ORs) or the relative risk (RR) with 95% confidence interval (95%CI; or crude data that allowed their calculation) were reported; and (3) languages were restricted to English and Chinese. Two independent authors collected the data including study design, characteristics of patients and potential risk factors. Random-effects models were used to estimate weighted mean differences (WMD), relative risks (RR) with corresponding 95% confidence intervals (CI). For analysis with significant heterogeneity, subgroup analyses stratified by study design and geographic area were performed. In all, 37 cohort studies met inclusion criteria. Several factors were associated with SDHC. Infection, acute hydrocephalus, placement of external ventricular drainage, older age, higher Hunt and Hess grade, intraventricular hemorrhage, rebleeding, and mechanical ventilation were associated with greater 2-fold increased risk of SDHC. Vasospasm, female gender, high Fisher grade, preexisting hypertension, aneurysm in posterior location and intracerebral hemorrhage were associated with less than 2-fold increased risk. Treatment modality and diabetes mellitus were not associated with SDHC. SDHC is a multi-factorial disease that is associated with patient and treatment factors. Acknowledgement of these potential factors could help prevent SDHC.
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Affiliation(s)
- Lingzhuo Chen
- Departments of Neurosurgery, The Third Affiliated Hospital, Naval Medical University, Shanghai, P.R. China
| | - Yichen Meng
- Departments of Orthopaedics, The Second Affiliated Hospital, Naval Medical University, Shanghai, P.R. China
| | - Qiang Xue
- Departments of Neurosurgery, The Third Affiliated Hospital, Naval Medical University, Shanghai, P.R. China
| | - Yuanyu Zhao
- Organ transplantation, The Second Affiliated Hospital, Naval Medical University, Shanghai, P.R. China
| | - Xuhui Zhou
- Departments of Orthopaedics, The Second Affiliated Hospital, Naval Medical University, Shanghai, P.R. China.
| | - Kejia Hu
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Second Ruijin Street, Shanghai, P.R. China.
- Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China.
| | - Hua He
- Departments of Neurosurgery, The Third Affiliated Hospital, Naval Medical University, Shanghai, P.R. China.
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Virta JJ, Satopää J, Luostarinen T, Kaprio J, Niemelä M, Korja M, Raj R. Temporal Changes in CSF Cell Parameters After SAH: Comparison of Ventricular and Spinal Drain Samples. Neurocrit Care 2024; 41:194-201. [PMID: 38356079 PMCID: PMC11335821 DOI: 10.1007/s12028-024-01942-2] [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: 11/10/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Forty percent of patients with aneurysmatic subarachnoid hemorrhage (aSAH) develop acute hydrocephalus requiring treatment with cerebrospinal fluid (CSF) drainage. CSF cell parameters are used in the diagnosis of nosocomial infections but also reflect sterile inflammation after aSAH. We aimed to study the temporal changes in CSF parameters and compare external ventricular drain (EVD)-derived and lumbar spinal drain-derived samples. METHODS We retrospectively identified consecutive patients with aSAH treated at our neurointensive care unit between January 2014 and May 2019. We mapped the temporal changes in CSF leucocyte count, erythrocyte count, cell ratio, and cell index during the first 19 days after aSAH separately for EVD-derived and spinal drain-derived samples. We compared the sample sources using a linear mixed model, controlling for repeated sampling. RESULTS We included 1360 CSF samples from 197 patients in the analyses. In EVD-derived samples, the CSF leucocyte count peaked at days 4-5 after aSAH, reaching a median of 225 × 106 (interquartile range [IQR] 64-618 × 106). The cell ratio and index peaked at 8-9 days (0.90% [IQR 0.35-1.98%] and 2.71 [IQR 1.25-6.73], respectively). In spinal drain-derived samples, the leucocyte count peaked at days 6-7, reaching a median of 238 × 106 (IQR 60-396 × 106). The cell ratio and index peaked at 14-15 days (4.12% [IQR 0.63-10.61%]) and 12-13 days after aSAH (8.84 [IQR 3.73-18.84]), respectively. Compared to EVD-derived samples, the leucocyte count was significantly higher in spinal drain-derived samples at days 6-17, and the cell ratio as well as the cell index was significantly higher in spinal drain-derived samples compared to EVD samples at days 10-15. CONCLUSIONS CSF cell parameters undergo dynamic temporal changes after aSAH. CSF samples from different CSF compartments are not comparable.
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Affiliation(s)
- Jyri J Virta
- Anesthesiology and Intensive Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Jarno Satopää
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Teemu Luostarinen
- Anesthesiology and Intensive Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jaakko Kaprio
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miikka Korja
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Pongkaew C, Noiphithak R, Rukskul P, Yodwisithsak P, Tantongtip D, Nimmannitya P, Punyarat P, Duangprasert G, Kaewwichai W, Songphul S, Chancharoenrat W, Jantarathaneewat K, Chokaouychai C, Sukhor S, Apisarnthanarak P, Camins BC, Weber DJ, Apisarnthanarak A. Effectiveness of a multimodal strategy to reduce external ventricular drain-associated infection: A quasi-experimental study. Am J Infect Control 2024:S0196-6553(24)00586-8. [PMID: 38969072 DOI: 10.1016/j.ajic.2024.06.026] [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: 05/09/2024] [Revised: 06/28/2024] [Accepted: 06/29/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Infection is a serious complication in neurosurgical patients who undergo external ventricular drain (EVD) insertion. METHODS We conducted a quasi-experimental study in patients who underwent EVD insertion to evaluate the impact of a multi-modal strategy to reduce the incidence of external ventricular drain associated infections (EVDAIs). The study was divided into 2 periods; (1) the pre-intervention period when techniques for EVD insertion and maintenance were up to the discretion of the neurosurgeons and (2) the post-intervention after implementation of a multi-modal strategy (cefazolin antibiotic prophylaxis, preoperative chlorhexidine showers, application of postoperative chlorhexidine-impregnated dressing, limited manipulation of the EVD, and meticulous EVD management). The primary outcome was the incidence rate of EVDAIs; secondary outcomes included in-hospital mortality rate, the hospital length of stay. RESULTS In total, 135 patients were included. The incidence rate of EVDAIs was significantly reduced in the post-intervention period (5.6 cases/1,000 EVD-days) compared with the pre-intervention period (18.2 cases/1,000 EVD-days; P=0.026). There were no differences in all secondary outcomes analyzed. This multi-modal strategy was associated with high satisfaction among health care personnel. CONCLUSIONS Implementation of a multi-modal strategy was associated with a reduction in the incidence of EVDAIs. This was in line with our goal of promoting a new culture of safety despite being in a resource-limited setting.
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Affiliation(s)
- Chaiwat Pongkaew
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Raywat Noiphithak
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Pataravit Rukskul
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Pornchai Yodwisithsak
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Dilok Tantongtip
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Pree Nimmannitya
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Prachya Punyarat
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Gahn Duangprasert
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Wadrawee Kaewwichai
- Neurosurgical Intensive Care Unit, Nursing Department, Thammasat University Hospital, Khlong Luang, Pathum Thani, Thailand
| | - Sirada Songphul
- General Neurosurgical Unit, Nursing Department, Thammasat University Hospital, Khlong Luang, Pathum Thani, Thailand
| | - Watcharee Chancharoenrat
- Infection Control Department, Thammasat University Hospital, Khlong Luang, Pathum Thani, Thailand
| | - Kittiya Jantarathaneewat
- Research Group in Infectious Diseases Epidemiology and Prevention, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand; Department of Pharmaceutical Care, Faculty of Pharmacy, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Chattrabongkot Chokaouychai
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Sasikan Sukhor
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Piyaporn Apisarnthanarak
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Bernard C Camins
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David J Weber
- University of North Carolina, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Anucha Apisarnthanarak
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand; Infection Control Department, Thammasat University Hospital, Khlong Luang, Pathum Thani, Thailand.
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Esteban Estallo L, Casado Pellejero J, Vázquez Sufuentes S, López López LB, Fustero de Miguel D, González Martínez LM. Risk factors for shunt-dependent hydrocephalus after spontaneous subarachnoid hemorrhage. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:196-204. [PMID: 38452929 DOI: 10.1016/j.neucie.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 01/28/2024] [Indexed: 03/09/2024]
Abstract
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.
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Omar AT, Diestro JDB, Spears J, Patorno E. Treatment modality for aneurysmal subarachnoid hemorrhage and risk of shunt dependent hydrocephalus and mortality: population based study. J Neurointerv Surg 2024:jnis-2024-021852. [PMID: 38839284 DOI: 10.1136/jnis-2024-021852] [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: 04/20/2024] [Accepted: 05/27/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Hydrocephalus is a significant contributor to morbidity following aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate the association between primary treatment modality and the incidence of hydrocephalus requiring CSF diversion, using a target trial approach for causal inference. METHODS This cohort study used US administrative health claims data (Clinformatics Data Mart) and was conducted among aSAH patients undergoing primary treatment with either clipping or coiling, from January 1, 2004, to February 28, 2023. The primary outcome was hydrocephalus requiring CSF diversion surgery while the secondary outcome was mortality. Multivariable regression and 1:1 propensity score (PS) matching were used for confounder control. Crude and adjusted hazard ratios (HRs) with 95% CIs were calculated. RESULTS A total of 5816 patients (mean age 59 years; 72% women) undergoing clipping (n=1794) or coiling (n=4022) were included in the primary cohort. The 1:1 PS matched cohort had 1794 participants per arm. Clipping demonstrated higher hazards of shunt dependent hydrocephalus compared with coiling in both the multivariable Fine-Gray model (HR 1.39, 95% CI 1.19 to 1.62) and the PS matched cohorts (HR 1.39, 95% CI 1.16 to 1.66). Mortality analysis favored clipping in the crude analysis (HR 0.78, 95% CI 0.69 to 0.88) but leaned toward coiling after confounder adjustment (HR 1.13, 95% CI 1.00 to 1.29 in the multivariable model; HR 1.11, 95% CI 0.95 to 1.29 in the PS matched cohort). CONCLUSION These findings suggest that coiling is associated with reduced hazards of shunt dependent hydrocephalus following aSAH compared with clipping, and provide valuable insights for shared decision making among clinicians and patients, in the context of conflicting evidence from smaller observational studies.
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Affiliation(s)
- Abdelsimar Tan Omar
- Division of Neurosurgery, Department of Surgery, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Jose Danilo Bengzon Diestro
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Julian Spears
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Wu B, Zhou Y, Fan H, Liu Z, Wu W, Chen Z, Yan Y, Yuan W, Luo W. Cerebrospinal fluid drainage and chronic hydrocephalus in aneurysmal subarachnoid hemorrhage patients with intraventricular hemorrhage. Front Neurol 2023; 14:1302622. [PMID: 38164202 PMCID: PMC10758233 DOI: 10.3389/fneur.2023.1302622] [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] [Received: 09/26/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
Background Patients with intraventricular hemorrhage (IVH) are at a higher risk of developing hydrocephalus and often require external ventricular drainage or long-term ventriculoperitoneal shunt surgery. Objective To investigate whether cerebrospinal fluid drainage in patients with IVH due to aneurysmal subarachnoid hemorrhage (aSAH) reduces the incidence of chronic hydrocephalus. Method A retrospective analysis was conducted on patients with aSAH treated at our hospital between January 2020 and December 2022. The first analysis compared patients with and without IVH, while the second analysis compared IVH patients with and without chronic hydrocephalus. The third analysis compared IVH patients who underwent in different drainage methods which is lumbar drainage (LD) or external ventricular drainage (EVD). The primary outcome measure was the incidence of chronic hydrocephalus. Result Of the 296 patients hospitalized with aSAH, 108 (36.5%) had IVH, which was associated with a significantly higher incidence of chronic hydrocephalus compared to patients without IVH (49.1% vs. 16.5%, p < 0.001). Multivariate logistic regression analysis showed that IVH was independently associated with the formation of chronic hydrocephalus (OR: 3.530, 95% CI: 1.958-6.362, p < 0.001). Among the 108 IVH patients, 53 (49.1%) developed chronic hydrocephalus. Multivariate logistic regression analysis revealed that the Hunt Hess grade at admission (OR: 3.362, 95% CI: 1.146-9.863, p = 0.027) and postoperative cerebrospinal fluid drainage (OR: 0.110, 95% CI: 0.036-0.336, p < 0.001) were independent risk factors for the development of chronic hydrocephalus in IVH patients. Among all IVH patients who underwent cerebrospinal fluid drainage, 45 (75%) received continuous lumbar puncture drainage, and 15 (25%) received external ventricular drainage. Univariate analysis did not show a statistically significant difference between the two groups in terms of postoperative chronic hydrocephalus (p = 0.283). However, multivariate logistic regression analysis suggested that the drainage methods of LD and EVD might be associated with the development of chronic hydrocephalus. Conclusion The presence of IVH increases the risk of chronic hydrocephalus in patients with aSAH, and postoperative cerebrospinal fluid drainage appears to reduce this risk. The specific effects of lumbar puncture drainage and ventricular drainage on the incidence of chronic hydrocephalus require further investigation.
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Affiliation(s)
- Botao Wu
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Yang Zhou
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Hongjun Fan
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Zhimin Liu
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Wanyun Wu
- Loudi Vocational and Technical College, Loudi, Hunan, China
| | - Zebo Chen
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Yong Yan
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Wen Yuan
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
| | - Wei Luo
- Department of Neurosurgery, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, Hunan, China
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Vandenbulcke A, Messerer M, Daniel RT, Cossu G. The Role of Cisternostomy and Cisternal Drainage in the Treatment of Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review. Brain Sci 2023; 13:1580. [PMID: 38002540 PMCID: PMC10670052 DOI: 10.3390/brainsci13111580] [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: 10/07/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) provokes a cascade reaction that is responsible for early and delayed brain injuries mediated by intracranial hypertension, hydrocephalus, cerebral vasospasm (CV), and delayed cerebral ischemia (DCI), which result in increased morbidity and mortality. During open microsurgical repair, cisternal access is achieved essentially to gain proximal vascular control and aneurysm exposition. Cisternostomy also allows brain relaxation, removal of cisternal clots, and restoration of the CSF dynamics through the communication between the anterior and posterior circulation cisterns and the ventricular system, with the opening of the Membrane of Liliequist and lamina terminalis, respectively. Continuous postoperative CSF drainage through a cisternal drain (CD) is a valuable option for treating acute hydrocephalus and intracranial hypertension. Moreover, it efficiently removes the blood and toxic degradation products, with a potential benefit on CV, DCI, and shunt-dependent hydrocephalus. Finally, the CD is an effective pathway to administer vasoactive, fibrinolytic, and anti-oxidant agents and shows promising results in decreasing CV and DCI rates while minimizing systemic effects. We performed a comprehensive review to establish the adjuvant role of cisternostomy and CD performed in cases of direct surgical repair for ruptured intracranial aneurysms and their role in the prevention and treatment of aSAH complications.
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Affiliation(s)
- Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, 1015 Lausanne, Switzerland
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Autio AH, Paavola J, Tervonen J, Lång M, Huuskonen TJ, Huttunen J, Kärkkäinen V, von Und Zu Fraunberg M, Lindgren AE, Koivisto T, Kurola J, Jääskeläinen JE, Kämäräinen OP. Should individual timeline and serial CT/MRI panels of all patients be presented in acute brain insult cohorts? A pilot study of 45 patients with decompressive craniectomy after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:3299-3323. [PMID: 36715752 PMCID: PMC10624760 DOI: 10.1007/s00701-022-05473-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/20/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Our review of acute brain insult articles indicated that the patients' individual (i) timeline panels with the defined time points since the emergency call and (ii) serial brain CT/MRI slice panels through the neurointensive care until death or final brain tissue outcome at 12 months or later are not presented. METHODS We retrospectively constructed such panels for the 45 aneurysmal subarachnoid hemorrhage (aSAH) patients with a secondary decompressive craniectomy (DC) after the acute admission to neurointensive care at Kuopio University Hospital (KUH) from a defined population from 2005 to 2018. The patients were indicated by numbers (1.-45.) in the pseudonymized panels, tables, results, and discussion. The timelines contained up to ten defined time points on a logarithmic time axis until death ([Formula: see text]; 56%) or 3 years ([Formula: see text]; 44%). The brain CT/MRI panels contained a representative slice from the following time points: SAH diagnosis, after aneurysm closure, after DC, at about 12 months (20 survivors). RESULTS The timelines indicated re-bleeds and allowed to compare the times elapsed between any two time points, in terms of workflow swiftness. The serial CT/MRI slices illustrated the presence and course of intracerebral hemorrhage (ICH), perihematomal edema, intraventricular hemorrhage (IVH), hydrocephalus, delayed brain injury, and, in the 20 (44%) survivors, the brain tissue outcome. CONCLUSIONS The pseudonymized timeline panels and serial brain imaging panels, indicating the patients by numbers, allowed the presentation and comparison of individual clinical courses. An obvious application would be the quality control in acute or elective medicine for timely and equal access to clinical care.
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Affiliation(s)
- Anniina H Autio
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.
| | - Juho Paavola
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Joona Tervonen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Maarit Lång
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Neurointensive Care Unit, Kuopio University Hospital, Kuopio, Finland
| | - Terhi J Huuskonen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jukka Huttunen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Virve Kärkkäinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
| | - Mikael von Und Zu Fraunberg
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Department of Neurosurgery, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Antti E Lindgren
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Timo Koivisto
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jouni Kurola
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Center for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - Juha E Jääskeläinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Olli-Pekka Kämäräinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Paavola JT, Jokimäki J, Huttunen TJ, Fraunberg MVUZ, Koivisto T, Kämäräinen OP, Lång M, Jääskeläinen JE, Kälviäinen R, Lindgren AE, Huttunen J. Long-term Risk of Epilepsy in Subarachnoid Hemorrhage Survivors With Positive Family History: A Population-Based Follow-up Study. Neurology 2023; 101:e1623-e1632. [PMID: 37643884 PMCID: PMC10585675 DOI: 10.1212/wnl.0000000000207737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/20/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating form of stroke affecting the working-age population, where epilepsy is a common complication and major prognostic factor for increased morbidity in aSAH survivors. The objective of this analysis was to assess whether epilepsy in first-degree relatives is a risk of developing epilepsy after aSAH. METHODS We used a region-specific database that includes all cases of unruptured and ruptured saccular intracranial aneurysm admitted to Kuopio University Hospital from its defined Eastern Finnish catchment population. We also retrieved data from Finnish national health registries for prescription drug purchases and reimbursement, hospital discharge, and cause of death and linked them to patients with aSAH, their first-degree relatives, and population controls matched 3:1 by age, sex, and birth municipality. Cox regression modeling and Kaplan-Meier survival curves were used for analysis. RESULTS We examined data for 760 consecutive 12-month survivors of aSAH, born in 1950 or after, with a first aSAH from January 1, 1995, to December 31, 2018. Of the 760 patients (median age, 47 years; 53% female; median follow-up, 11 years), 111 (15%) developed epilepsy at a median of 7 months (interquartile range, 2-14 months) after admission for aSAH. Of the 2,240 population controls and 4,653 first-degree relatives of patients with aSAH, 23 (0.9%) and 80 (1.7%), respectively, developed epilepsy during the follow-up period. Among 79 patients with epilepsy in first-degree relatives, 22 (28%) developed epilepsy after aSAH; by contrast, among 683 patients with no epilepsy in first-degree relatives, 89 (13%) developed epilepsy after aSAH. Having at least 1 relative with epilepsy was an independent risk factor of epilepsy after aSAH (hazard ratio, 2.44; 95% CI 1.51-3.95). Cumulative 1-year rates by first-degree relationship were 40% with 1 or more children with epilepsy, 38% with 1 or more affected parents, 5% with 1 or more affected siblings, and 10% with no relatives with epilepsy. DISCUSSION Patients who developed epilepsy after aSAH were significantly more likely to have first-degree relatives with epilepsy than those who did not develop epilepsy after the aSAH.
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Affiliation(s)
- Juho Tapio Paavola
- From the Neurosurgery of NeuroCenter (J.T.P., T.J.H., T.K., O.-P.K., J.E.J., R.K., A.E.L., J.H.), Kuopio University Hospital; Institute of Clinical Medicine (J.T.P., J.J., T.J.H., T.K., O.-P.K., M.L., J.E.J., A.E.L., J.H.), Faculty of Health Sciences, University of Eastern Finland, Kuopio; Department of Neurosurgery (M.U.Z.F.), Oulu University Hospital; Research Unit of Clinical Medicine (M.U.Z.F.), University of Oulu; Neurointensive Care Unit (M.L.), Kuopio University Hospital; Epilepsy Center (R.K.), Neuro Center, Kuopio University Hospital, Member of the European Reference Network EpiCARE; and Department of Clinical Radiology (A.E.L.), Kuopio University Hospital, Finland.
| | - Jenna Jokimäki
- From the Neurosurgery of NeuroCenter (J.T.P., T.J.H., T.K., O.-P.K., J.E.J., R.K., A.E.L., J.H.), Kuopio University Hospital; Institute of Clinical Medicine (J.T.P., J.J., T.J.H., T.K., O.-P.K., M.L., J.E.J., A.E.L., J.H.), Faculty of Health Sciences, University of Eastern Finland, Kuopio; Department of Neurosurgery (M.U.Z.F.), Oulu University Hospital; Research Unit of Clinical Medicine (M.U.Z.F.), University of Oulu; Neurointensive Care Unit (M.L.), Kuopio University Hospital; Epilepsy Center (R.K.), Neuro Center, Kuopio University Hospital, Member of the European Reference Network EpiCARE; and Department of Clinical Radiology (A.E.L.), Kuopio University Hospital, Finland
| | - Terhi Johanna Huttunen
- From the Neurosurgery of NeuroCenter (J.T.P., T.J.H., T.K., O.-P.K., J.E.J., R.K., A.E.L., J.H.), Kuopio University Hospital; Institute of Clinical Medicine (J.T.P., J.J., T.J.H., T.K., O.-P.K., M.L., J.E.J., A.E.L., J.H.), Faculty of Health Sciences, University of Eastern Finland, Kuopio; Department of Neurosurgery (M.U.Z.F.), Oulu University Hospital; Research Unit of Clinical Medicine (M.U.Z.F.), University of Oulu; Neurointensive Care Unit (M.L.), Kuopio University Hospital; Epilepsy Center (R.K.), Neuro Center, Kuopio University Hospital, Member of the European Reference Network EpiCARE; and Department of Clinical Radiology (A.E.L.), Kuopio University Hospital, Finland
| | - Mikael von Und Zu Fraunberg
- From the Neurosurgery of NeuroCenter (J.T.P., T.J.H., T.K., O.-P.K., J.E.J., R.K., A.E.L., J.H.), Kuopio University Hospital; Institute of Clinical Medicine (J.T.P., J.J., T.J.H., T.K., O.-P.K., M.L., J.E.J., A.E.L., J.H.), Faculty of Health Sciences, University of Eastern Finland, Kuopio; Department of Neurosurgery (M.U.Z.F.), Oulu University Hospital; Research Unit of Clinical Medicine (M.U.Z.F.), University of Oulu; Neurointensive Care Unit (M.L.), Kuopio University Hospital; Epilepsy Center (R.K.), Neuro Center, Kuopio University Hospital, Member of the European Reference Network EpiCARE; and Department of Clinical Radiology (A.E.L.), Kuopio University Hospital, Finland
| | - Timo Koivisto
- From the Neurosurgery of NeuroCenter (J.T.P., T.J.H., T.K., O.-P.K., J.E.J., R.K., A.E.L., J.H.), Kuopio University Hospital; Institute of Clinical Medicine (J.T.P., J.J., T.J.H., T.K., O.-P.K., M.L., J.E.J., A.E.L., J.H.), Faculty of Health Sciences, University of Eastern Finland, Kuopio; Department of Neurosurgery (M.U.Z.F.), Oulu University Hospital; Research Unit of Clinical Medicine (M.U.Z.F.), University of Oulu; Neurointensive Care Unit (M.L.), Kuopio University Hospital; Epilepsy Center (R.K.), Neuro Center, Kuopio University Hospital, Member of the European Reference Network EpiCARE; and Department of Clinical Radiology (A.E.L.), Kuopio University Hospital, Finland
| | - Olli-Pekka Kämäräinen
- From the Neurosurgery of NeuroCenter (J.T.P., T.J.H., T.K., O.-P.K., J.E.J., R.K., A.E.L., J.H.), Kuopio University Hospital; Institute of Clinical Medicine (J.T.P., J.J., T.J.H., T.K., O.-P.K., M.L., J.E.J., A.E.L., J.H.), Faculty of Health Sciences, University of Eastern Finland, Kuopio; Department of Neurosurgery (M.U.Z.F.), Oulu University Hospital; Research Unit of Clinical Medicine (M.U.Z.F.), University of Oulu; Neurointensive Care Unit (M.L.), Kuopio University Hospital; Epilepsy Center (R.K.), Neuro Center, Kuopio University Hospital, Member of the European Reference Network EpiCARE; and Department of Clinical Radiology (A.E.L.), Kuopio University Hospital, Finland
| | - Maarit Lång
- From the Neurosurgery of NeuroCenter (J.T.P., T.J.H., T.K., O.-P.K., J.E.J., R.K., A.E.L., J.H.), Kuopio University Hospital; Institute of Clinical Medicine (J.T.P., J.J., T.J.H., T.K., O.-P.K., M.L., J.E.J., A.E.L., J.H.), Faculty of Health Sciences, University of Eastern Finland, Kuopio; Department of Neurosurgery (M.U.Z.F.), Oulu University Hospital; Research Unit of Clinical Medicine (M.U.Z.F.), University of Oulu; Neurointensive Care Unit (M.L.), Kuopio University Hospital; Epilepsy Center (R.K.), Neuro Center, Kuopio University Hospital, Member of the European Reference Network EpiCARE; and Department of Clinical Radiology (A.E.L.), Kuopio University Hospital, Finland
| | - Juha Eerik Jääskeläinen
- From the Neurosurgery of NeuroCenter (J.T.P., T.J.H., T.K., O.-P.K., J.E.J., R.K., A.E.L., J.H.), Kuopio University Hospital; Institute of Clinical Medicine (J.T.P., J.J., T.J.H., T.K., O.-P.K., M.L., J.E.J., A.E.L., J.H.), Faculty of Health Sciences, University of Eastern Finland, Kuopio; Department of Neurosurgery (M.U.Z.F.), Oulu University Hospital; Research Unit of Clinical Medicine (M.U.Z.F.), University of Oulu; Neurointensive Care Unit (M.L.), Kuopio University Hospital; Epilepsy Center (R.K.), Neuro Center, Kuopio University Hospital, Member of the European Reference Network EpiCARE; and Department of Clinical Radiology (A.E.L.), Kuopio University Hospital, Finland
| | - Reetta Kälviäinen
- From the Neurosurgery of NeuroCenter (J.T.P., T.J.H., T.K., O.-P.K., J.E.J., R.K., A.E.L., J.H.), Kuopio University Hospital; Institute of Clinical Medicine (J.T.P., J.J., T.J.H., T.K., O.-P.K., M.L., J.E.J., A.E.L., J.H.), Faculty of Health Sciences, University of Eastern Finland, Kuopio; Department of Neurosurgery (M.U.Z.F.), Oulu University Hospital; Research Unit of Clinical Medicine (M.U.Z.F.), University of Oulu; Neurointensive Care Unit (M.L.), Kuopio University Hospital; Epilepsy Center (R.K.), Neuro Center, Kuopio University Hospital, Member of the European Reference Network EpiCARE; and Department of Clinical Radiology (A.E.L.), Kuopio University Hospital, Finland
| | - Antti Elias Lindgren
- From the Neurosurgery of NeuroCenter (J.T.P., T.J.H., T.K., O.-P.K., J.E.J., R.K., A.E.L., J.H.), Kuopio University Hospital; Institute of Clinical Medicine (J.T.P., J.J., T.J.H., T.K., O.-P.K., M.L., J.E.J., A.E.L., J.H.), Faculty of Health Sciences, University of Eastern Finland, Kuopio; Department of Neurosurgery (M.U.Z.F.), Oulu University Hospital; Research Unit of Clinical Medicine (M.U.Z.F.), University of Oulu; Neurointensive Care Unit (M.L.), Kuopio University Hospital; Epilepsy Center (R.K.), Neuro Center, Kuopio University Hospital, Member of the European Reference Network EpiCARE; and Department of Clinical Radiology (A.E.L.), Kuopio University Hospital, Finland
| | - Jukka Huttunen
- From the Neurosurgery of NeuroCenter (J.T.P., T.J.H., T.K., O.-P.K., J.E.J., R.K., A.E.L., J.H.), Kuopio University Hospital; Institute of Clinical Medicine (J.T.P., J.J., T.J.H., T.K., O.-P.K., M.L., J.E.J., A.E.L., J.H.), Faculty of Health Sciences, University of Eastern Finland, Kuopio; Department of Neurosurgery (M.U.Z.F.), Oulu University Hospital; Research Unit of Clinical Medicine (M.U.Z.F.), University of Oulu; Neurointensive Care Unit (M.L.), Kuopio University Hospital; Epilepsy Center (R.K.), Neuro Center, Kuopio University Hospital, Member of the European Reference Network EpiCARE; and Department of Clinical Radiology (A.E.L.), Kuopio University Hospital, Finland
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10
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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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11
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Kim M, Kim BJ, Yoon SY, Kwak Y. Unexpected shunt-dependent hydrocephalus after unruptured aneurysm surgery-a case report. J Surg Case Rep 2023; 2023:rjad415. [PMID: 37489162 PMCID: PMC10363004 DOI: 10.1093/jscr/rjad415] [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] [Received: 06/14/2023] [Accepted: 06/24/2023] [Indexed: 07/26/2023] Open
Abstract
A chronic hydrocephalus after unruptured aneurysm surgery is an extremely rare condition. Its etiology and pathophysiology are also unclear. We report a case of chronic hydrocephalus in a patient who underwent permanent shunt placement after unruptured aneurysm clipping surgery. A 65-year-old man developed chronic hydrocephalus requiring shunt placement after clipping surgery of left anterior cerebral artery aneurysm and right middle cerebral artery aneurysm. This case shows that chronic hydrocephalus is a possible complication of unruptured aneurysm surgery, which can be resolved with an appropriate shunt operation.
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Affiliation(s)
- Myungsoo Kim
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Byoung-Joon Kim
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Sang-Youl Yoon
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Youngseok Kwak
- Correspondence address: Department of Neurosurgery, Kyungpook National University Hospital, Chilgok, 807, Hoguk-ro, Buk-gu, Daegu, Republic of Korea. Tel: 82-10-8475-2022; E-mail:
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12
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Tack RWP, Lindgren A, Vergouwen MDI, van der Zwan A, van der Schaaf I, Rinkel GJE. Lumbar puncture for treating acute hydrocephalus after aneurysmal subarachnoid haemorrhage. J Neurol Sci 2023; 446:120566. [PMID: 36731357 DOI: 10.1016/j.jns.2023.120566] [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: 07/25/2022] [Revised: 01/17/2023] [Accepted: 01/22/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND External ventricular drainage (EVD) for acute hydrocephalus after aneurysmal subarachnoid haemorrhage (aSAH) carries a risk of complications. We studied the proportion of patients in whom EVD can be avoided by treating acute hydrocephalus with ≥1 lumbar punctures (LP). METHODS From a prospectively collected database, we retrieved data on all aSAH patients admitted between 2007 and 2017 who developed acute hydrocephalus (i.e. neurological deterioration and ventricular enlargement <72 h after aSAH). Our regime is to consider LP as initial treatment. We calculated the proportions of patients (with corresponding 95% confidence interval (CI)) who improved after the initial LP and the extent of clinical improvement, the proportions of patients who were treated with only ≥1 LP(s), and those of patients needing continuous external ventricular or external lumbar drainage, or permanent ventriculoperitoneal or lumboperitoneal drainage. RESULTS Of 1391 consecutive aSAH patients, 473 (34%) had acute hydrocephalus, of whom 388 (82%) were treated. Of the 86 patients with LP as initial treatment, 70 (81% [95% CI 72-88]) showed initial improvement (with increase in median Glasgow Coma Score from 10 (IQR 7-12) to 12 (IQR 9-14) after initial LP), 39 (45% [95% CI 35-56]) improved with LP only, 41 (48% [95% CI 37-58]) needed continuous drainage and six (7% [95% CI 3-14]) needed permanent drainage. CONCLUSION Around half the patients treated with LP for deterioration from acute hydrocephalus after aSAH does not require continuous extraventicular or extralumbar drainage.
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Affiliation(s)
- R W P Tack
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - A Lindgren
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - M D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - A van der Zwan
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - I van der Schaaf
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - G J E Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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13
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White Matter Injury: An Emerging Potential Target for Treatment after Subarachnoid Hemorrhage. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2023; 2023:3842493. [PMID: 36798684 PMCID: PMC9928519 DOI: 10.1155/2023/3842493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/20/2022] [Accepted: 01/04/2023] [Indexed: 02/10/2023]
Abstract
Subarachnoid hemorrhage (SAH) refers to vascular brain injury mainly from a ruptured aneurysm, which has a high lifetime risk and imposes a substantial burden on patients, families, and society. Previous studies on SAH mainly focused on neurons in gray matter (GM). However, according to literature reports in recent years, in-depth research on the mechanism of white matter (WM) is of great significance to injury and recovery after SAH. In terms of functional recovery after SAH, all kinds of cells in the central nervous system (CNS) should be protected. In other words, it is necessary to protect not only GM but also WM, not only neurons but also glial cells and axons, and not only for the lesion itself but also for the prevention and treatment of remote damage. Clarifying the mechanism of white matter injury (WMI) and repair after SAH is of great importance. Therefore, this present review systematically summarizes the current research on WMI after SAH, which might provide therapeutic targets for treatment after SAH.
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14
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Pacult MA, Catapano JS, Rumalla K, Winkler EA, Graffeo CS, Srinivasan VM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. Intraventricular Tissue Plasminogen Activator and Shunt Dependency in Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 170:242-243. [PMID: 36396046 DOI: 10.1016/j.wneu.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mark A Pacult
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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15
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Garvayo M, Messerer M, Starnoni D, Puccinelli F, Vandenbulcke A, Daniel RT, Cossu G. The positive impact of cisternostomy with cisternal drainage on delayed hydrocephalus after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:187-195. [PMID: 36504078 PMCID: PMC9840569 DOI: 10.1007/s00701-022-05445-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hydrocephalus is one of the major complications of aneurysmal subarachnoid haemorrhage (aSAH). In the acute setting, an external ventricular drain (EVD) is used for early management. A cisternal drain (CD) coupled with the micro-surgical opening of basal cisterns can be an alternative when the aneurysm is clipped. Chronic hydrocephalus after aSAH is managed with ventriculo-peritoneal (VP) shunt, a procedure associated with a wide range of complications. The aim of this study is to analyse the impact of micro-surgical opening of basal cisterns coupled with CD on the incidence of VP shunt, compared to patients treated with EVD. METHODS The authors conducted a retrospective review of 89 consecutive cases of patients with aSAH treated surgically and endovascularly with either EVD or CD between January 2009 and September 2021. Patients were stratified into two groups: Group 1 included patients with EVD, Group 2 included patients with CD. Subgroup analysis with only patients treated surgically was also performed. We compared their baseline characteristics, clinical outcomes and shunting rates. RESULTS There were no statistically significant differences between the two groups in terms of epidemiological characteristics, WFNS score, Fisher scale, presence of intraventricular hemorrhage (IVH), acute hydrocephalus, postoperative meningitis or of clinical outcomes at last follow-up. Cisternostomy with CD (Group 2) was associated with a statistically significant reduction in VP-shunt compared with the use of an EVD (Group 1) (9.09% vs 53.78%; p < 0.001). This finding was confirmed in our subgroup analysis, as among patients with a surgical clipping, the rate of VP shunt was 43.7% for the EVD group and 9.5% for the CD group (p = 0.02). CONCLUSIONS Cisternostomy with CD may reduce the rate of shunt-dependent hydrocephalus. Cisternostomy allows the removal of subarachnoid blood, thereby reducing arachnoid inflammation and fibrosis. CD may enhance this effect, thus resulting in lower rates of chronic hydrocephalus.
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Affiliation(s)
- Marta Garvayo
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Francesco Puccinelli
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland.
| | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
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16
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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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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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Achrén A, Raj R, Siironen J, Laakso A, Marjamaa J. Spontaneous angiogram-negative subarachnoid hemorrhage: a retrospective single center cohort study. Acta Neurochir (Wien) 2022; 164:129-140. [PMID: 34853936 PMCID: PMC8761132 DOI: 10.1007/s00701-021-05069-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 11/12/2021] [Indexed: 12/13/2022]
Abstract
Background Spontaneous angiogram-negative subarachnoid hemorrhage (SAH) is considered a benign illness with little of the aneurysmal SAH-related complications. We describe the clinical course, SAH-related complications, and outcome of patients with angiogram-negative SAH. Methods We retrospectively reviewed all adult patients admitted to a neurosurgical intensive care unit during 2004–2018 due to spontaneous angiogram-negative SAH. Our primary outcome was a dichotomized Glasgow Outcome Scale (GOS) at 3 months. We assessed factors that associated with outcome using multivariable logistic regression analysis. Results Of the 108 patients included, 84% had a favorable outcome (GOS 4–5), and mortality was 5% within 1 year. The median age was 58 years, 51% were female, and 93% had a low-grade SAH (World Federation of Neurosurgical Societies grading I–III). The median number of angiograms performed per patient was two. Thirty percent of patients showed radiological signs of acute hydrocephalus, 28% were acutely treated with an external ventricular drain, 13% received active vasospasm treatment and 17% received a permanent shunt. In the multivariable logistic regression model, only acute hydrocephalus associated with unfavorable outcome (odds ratio = 4.05, 95% confidence interval = 1.05–15.73). Two patients had a new bleeding episode. Conclusion SAH-related complications such as hydrocephalus and vasospasm are common after angiogram-negative SAH. Still, most patients had a favorable outcome. Only acute hydrocephalus was associated with unfavorable outcome. The high rate of SAH-related complications highlights the need for neurosurgical care in these patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-05069-7.
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Machine Learning and Intracranial Aneurysms: From Detection to Outcome Prediction. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 134:319-331. [PMID: 34862556 DOI: 10.1007/978-3-030-85292-4_36] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Machine learning (ML) is a rapidly rising research tool in biomedical sciences whose applications include segmentation, classification, disease detection, and outcome prediction. With respect to traditional statistical methods, ML algorithms have the potential to learn and improve their predictive performance when fed with large data sets without the need of being specifically programmed. In recent years, this technology has been increasingly applied for tackling clinical issues in intracranial aneurysm (IA) research. Several studies attempted to provide reliable models for enhanced aneurysm detection. Convolutional neural networks trained with variable degrees of human interaction on data from diverse imaging modalities showed high sensitivity in aneurysm detection tasks, also outperforming expert image analysis. Algorithms were also shown to differentiate ruptured from unruptured IAs, with however limited clinical relevance. For prediction of rupture and stability assessment, ML was preliminarily shown to achieve better performance compared to conventional statistical methods and existing risk scores. ML-based complication and functional outcome prediction in the event of SAH have been more extensively reported, in contrast with periprocedural outcome investigation in unruptured IA patients. ML has the potential to be a game changer in IA patient management. Currently clinical translation of experimental results is limited.
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20
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Debs LH, Rahimi SY, Rutkowski MJ, Macomson SD. Endoscopic third ventriculostomy may decrease shunt-dependency in patients with post-hemorrhagic hydrocephalus following aneurysmal subarachnoid hemorrhage. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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21
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Catapano JS, Rumalla K, Karahalios K, Srinivasan VM, Labib MA, Cole TS, Baranoski JF, Rutledge C, Rahmani R, Jadhav AP, Ducruet AF, Albuquerque FC, Zabramski JM, Lawton MT. Intraventricular Tissue Plasminogen Activator and Shunt Dependency in Aneurysmal Subarachnoid Hemorrhage Patients With Cast Ventricles. Neurosurgery 2021; 89:973-977. [PMID: 34460915 DOI: 10.1093/neuros/nyab333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/08/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patients with intraventricular hemorrhage (IVH) are at higher risk of hydrocephalus requiring an external ventricular drain and long-term ventriculoperitoneal shunt placement. OBJECTIVE To investigate whether intraventricular tissue plasminogen activator (tPA) administration in patients with ventricular casting due to IVH reduces shunt dependence. METHODS Patients from the Post-Barrow Ruptured Aneurysm Trial (PBRAT) database treated for aneurysmal subarachnoid hemorrhage (aSAH) from August 1, 2010, to July 31, 2019, were retrospectively reviewed. Patients with and without IVH were compared. A second analysis compared IVH patients with and without ventricular casting. A third analysis compared patients with ventricular casting with and without intraventricular tPA treatment. The primary outcome was chronic hydrocephalus requiring permanent shunt placement. RESULTS Of 806 patients hospitalized with aSAH, 561 (69.6%) had IVH. IVH was associated with a higher incidence of shunt placement (25.7% vs 4.1%, P < .001). In multivariable logistic regression analysis, IVH was independently associated with increased likelihood of shunt placement (odds ratio [OR]: 7.8, 95% CI: 3.8-16.2, P < .001). Generalized ventricular casting was present in 80 (14.3%) patients with IVH. In a propensity-score adjusted analysis, generalized ventricular casting was an independent predictor of shunt placement (OR: 3.0, 95% CI: 1.8-4.9, P < .001) in patients with IVH. Twenty-one patients with ventricular casting received intraventricular tPA. These patients were significantly less likely to require a shunt (OR: 0.30, 95% CI: 0.010-0.93, P = .04). CONCLUSION Ventricular casting in aSAH patients was associated with an increased risk of chronic hydrocephalus and shunt dependency. However, this risk decreased with the administration of intraventricular tPA.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Caleb Rutledge
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joseph M Zabramski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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22
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Tervonen J, Adams H, Lindgren A, Elomaa AP, Kämäräinen OP, Kärkkäinen V, von Und Zu Fraunberg M, Huttunen J, Koivisto T, Jääskeläinen JE, Leinonen V, Huuskonen TJ. Shunt performance in 349 patients with hydrocephalus after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2021; 163:2703-2714. [PMID: 34169389 PMCID: PMC8437876 DOI: 10.1007/s00701-021-04877-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/09/2021] [Indexed: 11/25/2022]
Abstract
Background Shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) is a common sequelae leading to poorer neurological outcomes and predisposing to various complications. Methods A total of 2191 consecutive patients with aSAH were acutely admitted to the Neurointensive Care at the Kuopio University Hospital between 1990 and 2018 from a defined population. A total of 349 (16%) aSAH patients received a ventriculoperitoneal shunt, 101 with an adjustable valve (2012–2018), 232 with a fixed pressure valve (1990–2011), and 16 a valveless shunt (2010–2013). Clinical timelines were reconstructed from the hospital records and nationwide registries until death (n = 120) or June 2019. Results Comparing the adjustable valves vs. the fixed pressure valves vs. the valveless shunts, intraventricular hemorrhage was present in 61%, 44% and 100%, respectively. The median times to the shunt were 7 days vs. 38 days vs. 10 days. The rates of the first revision were 25% vs. 32% vs. 69%. The causes included infection in 11% vs. 7% vs. 25% and overdrainage in 1% vs. 4% vs. 31%. The valveless shunt was the only independent risk factor (HR 2.9) for revision. After the first revision, more revisions were required in 48% vs. 52% vs. 45%. Conclusions The protocol to shunt evolved over time to favor earlier shunt. In post-aSAH hydrocephalus, adjustable valve shunts, without anti-siphon device, can be installed at an early phase after aSAH, in spite of intraventricular blood, with a modest risk (25%) of revision. Valveless shunts are not recommendable due to high risk of revisions.
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Affiliation(s)
- Joona Tervonen
- Department of Neurosurgery, Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland.
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.
| | - Hadie Adams
- Department of Neurosurgery, Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Antti Lindgren
- Department of Neurosurgery, Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Antti-Pekka Elomaa
- Department of Neurosurgery, Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Olli-Pekka Kämäräinen
- Department of Neurosurgery, Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Virve Kärkkäinen
- Department of Neurosurgery, Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Mikael von Und Zu Fraunberg
- Department of Neurosurgery, Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jukka Huttunen
- Department of Neurosurgery, Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Timo Koivisto
- Department of Neurosurgery, Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Juha E Jääskeläinen
- Department of Neurosurgery, Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ville Leinonen
- Department of Neurosurgery, Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Terhi J Huuskonen
- Department of Neurosurgery, Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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Nguyen AM, Dao LTN, Thai TT. Cerebrospinal fluid lumbar drainage in reducing vasospasm following aneurysmal subarachnoid hemorrhage in Vietnam: A single-center prospective study. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
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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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25
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García-Armengol R, Puyalto P, Misis M, Julian JF, Rodríguez-Hernández A, Perez-Balaguero AC, Menendez B, Brugada F, Muñoz-Narbona L, Dominguez C, Muñoz JR. Cerebrospinal Fluid Output as a Risk Factor of Chronic Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2021; 154:e572-e579. [PMID: 34325032 DOI: 10.1016/j.wneu.2021.07.084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/17/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic shunt-dependent hydrocephalus is a well-known complication of subarachnoid hemorrhage. Although the risk factors have been extensively investigated, most fail to predict permanent shunt dependency. It is unknown whether the volume of cerebrospinal fluid (CSF) from external ventricular drainage and the daily volume of drainage during the acute hydrocephalus phase (first 72 hours) can predict shunt dependency. We aimed to determine whether CSF output during the acute hydrocephalus phase is a risk factor for shunt dependency. METHODS Patients with aneurysmal subarachnoid hemorrhage and hydrocephalus treated with external ventricular drainage were prospectively registered in our database between January 2017 and March 2020. Factors evaluated for predicting shunt dependency included age; sex; Hunt and Hess grade; World Federation of Neurological Surgeons grade; acute hydrocephalus; modified Fisher grade; aneurysm treatment modality; hospital length of stay; modified Rankin score; average daily overall CSF production; average CSF output for the first 24, 48, and 72 hours; external ventricular drainage days; the number of wean/clamp failures; and ventriculoperitoneal shunting. RESULTS Univariate analysis identified Hunt and Hess grade; acute hydrocephalus at onset; external ventricular drainage; overall CSF output; average CSF output for the first 24, 48, and 72 hours; and CSF output until the first clamp as significant risk factors for shunt dependency (P < 0.001). In a multivariate logistic regression analysis, overall CSF output and average CSF output for the first 72 hours were significant risk factors for shunt dependency. CONCLUSIONS Overall CSF output, especially during the acute hydrocephalus phase (first 72 hours), predicts the development of chronic hydrocephalus.
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Affiliation(s)
- Roser García-Armengol
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, University Autonomous of Barcelona, Barcelona, Spain
| | - Paloma Puyalto
- Department of Radiology, Germans Trias i Pujol University Hospital, University Autonomous of Barcelona, Barcelona, Spain; Faculty of Medicine, Universitat Internacional de Catalunya (UIC), Barcelona, Spain.
| | - Maite Misis
- Intensive Care Unit, Germans Trias i Pujol University Hospital, University Autonomous of Barcelona, Barcelona, Spain
| | - Juan Francisco Julian
- Department of Surgery, Germans Trias i Pujol University Hospital, University Autonomous of Barcelona, Barcelona, Spain
| | - Ana Rodríguez-Hernández
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, University Autonomous of Barcelona, Barcelona, Spain
| | - Ana Cristina Perez-Balaguero
- Department of Radiology, Germans Trias i Pujol University Hospital, University Autonomous of Barcelona, Barcelona, Spain
| | - Belen Menendez
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, University Autonomous of Barcelona, Barcelona, Spain
| | - Ferran Brugada
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, University Autonomous of Barcelona, Barcelona, Spain
| | - Lucia Muñoz-Narbona
- Departament of Neurosciences, Institute for Health Science Research Germans Trias i Pujol (IGTP), Barcelona, Spain; RETICS Research group Health Institute Carlos III, Barcelona, Spain
| | - Carlos Dominguez
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, University Autonomous of Barcelona, Barcelona, Spain
| | - Jordi Rimbau Muñoz
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, University Autonomous of Barcelona, Barcelona, Spain
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Transient acute hydrocephalus after aneurysmal subarachnoid hemorrhage and aneurysm embolization: a single-center experience. Neuroradiology 2021; 63:2111-2119. [PMID: 34128086 DOI: 10.1007/s00234-021-02747-2] [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] [Received: 03/25/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
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.
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Predictors of Ventriculoperitoneal shunting following Subarachnoid Hemorrhage treated with External Ventricular Drainage. Neurocrit Care 2021; 32:755-764. [PMID: 31410771 DOI: 10.1007/s12028-019-00802-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND/OBJECTIVES Aneurysmal subarachnoid hemorrhage (aSAH) is commonly associated with hydrocephalus due to subarachnoid hemorrhage blood products obstructing cerebrospinal fluid outflow. Hydrocephalus after aSAH is routinely managed with temporary external ventricular drainage (EVD) followed by standard EVD weaning protocols, which determine the need for ventriculoperitoneal shunting (VPS). We sought to investigate aSAH patients who initially passed EVD weaning trials and had EVD removal, but later presented with recurrent, delayed, symptomatic hydrocephalus requiring a VPS. METHODS We conducted a retrospective review of all patients at our tertiary care medical center who presented with aSAH, requiring an EVD. We analyzed variables associated with ultimate VPS dependency during hospitalization. RESULTS We reviewed 489 patients with aSAH over a 6-year period (2008-2014). One hundred and thirty-eight (28.2%) developed hydrocephalus requiring a temporary EVD. Forty-four (31.9%) of these patients died or had withdrawal of care during admission, and were excluded from final analysis. Of the remaining 94 patients, 29 (30.9%) failed their clamp trial and required VPS. Sixty-five (69.1%) patients passed their clamp trial and were discharged without a VPS. However, 10 (15.4%) of these patients developed delayed hydrocephalus after discharge and ultimately required VPS [mean (range) days after discharge, 97.2 (35-188)]. Compared to early VPS, the delayed VPS group had a higher incidence of symptomatic vasospasm (90.0% vs 51.7%; P = 0.03). When comparing patients discharged from the hospital without VPS, delayed VPS patients also had higher 6- and 12-month mortality (P = 0.02) and longer EVD clamp trials (P < 0.01) than patients who never required VPS but had an EVD during hospitalization. Delayed hydrocephalus occurred in only 7.8% of patients who passed the initial EVD clamp trial, compared to 14.3% who failed the initial trial and 80.0% who failed 2 or more trials. CONCLUSION Patients who failed their initial or subsequent EVD clamp trials had a small, but increased risk of developing delayed hydrocephalus ultimately requiring VPS. Additionally, the majority of patients who presented with delayed hydrocephalus also suffered symptomatic vasospasm. These associations should be further explored and validated in a larger prospective study.
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Nurmonen HJ, Huttunen T, Huttunen J, Kurtelius A, Kotikoski S, Junkkari A, Koivisto T, von Und Zu Fraunberg M, Kämäräinen OP, Lång M, Isoniemi H, Jääskeläinen JE, Lindgren AE. Lack of impact of polycystic kidney disease on the outcome of aneurysmal subarachnoid hemorrhage: a matched case-control study. J Neurosurg 2021; 134:1871-1878. [PMID: 32619983 DOI: 10.3171/2020.4.jns20544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/15/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors set out to study whether autosomal dominant polycystic kidney disease (ADPKD), an established risk factor for intracranial aneurysms (IAs), affects the acute course and long-term outcome of aneurysmal subarachnoid hemorrhage (aSAH). METHODS The outcomes of 32 ADPKD patients with aSAH between 1980 and 2015 (median age 43 years; 50% women) were compared with 160 matched (age, sex, and year of aSAH) non-ADPKD aSAH patients in the prospectively collected Kuopio Intracranial Aneurysm Patient and Family Database. RESULTS At 12 months, 75% of the aSAH patients with ADPKD versus 71% of the matched-control aSAH patients without ADPKD had good outcomes (Glasgow Outcome Scale score 4 or 5). There was no significant difference in condition at admission. Hypertension had been diagnosed before aSAH in 69% of the ADPKD patients versus 27% of controls (p < 0.001). Multiple IAs were present in 44% of patients in the ADPKD group versus 25% in the control group (p = 0.03). The most common sites of ruptured IAs were the anterior communicating artery (47% vs 29%, p = 0.05) and the middle cerebral artery bifurcation (28% vs 31%), and the median size was 6.0 mm versus 8.0 mm (p = 0.02). During the median follow-up of 11 years, a second aSAH occurred in 3 of 29 (10%) ADPKD patients and in 4 of 131 (3%) controls (p = 0.11). A fatal second aSAH due to a confirmed de novo aneurysm occurred in 2 (6%) of the ADPKD patients but in none of the controls (p = 0.027). CONCLUSIONS The outcomes of ADPKD patients with aSAH did not differ significantly from those of matched non-ADPKD aSAH patients. ADPKD patients had an increased risk of second aSAH from a de novo aneurysm, warranting long-term angiographic follow-up.
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Affiliation(s)
- Heidi J Nurmonen
- 1Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio
- 2School of Medicine, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio
- 3Kuopio Health Center, Kuopio
| | - Terhi Huttunen
- 1Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio
| | - Jukka Huttunen
- 1Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio
| | - Arttu Kurtelius
- 1Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio
- 2School of Medicine, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio
| | - Satu Kotikoski
- 1Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio
- 2School of Medicine, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio
| | - Antti Junkkari
- 1Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio
| | - Timo Koivisto
- 1Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio
- 2School of Medicine, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio
| | - Mikael von Und Zu Fraunberg
- 1Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio
- 2School of Medicine, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio
| | - Olli-Pekka Kämäräinen
- 1Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio
- 2School of Medicine, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio
| | - Maarit Lång
- 2School of Medicine, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio
- 4Neurointensive Care and
| | - Helena Isoniemi
- 6Transplantation and Liver Surgery Clinic, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Juha E Jääskeläinen
- 1Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio
- 2School of Medicine, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio
| | - Antti E Lindgren
- 1Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio
- 2School of Medicine, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio
- 5Department of Clinical Radiology, Kuopio University Hospital, Kuopio; and
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Tabibkhooei A, Azar M, Taheri M, Ghalaenovi H, Fattahi A, Kheradmand H. Effect of Microscopic Third Ventriculostomy (Lamina Terminalis Fenestration) on Shunt-needed Hydrocephalus in Patients with Aneurysmal Subarachnoid Hemorrhage. Prague Med Rep 2021; 122:14-24. [PMID: 33646938 DOI: 10.14712/23362936.2021.2] [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: 10/22/2022] Open
Abstract
There are reports that in patients with aSAH (aneurysmal subarachnoid hemorrhage), LTF (lamina terminalis fenestration) reduces the rate of shunt-needed hydrocephalus via facilitation of CSF (cerebrospinal fluid) dynamic, diminished leptomeningeal inflammation, and decreased subarachnoid fibrosis. Regarding the conflicting results, this study was conducted to evaluate the effects of LTF on decreased shunt-needed hydrocephalus in patients with aSAH. A cross-sectional retrospective study was carried out to survey all patients with confirmed aSAH operated from March 2011 to September 2016 in an academic vascular center (Rasool Akram Hospital in Tehran, Iran). Of a total of 151 patients, 72 patients were male and 79 were female. The mean age of the participants was 51 years. A transiently CSF diversion (EVD - external ventricular drainage) was performed (the acute hydrocephalus rate) on 21 patients (13.9%). In 36 patients (23.8%), aneurysm occlusion with LTF and in 115 patients (76.2%) only aneurysm occlusion surgery was performed. In hydrocephalus follow-up after surgery, 13 (12%) patients needed shunt insertion (the rate of shunt-needed hydrocephalus). The statistical analysis demonstrated no significant relation between LTF and shunt-needed hydrocephalus. Confirmation of the hypothesis that LTF may decrease the rate of shunt-needed hydrocephalus can significantly decrease morbidity, mortality, and treatment costs of shunting (that is a simple, but a potentially dangerous procedure). So, it is advised to plan and perform an RCT (randomized controlled trial) that can remove the confounding factors, match the groups, and illustrate the exact effect of LTF on shunt-needed hydrocephalus.
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Affiliation(s)
- Alireza Tabibkhooei
- Department of Neurosurgery, Iran University of Medical Sciences, Rasool Akram Hospital, Tehran, Iran
| | - Maziar Azar
- Department of Neurosurgery, Iran University of Medical Sciences, Rasool Akram Hospital, Tehran, Iran
| | - Morteza Taheri
- Department of Neurosurgery, Iran University of Medical Sciences, 7Tir Hospital, Tehran, Iran.
| | - Hossein Ghalaenovi
- Department of Neurosurgery, Iran University of Medical Sciences, Rasool Akram Hospital, Tehran, Iran
| | - Arash Fattahi
- Department of Neurosurgery, Iran University of Medical Sciences, 7Tir Hospital, Tehran, Iran
| | - Hamed Kheradmand
- Department of Neurosurgery, Iran University of Medical Sciences, Rasool Akram Hospital, Tehran, Iran
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Clinical condition of 120 patients alive at 3 years after poor-grade aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2021; 163:1153-1166. [PMID: 33629124 PMCID: PMC7904392 DOI: 10.1007/s00701-021-04725-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 01/18/2021] [Indexed: 11/30/2022]
Abstract
Background To study the clinical condition of poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients alive at 3 years after neurointensive care. Methods Of the 769 consecutive aSAH patients from a defined population (2005–2015), 269 (35%) were in poor condition on admission: 145 (54%) with H&H 4 and 124 (46%) with H&H 5. Their clinical lifelines were re-constructed from the Kuopio Intracranial Aneurysm Database and Finnish nationwide registries. Of the 269 patients, 155 (58%) were alive at 14 days, 125 (46%) at 12 months, and 120 (45%) at 3 years. Results The 120 H&H 4–5 patients alive at 3 years form the final study population. On admission, 73% had H&H 4 but only 27% H&H 5, 59% intracerebral hematoma (ICH; median 22 cm3), and 26% intraventricular blood clot (IVH). The outcome was favorable (mRS 0–1) in 45% (54 patients: ICH 44%; IVH clot 31%; shunt 46%), moderate (mRS 2–3) in 30% (36 patients: ICH 64%; IVH clot 19%; shunt 42%), and unfavorable (mRS 4–5) in 25% (30 patients: ICH 80%; IVH clot 23%; shunt 50%). A total of 46% carried a ventriculoperitoneal shunt. ICH volume was a significant predictor of mRS at 3 years. Conclusions Of poor-grade aSAH patients, 45% were alive at 3 years, even 27% of those extending to pain (H&H 5). Of the survivors, 75% were at least in moderate condition, while only 2.6% ended in hospice care. Consequently, we propose non-selected admission to neurointensive care (1) for a possibility of moderate outcome, and (2), in case of brain death, possibly improved organ donation rates.
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Yang YC, Yin CH, Chen KT, Lin PC, Lee CC, Liao WC, Chen JS. 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. World Neurosurg 2021; 150:e12-e22. [PMID: 33556600 DOI: 10.1016/j.wneu.2021.01.138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Yao-Chung Yang
- Department of Surgery, Division of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Hao Yin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kuan-Ting Chen
- School of Medicine, National Defense Medical Center, Taipei, Taiwan; Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Radiology, Taichung Armed Force General Hospital, Taichung, Taiwan
| | - Pei-Chin Lin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Chih Lee
- School of Medicine, National Defense Medical Center, Taipei, Taiwan; Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Otolaryngology, Head and Neck Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Chuan Liao
- Department of Surgery, Division of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
| | - Jin-Shuen Chen
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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Muscas G, Matteuzzi T, Becattini E, Orlandini S, Battista F, Laiso A, Nappini S, Limbucci N, Renieri L, Carangelo BR, Mangiafico S, Della Puppa A. Development of machine learning models to prognosticate chronic shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2020; 162:3093-3105. [PMID: 32642833 PMCID: PMC7593274 DOI: 10.1007/s00701-020-04484-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/02/2020] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Giovanni Muscas
- Neurosurgery Clinic, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Largo Piero Palagi 1, 50137, Florence, Italy.
| | - Tommaso Matteuzzi
- Institute of Physics, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Eleonora Becattini
- Neurosurgery Clinic, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Largo Piero Palagi 1, 50137, Florence, Italy
| | - Simone Orlandini
- Neurosurgery Clinic, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Largo Piero Palagi 1, 50137, Florence, Italy
| | - Francesca Battista
- Neurosurgery Clinic, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Largo Piero Palagi 1, 50137, Florence, Italy
| | - Antonio Laiso
- Neurosurgery Clinic, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Largo Piero Palagi 1, 50137, Florence, Italy
- Interventional Neuroradiology Unit, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Florence, Italy
| | - Sergio Nappini
- Interventional Neuroradiology Unit, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Florence, Italy
| | - Nicola Limbucci
- Interventional Neuroradiology Unit, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Florence, Italy
| | - Leonardo Renieri
- Interventional Neuroradiology Unit, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Florence, Italy
| | | | - Salvatore Mangiafico
- Interventional Neuroradiology Unit, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Florence, Italy
| | - Alessandro Della Puppa
- Neurosurgery Clinic, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Largo Piero Palagi 1, 50137, Florence, Italy
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Vyas D, Booker J, Smith D, Al-Tamimi YZ. External Validation of Scoring Models to Predict Shunt Insertion after Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2020; 146:e1255-e1261. [PMID: 33276170 DOI: 10.1016/j.wneu.2020.11.146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Dillon Vyas
- Department of Neurosurgery, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, United Kingdom.
| | - James Booker
- Department of Neurosurgery, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, United Kingdom
| | - Daisy Smith
- Department of Neurosurgery, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, United Kingdom
| | - Yahia Z Al-Tamimi
- Department of Neurosurgery, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, United Kingdom; Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, United Kingdom
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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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Vemula RCV, Prasad BC, Kumar K. Retrospective Analytic Study of Neurosurgical Patients Who Developed Postoperative Hydrocephalus. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1717219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Objective This article discusses the causes, primary pathologies, management, and prognosis of patients who did not have hydrocephalus in preoperative stage, underwent definitive surgical procedure, and developed postoperative hydrocephalus requiring cerebrospinal fluid (CSF) diversion procedures.
Methods Retrospective data collection was done from operation theatre (OT) department database and patient records were obtained for the patients after, related literature was searched, all possible risk factors were analyzed, and our results were compared with other studies.
Results A total of 80 cases were found eligible for the study. Decompressive craniectomy was the most common cause followed by aneurysmal subarachnoid hemorrhage (SAH), intraventricular, and cerebellopontine angle (CPA) tumors. Rate of postsurgical hydrocephalus was 15 to 16%. Cases of decompressive craniectomy presented late, only few cases required diversion procedures during the immediate postop period, mostly aneurysm cases and tumors bed bleed. Out of total 6 mortalities, none of them were directly attributable to hydrocephalus. Since most patient presented after initial stabilization, permanent ventriculoperitoneal shunting was found to be the best option.
Conclusion Cases of decompression surgery should be under vigilant follow-up after discharge and even after cranioplasty for risk of development of hydrocephalus and requirement of permanent shunting. Cases with intraventricular hemorrhage or SAH should be considered as future candidate with risk of developing hydrocephalus. Lamina terminalis opening whenever possible results in favorable outcome in cases of anterior circulation aneurysms. CSF protein analysis in cases of intraventricular and CPA tumors should be done whenever possible, preferably routinely.
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Affiliation(s)
| | - B. C.M. Prasad
- Department of Neurosurgery, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, Andhra Pradesh, India
| | - Kunal Kumar
- Department of Neurosurgery, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, Andhra Pradesh, India
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Elsharkawy AA, Abdelhameed EA. Efficacy of translamina terminalis ventriculostomy tube in prevention of chronic hydrocephalus after aneurysmal subarachnoid hemorrhage. Surg Neurol Int 2020; 11:283. [PMID: 33033645 PMCID: PMC7538801 DOI: 10.25259/sni_278_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/03/2020] [Indexed: 01/01/2023] Open
Abstract
Background Chronic shunt-dependent hydrocephalus is still a common complication after aneurysmal SAH (aSAH) and is associated with increased morbidity. Pathology of chronic shunt-dependent hydrocephalus after aSAH is complex and multifactorial which makes its prevention challenging. We thought to evaluate whether external ventricular drainage (EVD) through fenestrated lamina terminalis would decrease the rate of chronic shunt-dependent hydrocephalus after aSAH. Methods A retrospective analysis of 68 consecutive patients with aSAH who underwent microsurgical clipping of the ruptured aneurysm. Patients were divided into two groups: Group A included patients with lamina terminalis fenestration without insertion of ventriculostomy tube and Group B included patients with EVD through fenestrated lamina terminalis. Demographic, clinical, radiological, and outcome variables were compared between groups. Results Group A comprised 29 patients with mean age of 47.8 years and Group B comprised 39 patients with mean age of 46.6 years. Group B patients had statistically significant (P < 0.05) lower incidence of chronic shunt- dependent hydrocephalus than Group A patients (30.8% vs. 55.2%, respectively). Conclusion EVD through fenestrated lamina terminalis is safe and may be effective in decreasing the incidence of chronic shunt-dependent hydrocephalus after aSAH.
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Rehman S, Chandra RV, Zhou K, Tan D, Lai L, Asadi H, Froelich J, Thani N, Nichols L, Blizzard L, Smith K, Thrift AG, Stirling C, Callisaya ML, Breslin M, Reeves MJ, Gall S. Sex differences in aneurysmal subarachnoid haemorrhage (aSAH): aneurysm characteristics, neurological complications, and outcome. Acta Neurochir (Wien) 2020; 162:2271-2282. [PMID: 32607744 DOI: 10.1007/s00701-020-04469-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 06/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Women are over-represented in aSAH cohorts, but whether their outcomes differ to men remains unclear. We examined if sex differences in neurological complications and aneurysm characteristics contributed to aSAH outcomes. METHODS In a retrospective cohort (2010-2016) of all aSAH cases across two hospital networks in Australia, information on severity, aneurysm characteristics and neurological complications (rebleed before/after treatment, postoperative stroke < 48 h, neurological infections, hydrocephalus, seizures, delayed cerebral ischemia [DCI], cerebral infarction) were extracted. We estimated sex differences in (1) complications and aneurysm characteristics using chi square/t-tests and (2) outcome at discharge (home, rehabilitation or death) using multinomial regression with and without propensity score matching on prestroke confounders. RESULTS Among 577 cases (69% women, 84% treated) aneurysm size was greater in men than women and DCI more common in women than men. In unadjusted log multinomial regression, women had marginally greater discharge to rehabilitation (RRR 1.15 95% CI 0.90-1.48) and similar likelihood of in-hospital death (RRR 1.02 95% CI 0.76-1.36) versus discharge home. Prestroke confounders (age, hypertension, smoking status) explained greater risk of death in women (rehabilitation RRR 1.13 95% CI 0.87-1.48; death RRR 0.75 95% CI 0.51-1.10). Neurological complications (DCI and hydrocephalus) were covariates explaining some of the greater risk for poor outcomes in women (rehabilitation RRR 0.87 95% CI 0.69-1.11; death RRR 0.80 95% CI 0.52-1.23). Results were consistent in propensity score matched models. CONCLUSION The marginally poorer outcome in women at discharge was partially attributable to prestroke confounders and complications. Improvements in managing complications could improve outcomes.
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Affiliation(s)
- Sabah Rehman
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Hobart, Australia
| | - Ronil V Chandra
- NeuroInterventional Radiology, Monash Health, Melbourne, Victoria, Australia
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Kevin Zhou
- NeuroInterventional Radiology, Monash Health, Melbourne, Victoria, Australia
| | - Darius Tan
- Neurosurgery, Monash Health, Melbourne, Victoria, Australia
| | - Leon Lai
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Neurosurgery, Monash Health, Melbourne, Victoria, Australia
| | - Hamed Asadi
- NeuroInterventional Radiology, Monash Health, Melbourne, Victoria, Australia
| | - Jens Froelich
- NeuroInterventional Radiology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Nova Thani
- Neurosurgery, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Linda Nichols
- School of Nursing, University of Tasmania, Hobart, Tasmania, Australia
| | - Leigh Blizzard
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Hobart, Australia
| | | | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | | | - Michele L Callisaya
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Hobart, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Monique Breslin
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Hobart, Australia
| | - Mathew J Reeves
- Department of Epidemiology, Michigan State University, East Lansing, MI, USA
| | - Seana Gall
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Hobart, Australia.
- Monash University, Melbourne, Victoria, Australia.
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Ilic I, Schuss P, Borger V, Hadjiathanasiou A, Vatter H, Fimmers R, Güresir E. Ventriculostomy with subsequent ventriculoperitoneal shunt placement after subarachnoid hemorrhage: the effect of implantation site on postoperative complications-a single-center series. Acta Neurochir (Wien) 2020; 162:1831-1836. [PMID: 32415487 DOI: 10.1007/s00701-020-04362-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Patients suffering from aneurysmal subarachnoid hemorrhage (SAH) with shunt-dependent hydrocephalus require subsequent placement of a ventriculoperitoneal shunt (VPS) after ventriculostomy. However, in patients with previous ventriculostomy, the site for proximal VPS catheter placement is still controversial. We investigated the effect of catheter placement on postoperative complications by analyzing patients with ventriculostomy and subsequent VPS placement after SAH. METHODS From January 2004 to December 2018, 164 of 1128 patients suffering from SAH underwent subsequent VPS placement after ventriculostomy in the authors' institution. Patients were divided into two groups according to the position of the ventriculostomy and the site of the proximal VPS catheter ("same site" group versus "contralateral site" group). VPS-related infectious and bleeding complications following VPS placement were assessed and analyzed. RESULTS Overall, VPS-related infections occurred in 11 of the 164 patients (7%). Furthermore, five of the 164 patients (3%) suffered from VPS-related hemorrhage. However, VPS infection rate was lower 5% (6/115) in the same site compared to 10% (5/49) in the contralateral site group, although without reaching statistical significance (OR = 0.48 (0.14, 1.67) 95% confidence interval, p = 0.3). VPS-related hemorrhage rate did not differ significantly between patients in the same site group (3.5%, 4/115) and the contralateral site group (2.0%, 1/49; OR = 1.73 (0.18, 15.9), p = 1.0). CONCLUSIONS Our study suggests that the use of the ventriculostomy site for VPS placement does not significantly increase the risk of either VPS-related infections or VPS-related hemorrhages.
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Arnts H, van Erp WS, Sanz LRD, Lavrijsen JCM, Schuurman R, Laureys S, Vandertop WP, van den Munckhof P. The Dilemma of Hydrocephalus in Prolonged Disorders of Consciousness. J Neurotrauma 2020; 37:2150-2156. [PMID: 32484029 DOI: 10.1089/neu.2020.7129] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Prolonged disorders of consciousness (DOC) are considered to be among the most severe outcomes after acquired brain injury. Medical care for these patients is mainly focused on minimizing complications, given that treatment options for patients with unresponsive wakefulness or minimal consciousness remain scarce. The complication rate in patients with DOC is high, both in the acute hospital setting, as in the rehabilitation or long-term care phase. Hydrocephalus is one of these well-known complications and usually develops quickly after acute changes in cerebrospinal fluid (CSF) circulation after different types of brain damage. However, hydrocephalus may also develop with a significant delay, weeks, or even months after the initial injury, reducing the potential for natural recovery of consciousness. In this phase, hydrocephalus is likely to be missed in DOC patients, given that their limited behavioral responsiveness camouflages the classic signs of increased intracranial pressure or secondary normal-pressure hydrocephalus. Moreover, the development of late-onset hydrocephalus may exceed the period of regular outpatient follow-up. Several controversies remain about the diagnosis of clinical hydrocephalus in patients with ventricular enlargement after severe brain injury. In this article, we discuss both the difficulties in diagnosis and dilemmas in the treatment of CSF disorders in patients with prolonged DOC and review evidence from the literature to advance an active surveillance protocol for the detection of this late, but treatable, complication. Moreover, we advocate a low threshold for CSF diversion when hydrocephalus is suspected, even months or years after brain injury.
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Affiliation(s)
- Hisse Arnts
- Department of Neurosurgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Willemijn S van Erp
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands.,GIGA Consciousness, University of Liège, Liège, Belgium; Coma Science Group, University Hospital of Liège, Liège, Belgium
| | - Leandro R D Sanz
- GIGA Consciousness, University of Liège, Liège, Belgium; Coma Science Group, University Hospital of Liège, Liège, Belgium
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rick Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Steven Laureys
- GIGA Consciousness, University of Liège, Liège, Belgium; Coma Science Group, University Hospital of Liège, Liège, Belgium
| | - William P Vandertop
- Department of Neurosurgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Gerner ST, Reichl J, Custal C, Brandner S, Eyüpoglu IY, Lücking H, Hölter P, Kallmünzer B, Huttner HB. Long-Term Complications and Influence on Outcome in Patients Surviving Spontaneous Subarachnoid Hemorrhage. Cerebrovasc Dis 2020; 49:307-315. [DOI: 10.1159/000508577] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/06/2020] [Indexed: 11/19/2022] Open
Abstract
Background: While the short-term clinical outcome of patients with subarachnoid hemorrhage (SAH) is well described, there are limited data on long-term complications and their impact on social reintegration. This study aimed to assess the frequency of complications post-SAH and to investigate whether these complications attribute to functional and self-reported outcomes as well as the ability to return to work in these patients. Methods: This retrospective single-center study included patients with atraumatic SAH over a 5-year period at a tertiary care center. Patients received a clinical follow-up for 12 months. In addition to demographics, imaging data, and parameters of acute treatment, the rate and extent of long-term complications after SAH were recorded. The functional outcome was assessed using the modified Rankin Scale (mRS; favorable outcome defined as mRS = 0–2). Further outcomes comprised self-reported subjective health measured by the EQ-5D and return to work for SAH patients with appropriate age. Multivariable analyses including in-hospital parameters and long-term complications were conducted to identify parameters independently associated with outcomes in SAH survivors. Results: This study cohort consisted of 505 SAH patients of whom 405 survived the follow-up period of 12 months (i.e., mortality rate of 19.8%). Outcome data were available in 359/405 (88.6%) patients surviving SAH. At 12 months, a favorable functional outcome was achieved in 287/359 (79.9%) and 145/251 (57.8%) SAH patients returned to work. The rates of post-acute complications were headache (32.3%), chronic hydrocephalus requiring permanent ventriculoperitoneal shunting (VP shunt 25.4%) and epileptic seizures (9.5%). Despite patient’s and clinical characteristics, both presence of epilepsy and need for VP shunt were independently and negatively associated with a favorable functional outcome (epilepsy: adjusted odds ratio [aOR] (95% confidence interval [95% CI]): 0.125 [0.050–0.315]; VP shunt: 0.279 [0.132–0.588]; both p < 0.001) as well as with return to work (aOR [95% CI]: epilepsy 0.195 [0.065–0.584], p = 0.003; VP shunt 0.412 [0.188–0.903], p = 0.027). Multivariable analyses revealed presence of headache, VP shunt, or epilepsy to be significantly related to subjective health impairment (aOR [95% CI]: headache 0.248 [0.143–0.430]; epilepsy 0.223 [0.085–0.585]; VP shunt 0.434 [0.231–0.816]; all p < 0.01). Conclusions: Long-term complications occur frequently after SAH and are associated with an impairment of functional and social outcomes. Further studies are warranted to investigate if treatment strategies specifically targeting these complications, including preventive aspects, may improve the outcomes after SAH.
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Yee SV, Ghani AR, Raffiq A. Review of CHESS Score in SAH Patients in Local Malaysian Population. J Neurosci Rural Pract 2020; 11:113-118. [PMID: 32140013 PMCID: PMC7055635 DOI: 10.1055/s-0039-3402573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Sze-Voon Yee
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.,Department of Neurosurgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Abdul Rahman Ghani
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Azman Raffiq
- Department of Neurosurgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
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Roethlisberger M, Moffa G, Fisch U, Wiggli B, Schoen S, Kelly C, Leu S, Croci D, Zumofen DW, Cueni N, Nogarth D, Schulz M, Bucher HC, Weisser-Rohacek M, Wasner MG, Widmer AF, Mariani L. Effectiveness of a Chlorhexidine Dressing on Silver-coated External Ventricular Drain-associated Colonization and Infection: A Prospective Single-blinded Randomized Controlled Clinical Trial. Clin Infect Dis 2019; 67:1868-1877. [PMID: 29733329 DOI: 10.1093/cid/ciy393] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/02/2018] [Indexed: 11/14/2022] Open
Abstract
Background Observational studies have shown that dressings containing chlorhexidine gluconate (CHX) lower the incidence external ventricular drain (EVD)-associated infections (EVDAIs). This prospective, randomized controlled trial (RCT) studies the efficacy of CHX-containing dressings in reducing bacterial colonization. Methods In this RCT, patients aged ≥18 years undergoing emergency EVD placement were randomly given either a CHX-containing or an otherwise identical control dressing at the skin exit wound. The primary end-point was bacterial regrowth in cultured skin swab samples of the EVD exit wound. The secondary end-points were catheters processed by sonication, clinically diagnosed EVDAI and surgical treatment of hydrocephalus. Results From October 2013 to January 2016, a total of 57 patients were randomized to receive either a CHX or a control dressing (29 and 28 patients, respectively). Cutaneous bacterial regrowth at the EVD exit wound was significantly reduced over time (geometric mean ratio, 0.18; 95% confidence interval, .08-.42; P < .001). The incidence of colonized catheters was lower in the CHX group (5 of 28; 18%) than in the control group (10 of 27; 33%), with less microbial colonization on the subcutaneous portion. The infection rate was 4 of 28 (14%) in the CHX group, compared with 7 of 27 (26%) in the control group, with a substantially lower hydrocephalus treatment rate (7 of 28 [25%] vs 14 of 27 [52%], respectively). Conclusion Our data support the use of CHX dressings to reduce EVD exit site contamination, potentially reducing EVDAIs and permanent cerebrospinal fluid diversion procedures for hydrocephalus. Clinical Trials Registration NCT02078830.
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Affiliation(s)
| | - Giusi Moffa
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University of Basel, Switzerland
| | - Urs Fisch
- Department of Neurosurgery, University of Basel, Switzerland
| | - Benedikt Wiggli
- Department of Infectious Diseases & Hospital Epidemiology, University of Basel, Switzerland
| | - Stephan Schoen
- Department of Neurosurgery, University of Basel, Switzerland
| | | | - Severina Leu
- Department of Neurosurgery, University of Basel, Switzerland
| | - Davide Croci
- Department of Neurosurgery, University of Basel, Switzerland
| | | | - Nadine Cueni
- Department of Anaesthesiology and Intensive-Care, University of Basel, Switzerland
| | - Danica Nogarth
- Department of Infectious Diseases & Hospital Epidemiology, University of Basel, Switzerland.,Division of Clinical Microbiology, University Hospital Basel, University of Basel, Switzerland
| | - Marianne Schulz
- Department of Neurosurgery, University of Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University of Basel, Switzerland
| | | | | | - Andreas F Widmer
- Department of Infectious Diseases & Hospital Epidemiology, University of Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University of Basel, Switzerland
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Huhtakangas J, Lehecka M, Lehto H, Rezai Jahromi B, Niemelä M, Kivisaari R. Riskier-than-expected occlusive treatment of ruptured posterior communicating artery aneurysms: treatment and outcome of 620 consecutive patients. J Neurosurg 2019; 131:1269-1277. [PMID: 30485236 DOI: 10.3171/2018.4.jns18145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Occlusive treatment of posterior communicating artery (PCoA) aneurysms has been seen as a fairly uncomplicated procedure. The objective here was to determine the radiological and clinical outcome of patients after PCoA aneurysm rupture and treatment and to evaluate the risk factors for impaired outcome. METHODS In a retrospective clinical follow-up study, data were collected from 620 consecutive patients who had been treated for ruptured PCoA aneurysms at a single center between 1980 and 2014. The follow-up was a minimum of 1 year after treatment or until death. RESULTS Of the 620 patients, 83% were treated with microsurgical clipping, 8% with endovascular coiling, 2% with the two procedures combined, 1% with indirect surgical methods, and 6% with conservative methods. The most common procedural complications were treatment-related brain infarctions (15%). The occurrence of artery occlusions (10% microsurgical, 8% endovascular) was higher than expected. Most patients made a good recovery at 1 year after aneurysmal subarachnoid hemorrhage (modified Rankin Scale [mRS] score 0-2: 386 patients [62%]). A fairly small proportion of patients were left severely disabled (mRS score 4-5: 27 patients [4%]). Among all patients, 20% died during the 1st year. Independent risk factors for an unfavorable outcome, according to the multivariable analysis, were poor preoperative clinical condition, intracerebral or subdural hematoma due to aneurysm rupture, age over 65 years, artery occlusion on postoperative angiography, occlusive treatment-related ischemia, delayed cerebral vasospasm, and hydrocephalus requiring a shunt. CONCLUSIONS Even though most patients made a good recovery after PCoA aneurysm rupture and treatment during the 1st year, the occlusive treatment-related complications were higher than expected and caused morbidity even among initially good-grade patients. Occlusive treatment of ruptured PCoA aneurysms seems to be a high-risk procedure, even in a high-volume neurovascular center.
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Han MH, Won YD, Na MK, Kim CH, Kim JM, Ryu JI, Yi HJ, Cheong JH. Association Between Possible Osteoporosis and Shunt-Dependent Hydrocephalus After Subarachnoid Hemorrhage. Stroke 2019; 49:1850-1858. [PMID: 29946014 DOI: 10.1161/strokeaha.118.021063] [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] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Pathological obstruction in arachnoid granulations after subarachnoid hemorrhage (SAH) can impede cerebrospinal fluid flow outward to the venous sinus and causing hydrocephalus. Because bone and arachnoid granulations share the same collagen type, we evaluated the possible relation between bone mineral density and shunt-dependent hydrocephalus after SAH. Methods- We measured Hounsfield units of the frontal skull on admission brain computed tomography in patients with SAH. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff Hounsfield unit in skull to predict osteopenia and osteoporosis in a large sample registry. According to the optimal cutoff skull Hounsfield unit values, study patients were then categorized as hypothetical normal, osteopenia, and osteoporosis. Odds ratios were estimated using logistic regression to determine whether the osteoporotic conditions are independent predictive factors for the development of shunt-dependent hydrocephalus after clipping for SAH. Results- A total of 447 patients (alive ≥14 days) with ruptured aneurysm SAH who underwent surgical clipping were retrospectively enrolled in this study during a 9-year period from 2 hospitals. We found that hypothetical osteoporosis was an independent predictor for shunt-dependent hydrocephalus after aneurysmal clipping for SAH after full adjustment for other predictive factors, including age (odds ratio, 2.08; 95% confidence interval, 1.06-4.08; P=0.032). Conclusions- Our study demonstrates a possible relation between possible osteoporosis and hydrocephalus after SAH. Hounsfield unit measurement on admission brain computed tomography may be helpful for predicting hydrocephalus during the clinical course of SAH in patients with osteoporosis or suspected osteoporosis.
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Affiliation(s)
- Myung-Hoon Han
- From the Department of Neurosurgery, Hanyang University Guri Hospital, Korea (M.-H.H., Y.D.W., M.K.N., C.H.K., J.M.K., J.I.R., J.H.C.)
| | - Yu Deok Won
- From the Department of Neurosurgery, Hanyang University Guri Hospital, Korea (M.-H.H., Y.D.W., M.K.N., C.H.K., J.M.K., J.I.R., J.H.C.)
| | - Min Kyun Na
- From the Department of Neurosurgery, Hanyang University Guri Hospital, Korea (M.-H.H., Y.D.W., M.K.N., C.H.K., J.M.K., J.I.R., J.H.C.)
| | - Choong Hyun Kim
- From the Department of Neurosurgery, Hanyang University Guri Hospital, Korea (M.-H.H., Y.D.W., M.K.N., C.H.K., J.M.K., J.I.R., J.H.C.)
| | - Jae Min Kim
- From the Department of Neurosurgery, Hanyang University Guri Hospital, Korea (M.-H.H., Y.D.W., M.K.N., C.H.K., J.M.K., J.I.R., J.H.C.)
| | - Je Il Ryu
- From the Department of Neurosurgery, Hanyang University Guri Hospital, Korea (M.-H.H., Y.D.W., M.K.N., C.H.K., J.M.K., J.I.R., J.H.C.)
| | - Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea (H.-J.Y.)
| | - Jin Hwan Cheong
- From the Department of Neurosurgery, Hanyang University Guri Hospital, Korea (M.-H.H., Y.D.W., M.K.N., C.H.K., J.M.K., J.I.R., J.H.C.)
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Paavola JT, Väntti N, Junkkari A, Huttunen TJ, von und zu Fraunberg M, Koivisto T, Kämäräinen OP, Lång M, Meretoja A, Räikkönen K, Viinamäki H, Jääskeläinen JE, Huttunen J, Lindgren AE. Antipsychotic Use Among 1144 Patients After Aneurysmal Subarachnoid Hemorrhage. Stroke 2019; 50:1711-1718. [DOI: 10.1161/strokeaha.119.024914] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background and Purpose—
At acute phase and neurointensive care, patients with aneurysmal subarachnoid hemorrhage (aSAH) may become agitated or delirious. We found no previous studies on psychotic disorders or antipsychotic drug (APD) use by long-term aSAH survivors. We defined the APD use and its risk factors among 12-month survivors of aSAH in an Eastern Finnish population–based cohort with long-term follow-up.
Methods—
We analyzed APD use in 1144 consecutive patients with aSAH alive at 12 months of the Kuopio intracranial aneurysm patient and family database and their age, sex, and birth municipality matched controls (3:1; n=3432) from 1995 to 2013 and median follow-up of 9 years. Using the Finish nationwide health registries, we obtained drug purchase and hospital discharge data.
Results—
In total, 140 (12%) of the 1144 patients started APD use first time after aSAH (index date), in contrast to 145 (4%) of the 3432 matched population controls. The cumulative rate of starting APD was 6% at 1 year and 9% at 5 years, in contrast to 1% and 2% in the controls, respectively. The rates at 1 and 5 years were only 1% and 2% in the 489 patients with a good condition (modified Rankin Scale score, 0 or 1 at 12 months; no shunt, intracerebral hemorrhage, or intraventricular hemorrhage). Instead, the highest rate of APD use, 23% at 5 years was among the 192 patients shunted for hydrocephalus after aSAH. Eighty-eight (63%) of the 140 aSAH patients with APD use had also concomitant antidepressant or antiepileptic drug use.
Conclusions—
The 12-month survivors of aSAH were significantly more likely to be started on APD after aSAH than their matched population controls. These patients often used antidepressant and antiepileptic drugs concomitantly. The use of APDs strongly correlated with signs of brain injury after aSAH, with low use if no signs of significant brain injury were present.
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Affiliation(s)
- Juho T. Paavola
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
- School of Medicine (J.T.P., N.V., O.-P.K., H.V., J.E.J., J.H.), University of Eastern Finland, Kuopio
| | - Nelli Väntti
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
- School of Medicine (J.T.P., N.V., O.-P.K., H.V., J.E.J., J.H.), University of Eastern Finland, Kuopio
| | - Antti Junkkari
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
| | - Terhi J. Huttunen
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
| | - Mikael von und zu Fraunberg
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
| | - Timo Koivisto
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
| | - Olli-Pekka Kämäräinen
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
- School of Medicine (J.T.P., N.V., O.-P.K., H.V., J.E.J., J.H.), University of Eastern Finland, Kuopio
| | - Maarit Lång
- Neurointensive Care, Institute of Clinical Medicine (M.L.), University of Eastern Finland, Kuopio
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Finland (A.M.)
- Department of Medicine at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (A.M.)
| | - Katri Räikkönen
- Department of Psychology and Logopedics, University of Helsinki, Finland (K.R.)
| | - Heimo Viinamäki
- Psychiatry (H.V.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
- School of Medicine (J.T.P., N.V., O.-P.K., H.V., J.E.J., J.H.), University of Eastern Finland, Kuopio
| | - Juha E. Jääskeläinen
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
- School of Medicine (J.T.P., N.V., O.-P.K., H.V., J.E.J., J.H.), University of Eastern Finland, Kuopio
| | - Jukka Huttunen
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
- School of Medicine (J.T.P., N.V., O.-P.K., H.V., J.E.J., J.H.), University of Eastern Finland, Kuopio
| | - Antti E. Lindgren
- From the Neurosurgery of NeuroCenter (J.T.P., N.V., A.J., T.J.H., M.v.u.z.F., T.K., O.-P.K., J.E.J., J.H., A.E.L.), Kuopio University Hospital and Institute of Clinical Medicine, Finland
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Kim JH, Kim JH, Kang HI, Kim DR, Moon BG, Kim JS. Risk Factors and Preoperative Risk Scoring System for Shunt-Dependent Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage. J Korean Neurosurg Soc 2019; 62:643-648. [PMID: 31064043 PMCID: PMC6835141 DOI: 10.3340/jkns.2018.0152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/12/2018] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Joo Hyun Kim
- Department of Neurosurgery, Eulji University Eulji Hospital, Seoul, South Korea
| | - Jae Hoon Kim
- Department of Neurosurgery, Eulji University Eulji Hospital, Seoul, South Korea
| | - Hee In Kang
- Department of Neurosurgery, Eulji University Eulji Hospital, Seoul, South Korea
| | - Deok Ryeong Kim
- Department of Neurosurgery, Eulji University Eulji Hospital, Seoul, South Korea
| | - Byung Gwan Moon
- Department of Neurosurgery, Eulji University Eulji Hospital, Seoul, South Korea
| | - Joo Seung Kim
- Department of Neurosurgery, Eulji University Eulji Hospital, Seoul, South Korea
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Koyanagi M, Fukuda H, Saiki M, Tsuji Y, Lo B, Kawasaki T, Ioroi Y, Fukumitsu R, Ishibashi R, Oda M, Narumi O, Chin M, Yamagata S, Miyamoto S. Effect of choice of treatment modality on the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage. J Neurosurg 2019; 130:949-955. [PMID: 29521594 DOI: 10.3171/2017.9.jns171806] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/25/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Shunt-dependent hydrocephalus (SDHC) may arise after aneurysmal subarachnoid hemorrhage (aSAH) as CSF resorptive mechanisms are disrupted. Using propensity score analysis, the authors aimed to investigate which treatment modality, surgical clipping or endovascular treatment, is superior in reducing rates of SDHC after aSAH. METHODS The authors' multicenter SAH database, comprising 3 stroke centers affiliated with Kyoto University, Japan, was used to identify patients treated between January 2009 and July 2016. Univariate and multivariate analyses were performed to characterize risk factors for SDHC after aSAH. A propensity score model was generated for both treatment groups, incorporating relevant patient covariates to detect any superiority for prevention of SDHC after aSAH. RESULTS A total of 566 patients were enrolled in this study. SDHC developed in 127 patients (22%). On multivariate analysis, age older than 53 years, the presence of intraventricular hematoma, and surgical clipping as opposed to endovascular coiling were independently associated with SDHC after aSAH. After propensity score matching, 136 patients treated with surgical clipping and 136 with endovascular treatment were matched. Propensity score-matched cohorts exhibited a significantly lower incidence of SDHC after endovascular treatment than after surgical clipping (16% vs 30%, p = 0.009; OR 2.2, 95% CI 1.2-4.2). SDHC was independently associated with poor neurological outcomes (modified Rankin Scale score 3-6) at discharge (OR 4.3, 95% CI 2.6-7.3; p < 0.001). CONCLUSIONS SDHC after aSAH occurred significantly more frequently in patients who underwent surgical clipping. Strategies for treatment of ruptured aneurysms should be used to mitigate SDHC and minimize poor outcomes.
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Affiliation(s)
- Masaomi Koyanagi
- 1Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji
| | - Hitoshi Fukuda
- 2Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki
| | - Masaaki Saiki
- 3Department of Neurosurgery, Otsu Red Cross Hospital, Otsu
| | | | - Benjamin Lo
- 4Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Yoshihiko Ioroi
- 1Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji
| | - Ryu Fukumitsu
- 3Department of Neurosurgery, Otsu Red Cross Hospital, Otsu
| | - Ryota Ishibashi
- 2Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki
| | - Masashi Oda
- 1Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji
| | - Osamu Narumi
- 1Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji
| | - Masaki Chin
- 2Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki
| | - Sen Yamagata
- 2Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki
| | - Susumu Miyamoto
- 5Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; and
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Ban VS, El Ahmadieh TY, Aoun SG, Plitt AR, Lyon KA, Eddleman C, Beecher J, McDougall CM, Reisch J, Welch BG, Samson D, Batjer HH, White J. Prediction of Outcomes for Ruptured Aneurysm Surgery. Stroke 2019; 50:595-601. [DOI: 10.1161/strokeaha.118.023771] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Vin Shen Ban
- From the Department of Neurological Surgery (V.S.B., T.Y.E.A., S.G.A., A.R.P., K.A.L., C.E., J.B., C.M.M., B.G.W., D.S., H.H.B., J.W.), University of Texas Southwestern Medical Center, Dallas
| | - Tarek Y. El Ahmadieh
- From the Department of Neurological Surgery (V.S.B., T.Y.E.A., S.G.A., A.R.P., K.A.L., C.E., J.B., C.M.M., B.G.W., D.S., H.H.B., J.W.), University of Texas Southwestern Medical Center, Dallas
| | - Salah G. Aoun
- From the Department of Neurological Surgery (V.S.B., T.Y.E.A., S.G.A., A.R.P., K.A.L., C.E., J.B., C.M.M., B.G.W., D.S., H.H.B., J.W.), University of Texas Southwestern Medical Center, Dallas
| | - Aaron R. Plitt
- From the Department of Neurological Surgery (V.S.B., T.Y.E.A., S.G.A., A.R.P., K.A.L., C.E., J.B., C.M.M., B.G.W., D.S., H.H.B., J.W.), University of Texas Southwestern Medical Center, Dallas
| | - Kristopher A. Lyon
- From the Department of Neurological Surgery (V.S.B., T.Y.E.A., S.G.A., A.R.P., K.A.L., C.E., J.B., C.M.M., B.G.W., D.S., H.H.B., J.W.), University of Texas Southwestern Medical Center, Dallas
| | - Christopher Eddleman
- From the Department of Neurological Surgery (V.S.B., T.Y.E.A., S.G.A., A.R.P., K.A.L., C.E., J.B., C.M.M., B.G.W., D.S., H.H.B., J.W.), University of Texas Southwestern Medical Center, Dallas
| | - Jeffrey Beecher
- From the Department of Neurological Surgery (V.S.B., T.Y.E.A., S.G.A., A.R.P., K.A.L., C.E., J.B., C.M.M., B.G.W., D.S., H.H.B., J.W.), University of Texas Southwestern Medical Center, Dallas
| | - Cameron M. McDougall
- From the Department of Neurological Surgery (V.S.B., T.Y.E.A., S.G.A., A.R.P., K.A.L., C.E., J.B., C.M.M., B.G.W., D.S., H.H.B., J.W.), University of Texas Southwestern Medical Center, Dallas
- Department of Radiology (C.M.M., B.G.W.), University of Texas Southwestern Medical Center, Dallas
| | - Joan Reisch
- Department of Clinical Sciences (J.R.), University of Texas Southwestern Medical Center, Dallas
| | - Babu G. Welch
- From the Department of Neurological Surgery (V.S.B., T.Y.E.A., S.G.A., A.R.P., K.A.L., C.E., J.B., C.M.M., B.G.W., D.S., H.H.B., J.W.), University of Texas Southwestern Medical Center, Dallas
- Department of Radiology (C.M.M., B.G.W.), University of Texas Southwestern Medical Center, Dallas
| | - Duke Samson
- From the Department of Neurological Surgery (V.S.B., T.Y.E.A., S.G.A., A.R.P., K.A.L., C.E., J.B., C.M.M., B.G.W., D.S., H.H.B., J.W.), University of Texas Southwestern Medical Center, Dallas
| | - H. Hunt Batjer
- From the Department of Neurological Surgery (V.S.B., T.Y.E.A., S.G.A., A.R.P., K.A.L., C.E., J.B., C.M.M., B.G.W., D.S., H.H.B., J.W.), University of Texas Southwestern Medical Center, Dallas
| | - Jonathan White
- From the Department of Neurological Surgery (V.S.B., T.Y.E.A., S.G.A., A.R.P., K.A.L., C.E., J.B., C.M.M., B.G.W., D.S., H.H.B., J.W.), University of Texas Southwestern Medical Center, Dallas
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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 2018; 129:1166-1172. [PMID: 29243978 DOI: 10.3171/2017.5.jns163271] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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Lenski M, Biczok A, Huge V, Forbrig R, Briegel J, Tonn JC, Thon N. Role of Cerebrospinal Fluid Markers for Predicting Shunt-Dependent Hydrocephalus in Patients with Subarachnoid Hemorrhage and External Ventricular Drain Placement. World Neurosurg 2018; 121:e535-e542. [PMID: 30268545 DOI: 10.1016/j.wneu.2018.09.159] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/19/2018] [Accepted: 09/20/2018] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Markus Lenski
- Neurochirurgische Klinik und Poliklinik, Klinikum Großhadern, Ludwig Maximilian Universität, Munich, Germany.
| | - Annamaria Biczok
- Neurochirurgische Klinik und Poliklinik, Klinikum Großhadern, Ludwig Maximilian Universität, Munich, Germany
| | - Volker Huge
- Klinik für Anästhesiologie, Klinikum Großhadern, Ludwig Maximilian Universität, Munich, Germany
| | - Robert Forbrig
- Klinik für Neuroradiologie, Klinikum Großhadern, Ludwig Maximilian Universität, Munich, Germany
| | - Josef Briegel
- Klinik für Anästhesiologie, Klinikum Großhadern, Ludwig Maximilian Universität, Munich, Germany
| | - Jörg-Christian Tonn
- Neurochirurgische Klinik und Poliklinik, Klinikum Großhadern, Ludwig Maximilian Universität, Munich, Germany
| | - Niklas Thon
- Neurochirurgische Klinik und Poliklinik, Klinikum Großhadern, Ludwig Maximilian Universität, Munich, Germany
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