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Yamanaka T, Nishikawa Y, Iwata T, Shibata T, Uchida M, Hayashi Y, Katano H, Tanikawa M, Yamada S, Mase M. Preventive effect of intermittent cerebrospinal fluid drainage for secondary chronic hydrocephalus after aneurysmal subarachnoid hemorrhage. Fluids Barriers CNS 2023; 20:91. [PMID: 38057907 DOI: 10.1186/s12987-023-00486-5] [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: 06/14/2023] [Accepted: 10/31/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND The efficacy of intermittent cerebrospinal fluid (CSF) drainage compared with that of continuous CSF drainage in patients with subarachnoid hemorrhage (SAH) remains undetermined to date. Therefore, we investigated whether intermittent CSF drainage is effective in reducing secondary chronic hydrocephalus (sCH) after aneurysmal SAH. METHODS Overall, 204 patients (69 men and 135 women) treated for aneurysmal SAH between 2007 and 2022 were included in this study. Following SAH onset, 136 patients were managed with continuous CSF drainage, whereas 68 were managed with intermittent CSF drainage. Logistic regression analyses were used to calculate the age-adjusted and multivariate odds ratios for the development of sCH. The Cox proportional hazards regression model were used to compare the effects of intermittent and continuous CSF drainage on sCH development. RESULTS Overall, 96 patients developed sCH among the 204 patients with SAH. In total, 74 (54.4%) of the 136 patients managed with continuous CSF drainage developed sCH, whereas 22 (32.4%) of the 68 patients managed with intermittent CSF drainage developed sCH. This demonstrated that the rate of sCH development was significantly lower among patients managed with intermittent CSF drainage. Compared with continuous CSF drainage, intermittent CSF drainage exhibited a multivariate odds ratio (95% confidential interval) of 0.25 (0.11-0.57) for sCH development. Intermittent CSF drainage was more effective (0.20, 0.04-0.95) in patients with severe-grade SAH than in those with mild-grade SAH (0.33, 0.12-0.95). Intermittent CSF drainage was ineffective in patients with acute hydrocephalus (8.37, 0.56-125.2), but it was effective in patients without acute hydrocephalus (0.11, 0.04-0.31). CONCLUSIONS Compared with continuous CSF drainage, intermittent drainage is more effective in reducing sCH after aneurysmal SAH. Although intermittent drainage was ineffective in cases of co-occurrence of acute hydrocephalus, it was effective in reducing sCH development regardless of the severity of initial symptoms at SAH onset.
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Affiliation(s)
- Tomoyasu Yamanaka
- Department of Neurosurgery, Graduate School of Medical Science, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya City, Aichi, 467-8601, Japan
| | - Yusuke Nishikawa
- Department of Neurosurgery, Graduate School of Medical Science, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya City, Aichi, 467-8601, Japan
| | - Takashi Iwata
- Department of Neurosurgery, Nagoya City East Medical Center, Aichi, Japan
| | - Teishiki Shibata
- Department of Neurosurgery, Graduate School of Medical Science, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya City, Aichi, 467-8601, Japan
- Department of Neurosurgery, Nagoya City West Medical Center, Aichi, Japan
| | - Mitsuru Uchida
- Department of Neurosurgery, Graduate School of Medical Science, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya City, Aichi, 467-8601, Japan
| | - Yuki Hayashi
- Department of Neurosurgery, Graduate School of Medical Science, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya City, Aichi, 467-8601, Japan
| | - Hiroyuki Katano
- Department of Neurosurgery, Graduate School of Medical Science, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya City, Aichi, 467-8601, Japan
| | - Motoki Tanikawa
- Department of Neurosurgery, Graduate School of Medical Science, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya City, Aichi, 467-8601, Japan
| | - Shigeki Yamada
- Department of Neurosurgery, Graduate School of Medical Science, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya City, Aichi, 467-8601, Japan.
- Interfaculty Initiative in Information Studies, Institute of Industrial Science, The University of Tokyo, Tokyo, Japan.
| | - Mitsuhito Mase
- Department of Neurosurgery, Graduate School of Medical Science, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya City, Aichi, 467-8601, Japan.
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Pu J, Zhao YL, Gu YX, Hang CH, You YP, Wang MD, Qu Y, Lu H, Wang S. Chinese expert consensus on the management of aneurysmal subarachnoid hemorrhage-related hydrocephalus. Chin Neurosurg J 2023; 9:7. [PMID: 36935494 PMCID: PMC10026498 DOI: 10.1186/s41016-022-00314-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/25/2022] [Indexed: 03/21/2023] Open
Affiliation(s)
- Jun Pu
- Department of Neurosurgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yuan-Li Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu-Xiang Gu
- Huashan Hospital, Affiliated to Fudan University, Shanghai, China
| | - Chun-Hua Hang
- Nanjing Drum Tower Hospital, Nanjing University Medical College, Nanjing, China
| | - Yong-Ping You
- Department of Interventional Neuroradiology, Jiangsu Province Hospital, Nanjing, China
| | - Mao-de Wang
- First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yan Qu
- Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Hua Lu
- Department of Interventional Neuroradiology, Jiangsu Province Hospital, Nanjing, China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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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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Bershad EM, Suarez JI. Aneurysmal Subarachnoid Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00029-6] [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]
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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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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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Bhattacharjee S, Rakesh D, Ramnadha R, Manas P. Subarachnoid Hemorrhage and Hydrocephalus. Neurol India 2021; 69:S429-S433. [PMID: 35102999 DOI: 10.4103/0028-3886.332266] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hydrocephalus associated with subarachnoid hemorrhage is a common neurosurgical problem, the management of which is tailor-made to the patient. It is usually seen with an aneurysmal bleed and is independent of the primary modality of treatment. AIM This study aimed to provide a comprehensive overview of this important association and discuss the various available treatment modalities. MATERIALS AND METHODS A detailed review of the literature was done on the risk factors, pathogenesis, and treatment of hydrocephalus in the setting of subarachnoid hemorrhage. RESULTS Hydrocephalus occurs in 6% to 67% of subarachnoid hemorrhage (SAH). It may present as acute, subacute, or chronic at the time of presentation. Diagnosis is made with a plain computed tomography scan of the brain, and the treatment is observant, temporary, or permanent cerebrospinal fluid diversion. CONCLUSION Hydrocephalus associated with SAH interferes with the outcome of SAH. It prolongs the hospital stay, besides causing additional morbidity. The various risk factors, if present, should warn us to be vigilant, and management is definitely not uniform and is custom made to the patients' needs.
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Affiliation(s)
- Suchanda Bhattacharjee
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Das Rakesh
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Reddy Ramnadha
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Panigrahi Manas
- Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
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Torregrossa F, Grasso G. The Quest for Predictors of Shunt-Dependent Chronic Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: Toward a Tailored Approach for Permanent Shunt-Dependency Following Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2021; 157:96-98. [PMID: 34662659 DOI: 10.1016/j.wneu.2021.10.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 12/29/2022]
Affiliation(s)
- Fabio Torregrossa
- Neurosurgical Unit, Surgical Neuro-oncology Section, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Giovanni Grasso
- Neurosurgical Unit, Surgical Neuro-oncology Section, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy.
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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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Youn DH, Kim BJ, Kim Y, Jeon JP. Extracellular Mitochondrial Dysfunction in Cerebrospinal Fluid of Patients with Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2020; 33:422-428. [PMID: 31898178 DOI: 10.1007/s12028-019-00895-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mitochondrial dysfunction is related to brain ischemic injury and neural cell death. However, little is known about the association between mitochondrial dysfunction of cerebrospinal fluid (CSF) and delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). The objective of this study was to investigate whether extracellular CSF mitochondria might serve as a potential biomarker for DCI. METHODS CSF samples were serially collected at 1, 3, and 5 days following SAH in 33 patients (DCI, n = 12; and non-DCI, n = 21) who underwent coil embolization. To monitor mitochondrial membrane potentials, JC-1 dye was used. The ratio (red/green) of JC-1 was considered as an indicator of intact mitochondrial membrane potential. Flow cytometry was done to analyze extracellular mitochondria particles and their possible cellular origins. RESULTS DCI patients had lower JC-1 red/green ratios than non-DCI patients at 1 day (3.35 [3.20-3.75] vs. 3.70 [3.40-3.95] in non-DCI) and 3 days (4.65 [4.45-5.00] vs. 5.10 [4.65-5.30] in non-DCI) after SAH. At 5 days after SAH, JC-1 red/green ratio was significantly lower in DCI than that in non-DCI (3.05 [2.90-3.35] vs. 4.20 [4.10-4.50]; p < 0.01) patients. DCI patients had a higher percentage of vWF-positive mitochondria (40.10% [38.25%-44.90%] vs. 30.20% [25.70%-36.68%]) and a lower percentage of GLAST-positive mitochondria particles (26.85% [17.10%-30.00%] vs. 31.60% [26.70%-35.00%]) than non-DCI patients. However, there was no significant difference in CD45-positive (p = 0.369) or CD41/61-positive mitochondrial particles (p = 0.155) between the two groups of patients. CONCLUSIONS Mitochondrial membrane potential could be a marker of DCI. JC-1 ratios seemed to be able to predict future DCI onset. Further studies are needed to determine detailed mechanisms of extracellular mitochondria-mediated cell-to-cell signals in DCI.
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Affiliation(s)
- Dong Hyuk Youn
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon, Korea
| | - Bong Jun Kim
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon, Korea
| | - Youngmi Kim
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon, Korea
| | - Jin Pyeong Jeon
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon, Korea. .,Genetic and Research Inc, Chuncheon, Korea. .,Department of Neurosurgery, Hallym University College of Medicine, 77 Sakju-ro, Chuncheon, 24253, Republic of 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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Mao J, Zhu Q, Ma Y, Lan Q, Cheng Y, Liu G. Fenestration of Lamina Terminalis During Anterior Circulation Aneurysm Clipping on Occurrence of Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: Meta-Analysis. World Neurosurg 2019; 129:e1-e5. [PMID: 30780038 DOI: 10.1016/j.wneu.2019.01.270] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 01/28/2019] [Accepted: 01/30/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Shunt-dependent hydrocephalus (SDH) is a common complication after aneurysmal subarachnoid hemorrhage and affects its outcome significantly. Whether fenestration of the lamina terminalis (FLT) during anterior circulation aneurysm clipping for aneurysmal subarachnoid hemorrhage can decrease the occurrence of SDH is still controversial. METHODS Ovid and PubMed databases were retrieved by the following key words: "hydrocephalus," "subarachnoid hemorrhage," "aneurysm," "fenestration," and "lamina terminalis." The Cochran-Mantel-Haenszel test was used to compare overall incidence of SDH. RESULTS The literatures were searched, and 15 were included involving 2839 patients. The overall incidence of SDH in fenestrated cohort was 11.4%, compared with 15.3% in the nonfenestrated cohort (P = 0.008). The relative risk of SDH in fenestrated cohort was 0.67 (95% confidence interval 0.50-0.90). CONCLUSIONS This meta-analysis suggests that FLT during anterior circulation aneurysm clipping reduces the incidence of SDH. However, a well-designed, randomized controlled trial is necessary to prove the efficacy of FLT to reduce SDH.
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Affiliation(s)
- Jinning Mao
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qing Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Ying Ma
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qing Lan
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yuan Cheng
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guodong Liu
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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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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Microsurgical Vascular Manipulation in Aneurysm Surgery and Delayed Ischemic Injury. Can J Neurol Sci 2017; 44:410-414. [PMID: 28767031 DOI: 10.1017/cjn.2016.408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The role of aggressive surgical manipulation with clot evacuation, arachnoid dissection, and papaverine-guided adventitial dissection of large vessels during ruptured aneurysm surgery in reducing vasospasm is controversial. Here we describe a single-institution experience in aneurysm surgery outcomes with and without aggressive surgery. METHODS We performed retrospective analysis of all patients >18 years of age with subarachnoid hemorrhage (SAH) from anterior circulation aneurysms between 2008 and 2013 at the University of New Mexico Hospital. Vasospasm was characterized on days 3 through 14 after SAH based on: (1) angiography, (2) vasospasm requiring angiographic intervention, (3) development of delayed ischemic neurologic deficit (DIND), and (4) radiological appearance of new strokes. RESULTS Of 159 patients, 114 (71.6%) had "aggressive" and 45 (28.3%) had standard microsurgery. More than 60% of patients presented with a Hunt and Hess score of ≥3 and a Fisher grade (FG) of 4. Compared with standard surgery, there was a statistically significant decrease in the incidence of DIND in patients undergoing aggressive surgery (18.4% vs 37.8%, p=0.01). Moreover, there was a reduction in the number of new strokes by 30% in the aggressive surgery group with moderate or higher degrees of vasospasm (46.0% vs 76.5%, p=0.06). In the same group with FG 4 SAH, however, this difference was more than 50% (30% vs 64.7%, p=0.02). CONCLUSIONS We conclude that aggressive surgical manipulation during aneurysm surgery results in lower incidence of DIND and new strokes. This effect is most pronounced in patients with FG 4 SAH.
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Xie Z, Hu X, Zan X, Lin S, Li H, You C. Predictors of Shunt-dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage? A Systematic Review and Meta-Analysis. World Neurosurg 2017; 106:844-860.e6. [PMID: 28652120 DOI: 10.1016/j.wneu.2017.06.119] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 06/17/2017] [Accepted: 06/19/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hydrocephalus is a well-recognized complication after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to identify predictors for shunt-dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis. METHODS A systematic search was conducted using the Embase, MEDLINE, and Web of Science databases for studies pertaining to aSAH and SDHC. Risk factors were assessed by meta-analysis when they were reported by at least 2 studies. The results were presented as odd ratios or risk ratios according to the study design with the corresponding 95% confidence intervals (CI). RESULTS Twenty-five studies were included. In primary analysis of 14 potential risk factors, 12 were identified as predictors of SDHC after aSAH including age ≥50 years, female gender, high Hunt-Hess grade, Glasgow Coma Scale ≤8, Fisher grade ≥3, acute hydrocephalus, external ventricular drainage insertion, intraventricular hemorrhage, postcirculation aneurysm, anterior communicating artery aneurysm, meningitis, and rebleeding. The meta-analysis based on cohort studies found a significantly increased risk for SDHC in patients with aSAH treated by coiling (risk ratio, 1.16; 95% CI, 1.05-1.29), while the meta-analysis based on case-controlled studies failed to replicate this finding (odds ratio, 1.27; 95% CI, 0.95-1.71). CONCLUSIONS Several new predictors of SDHC after aSAH were identified that may assist with the early recognition and prevention of SDHC. The controversial evidence found in this study was insufficient to support the potential of neurosurgical clipping for reducing the risk of shunt dependency. Further well-designed studies are warranted to explore the effect of treatment modality on SDHC risk.
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Affiliation(s)
- Zhiyi Xie
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xin Zan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sen Lin
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Xie Z, Hu X, Li H, Lin S, You C. Letter to the Editor: Risk factors for shunt dependency after aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 126:652-654. [DOI: 10.3171/2016.5.jns161244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Tao C, Fan C, Hu X, Ma J, Ma L, Li H, Liu Y, Sun H, He M, You C. The effect of fenestration of the lamina terminalis on the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (FISH): Study protocol for a randomized controlled trial. Medicine (Baltimore) 2016; 95:e5727. [PMID: 28033279 PMCID: PMC5207575 DOI: 10.1097/md.0000000000005727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Shunt-dependent hydrocephalus (SDH) is a well-known sequela following aneurysmal hemorrhage, adversely affecting the outcome after securing ruptured aneurysm. Fenestration of lamina terminalis (FLT) creates an anterior ventriculostomy, facilitates cerebrospinal fluid circulation and clot clearance in the basal cistern. However, controversy exists over whether microsurgical FLT during aneurysm repair can decrease the incidence of SDH. AIMS The study is designed to determine the efficacy of lamina terminalis fenestration on the reduction of SDH after aneurysm clipping. METHODS/DESIGN A total of 288 patients who meet the inclusion criteria will be randomized into single aneurysm clipping or aneurysm clipping plus FLT in the Department of Neurosurgery, West China Hospital. Follow-up was performed 1, 3, 6, and 12 months after aneurysm clipping. The primary outcome is the incidence of SDH and the secondary outcomes include cerebral vasospasm, functional outcome evaluated by the modified Rankin Scale and Extended Glasgow Outcome Scale, and mortality. DISCUSSION The FISH trial is a large randomized, parallel controlled clinical trial to define the therapeutic value of FLT, the results of which will help to guide the surgical procedure and resolve the long-puzzled debate in the neurosurgical community. CONCLUSIONS This protocol will determine the efficacy of FLT in the setting of aneurysmal subarachnoid hemorrhage. TRIAL REGISTRATION IDENTIFIER CHINESE CLINICAL TRIAL REGISTRY:: ChiCTR-INR-16009249.
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Adams H, Ban VS, Leinonen V, Aoun SG, Huttunen J, Saavalainen T, Lindgren A, Frosen J, Fraunberg M, Koivisto T, Hernesniemi J, Welch BG, Jaaskelainen JE, Huttunen TJ. Risk of Shunting After Aneurysmal Subarachnoid Hemorrhage. Stroke 2016; 47:2488-96. [DOI: 10.1161/strokeaha.116.013739] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 08/05/2016] [Indexed: 01/30/2023]
Abstract
Background and Purpose—
Shunt dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) is a common sequela that may lead to poor neurological outcome and predisposes to various interventions, admissions, and complications. We reviewed post-aSAH shunt dependency in a population-based sample and tested the feasibility of a clinical risk score to identify subgroups of aSAH patients with increasing risk of shunting for hydrocephalus.
Methods—
A total of 1533 aSAH patients from the population-based Eastern Finland Saccular Intracranial Aneurysm Database (Kuopio, Finland) were used in a recursive partitioning analysis to identify risk factors for shunting after aSAH. The risk model was built and internally validated in random split cohorts. External validation was conducted on 946 aSAH patients from the Southwestern Tertiary Aneurysm Registry (Dallas, TX) and tested using receiver-operating characteristic curves.
Results—
Of all patients alive ≥14 days, 17.7% required permanent cerebrospinal fluid diversion. The recursive partitioning analysis defined 6 groups with successively increased risk for shunting. These groups also successively risk stratified functional outcome at 12 months, shunt complications, and time-to-shunt rates. The area under the curve–receiver-operating characteristic curve for the exploratory sample and internal validation sample was 0.82 and 0.78, respectively, with an external validation of 0.68.
Conclusions—
Shunt dependency after aSAH is associated with higher morbidity and mortality, and prediction modeling of shunt dependency is feasible with clinically useful yields. It is important to identify and understand the factors that increase risk for shunting and to eliminate or mitigate the reversible factors. The aSAH-PARAS Consortium (Aneurysmal Subarachnoid Hemorrhage Patients’ Risk Assessment for Shunting) has been initiated to pool the collective insights and resources to address key questions in post-aSAH shunt dependency to inform future aSAH treatment guidelines.
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Affiliation(s)
- Hadie Adams
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Vin Shen Ban
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Ville Leinonen
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Salah G. Aoun
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Jukka Huttunen
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Taavi Saavalainen
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Antti Lindgren
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Juhana Frosen
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Mikael Fraunberg
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Timo Koivisto
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Juha Hernesniemi
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Babu G. Welch
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Juha E. Jaaskelainen
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Terhi J. Huttunen
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
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Hatefi M, Azhary S, Naebaghaee H, Mohamadi HR, Jaafarpour M. The Effect of Fenestration of Lamina Terminalis on the Vasospasm and Shunt-Dependent Hydrocephalus in Patients Following Subarachnoid Haemorrhage. J Clin Diagn Res 2015; 9:PC15-8. [PMID: 26393164 DOI: 10.7860/jcdr/2015/13603.6264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 05/19/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS SAH (Sub Arachnoid Haemorrhage) is a life threatening that is associated with complications such as vasospasm and shunt-dependent hydrocephalus. The purpose of this study was to assess the effect of FLT (Fenestration of Lamina Terminalis) on the incidence of vasospasm and shunt-dependent hydrocephalus in ACoA (Anterior Communicating Artery) aneurismal in SAH. MATERIALS AND METHODS The data of 50 ruptured ACoA aneurism patients were selected during the year 2001-2009 admitted to Imam Hussein hospital, Tehran, IR. In a randomized double-blind trial patients assigned in two group {with fenestration (FLT, n=25), without fenestration (No FLT, n=25)}. All patients underwent craniotomy by a single neurosurgeon. Patient's age, sex, Hunt-Hess grade, Fisher grade, vasospasm, presence of hydrocephalus and incidences of shunt-dependent hydrocephalus were compared between groups. RESULTS There were no significant differences among groups in relation to demographic characteristics, neurological scale scores (Hunt-Hess grade) and the severity of the SAH (Fisher grade) (p>0.05). The rate of hydrocephalus on admission, were 24% and 16% in FLT and no FLT group respectively (p>0.05). The shunt placement postoperatively in FLT and no FLT group were 16% and 12% respectively (p>0.05). The clinical vasospasm was 20% and 24% in FLT and no FLT group respectively (p>0.05). CONCLUSION Despite FLT can be a safe method there were not significant differences of FLT on the incidence of vasospasm and shunt-dependent hydrocephalus. A systematic evaluation with multisurgeon, multicentre and with greater sample size to disclose reality is suggested.
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Affiliation(s)
- Masoud Hatefi
- Neurosurgeon, Department of Neurosurgery, Medicine Faculty , Ilam University of Medical Science , Ilam, IR-Iran
| | - Shirzad Azhary
- Neurosurgeon, Department of Neurosurgery, Imam Hussein Hospital, Shahid Beheshti University of Medical Sciences , Tehran, IR- Iran
| | - Hussein Naebaghaee
- Neurosurgeon, Department of Neurosurgery, Imam Hussein Hospital, Shahid Beheshti University of Medical Sciences , Tehran, IR- Iran
| | - Hasan Reza Mohamadi
- Neurosurgeon, Department of Neurosurgery, Imam Hussein Hospital, Shahid Beheshti University of Medical Sciences , Tehran, IR- Iran
| | - Molouk Jaafarpour
- Department of Midwifery, Nursing & amp, Midwifery Faculty, Ilam University of Medical Science , IR-Iran
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Tomasello F, Angileri FF, Cardali S, Conti A. Letter to the Editor: Lamina terminalis fenestration. J Neurosurg 2014; 121:219-20. [DOI: 10.3171/2014.2.jns14191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Chohan MO, Carlson AP, Hart BL, Yonas H. Lack of functional patency of the lamina terminalis after fenestration following clipping of anterior circulation aneurysms. J Neurosurg 2013; 119:629-33. [PMID: 23808534 DOI: 10.3171/2013.5.jns13251] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Fenestration of the lamina terminalis (FLT) during aneurysm surgery for subarachnoid hemorrhage can, in theory, improve CSF circulation from the lateral and third ventricles to the cortical subarachnoid space, which may, in turn, decrease the incidence of hydrocephalus and vasospasm. However, the actual effects of FLT on CSF circulation have been difficult to determine, due to confounding factors. In addition, it is unclear whether the lamina terminalis remains functionally patent when the brain resumes its normal position. The goal of this study was to assess the functional patency of the fenestrated lamina terminalis in patients who underwent surgery for ruptured aneurysms. METHODS This prospective study included 15 patients who underwent surgical clipping of ruptured anterior circulation aneurysms, with FLT performed during surgery. On postoperative Day 1, the external ventricular drain of each patient was closed, and 1 ml of Omnipaque 300, an iodine based contrast agent, was injected intraventricularly, accompanied by cranial maneuvering designed to position the contrast agent adjacent to the lamina terminalis. Three to 5 minutes after cranial maneuvering, the flow of contrast agent into the basal cisterns was assessed with CT imaging. Flow was verified by an increase in Hounsfield units in a prespecified "region of interest" within the basal cisterns on the CT scan. This procedure was performed using a standardized protocol designed in consultation with the Department of Radiology and approved by the institutional review board. One patient who underwent endoscopic third ventriculostomy was recruited as a positive control to validate the technique, and 1 patient who underwent aneurysm clipping but not FLT was recruited as a negative control. RESULTS Seventeen patients consented to study participation. In the 15 patients who underwent aneurysm clipping and FLT, and the negative control patient who underwent aneurysm clipping but not FLT, the contrast agent followed the normal ventricular pathway from the lateral ventricles into the fourth ventricle, and did not appear in the basal cisterns. In the positive control patient, the contrast agent robustly and immediately filled the basal cisterns. CONCLUSIONS Fenestration of the lamina terminalis did not result in functional patency of the lamina terminalis when performed as part of surgical clipping for ruptured aneurysms.
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Affiliation(s)
- Muhammad Omar Chohan
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico 87131, USA.
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Caplan JM, Colby GP, Coon AL, Huang J, Tamargo RJ. Managing subarachnoid hemorrhage in the neurocritical care unit. Neurosurg Clin N Am 2013; 24:321-37. [PMID: 23809028 DOI: 10.1016/j.nec.2013.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patients with aneurysmal subarachnoid hemorrhage who survive the initial hemorrhage require complex interventions to occlude the aneurysm, typically followed by a prolonged intensive care unit and hospital course to manage the complications that follow. Much of the morbidity and mortality from this disease happens in delayed fashion in the neurocritical care unit. Despite progress made in the last decades, much remains to be understood about this disease and how to best manage these patients. This article provides a review of current evidence and the authors' experience, aimed at providing practical aid to those caring for patients with this disease.
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Affiliation(s)
- Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Room 6007, Baltimore, MD 21287, USA
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Tubbs RS, Nguyen HS, Loukas M, Cohen-Gadol AA. Anatomic study of the lamina terminalis: neurosurgical relevance in approaching lesions within and around the third ventricle. Childs Nerv Syst 2012; 28:1149-56. [PMID: 22678496 DOI: 10.1007/s00381-012-1831-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 05/28/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND The lamina terminalis (LT) represents an important neurosurgical corridor by which to fenestrate the third ventricle into the subarachnoid space or to approach lesions of the third ventricle. However, a comprehensive review of its anatomy and approaches to it for various pathologies is lacking in the literature. We studied the anatomy of the LT in 21 cadavers and described the LT as observed in cadaveric dissections. We also reviewed the literature regarding the detailed anatomy and pathology of the LT. In addition, a case illustration that demonstrates the use of this structure as a corridor to third ventricular tumors is presented. Our aim was to explore the anatomy of the LT through cadaveric dissection, a review of the literature, and a case study. METHODS Twenty-one adult cadaver heads underwent microdissection of the LT with a focus on the working distance available to enter the third ventricle and related vascular structures. RESULTS Inferior to the anterior communicating artery was the safer region to open due to the lack of perforating arteries. A working distance of approximately 1 cm can be expected through the LT. CONCLUSIONS This information may aid neurosurgeons during approaches through and around the LT.
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Affiliation(s)
- R Shane Tubbs
- Pediatric Neurosurgery, Children's Hospital, Birmingham, Birmingham, AL, USA.
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Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012; 43:1711-37. [PMID: 22556195 DOI: 10.1161/str.0b013e3182587839] [Citation(s) in RCA: 2269] [Impact Index Per Article: 189.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). METHODS A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years. RESULTS Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications. CONCLUSIONS aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.
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Mura J, Torche E. Re: The method of aneurysm treatment does not affect clot clearance after aneurysmal subarachnoid hemorrhage. Neurosurgery 2012; 70:E1336-7; author reply E1337-9. [PMID: 22513810 DOI: 10.1227/neu.0b013e31824ae70d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Hoh BL, Kleinhenz DT, Chi YY, Mocco J, Barker FG. Incidence of ventricular shunt placement for hydrocephalus with clipping versus coiling for ruptured and unruptured cerebral aneurysms in the Nationwide Inpatient Sample database: 2002 to 2007. World Neurosurg 2012; 76:548-54. [PMID: 22251503 DOI: 10.1016/j.wneu.2011.05.054] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 05/16/2011] [Accepted: 05/26/2011] [Indexed: 01/29/2023]
Abstract
BACKGROUND Few studies have compared the incidence of ventricular shunt placement for hydrocephalus after clipping versus coiling of cerebral aneurysms. OBJECTIVE The Nationwide Inpatient Sample (NIS) database was used to compare, on a national level, the incidence of ventricular shunt placement after clipping versus coiling of ruptured and unruptured aneurysms. METHODS Hospitalizations for clipping and coiling of ruptured and unruptured aneurysms from 2002 to 2007 were collected from the NIS by cross-matching International Classification of Diseases-9 codes for diagnoses of subarachnoid hemorrhage or unruptured cerebral aneurysm with procedure codes for clipping or coiling. The incidence of ventricular shunt placement for hydrocephalus after clipping and coiling was compared using generalized linear models with generalized estimating equations (GEE) to adjust for patient- and hospital-specific factors and correlation between admissions. RESULTS Of 10,899 ruptured aneurysm patients (6593 clipping, 4306 coiling), clipping had a similar incidence of ventricular shunt placement (9.3%) compared to coiling (10.5%) (odds ratio = 0.984; 95% confidence interval = 0.85, -1.14; P value = 0.833 after adjustment for patient-specific and hospital-specific factors). Likewise, of 9686 unruptured aneurysm patients (4483 clipping, 5203 coiling), clipping had similar incidence of ventricular shunt placement (0.4%) compared to coiling (0.5%) (odds ratio = 0.763; 95% confidence interval = 0.37, -1.58; P value = 0.465 after adjustment for patient-specific and hospital-specific factors). Predictors of shunt placement in ruptured aneurysm patients were age, comorbidity score, admission type, payer, and hospital aneurysm volume. Predictors of shunt placement in unruptured aneurysm patients were comorbidity score and admission type. CONCLUSIONS In an observational study, clipping and coiling of ruptured and unruptured cerebral aneurysms are associated with similar incidences of ventricular shunt placement for hydrocephalus.
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Affiliation(s)
- Brian L Hoh
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA.
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Abstract
Hydrocephalus is a common and potentially devastating complication of aneurysmal subarachnoid hemorrhage (SAH). Its incidence is approximately 20% to 30%, and its onset can be acute, within 48 hours after SAH, or rarely chronic, occurring in a delayed fashion weeks and even months after the hemorrhage. Early recognition of its signs and symptoms and accurate interpretation of computed tomography (CT) studies are important for the management of patients with SAH. Clinically, a poor neurologic grade has the highest correlation with an increased incidence of hydrocephalus. Radiographically, the bicaudate index on CT studies has emerged as the best marker of this condition. Although further studies are needed to understand the complex pathophysiology of this condition, hydrocephalus after SAH can be treated effectively using current technology.
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Colby GP, Coon AL, Tamargo RJ. Surgical management of aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am 2010; 21:247-61. [PMID: 20380967 DOI: 10.1016/j.nec.2009.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a common and often devastating condition that requires prompt neurosurgical evaluation and intervention. Modern management of aSAH involves a multidisciplinary team of subspecialists, including vascular neurosurgeons, neurocritical care specialists and, frequently, neurointerventional radiologists. This team is responsible for stabilizing the patient on presentation, diagnosing the offending ruptured aneurysm, securing the aneurysm, and managing the patient through a typically prolonged and complicated hospital course. Surgical intervention has remained a definitive treatment for ruptured cerebral aneurysms since the early 1900s. Over the subsequent decades, many innovations in microsurgical technique, adjuvant maneuvers, and intraoperative and perioperative medical therapies have advanced the care of patients with aSAH. This report focuses on the modern surgical management of patients with aSAH. Following a brief historical perspective on the origin of aneurysm surgery, the topics discussed include the timing of surgical intervention after aSAH, commonly used surgical approaches and craniotomies, fenestration of the lamina terminalis, intraoperative neurophysiological monitoring, intraoperative digital subtraction and fluorescent angiography, temporary clipping, deep hypothermic cardiopulmonary bypass, management of acute hydrocephalus, cerebral revascularization, and novel clip configurations and microsurgical techniques. Many of the topics highlighted in this report represent some of the more debated techniques in vascular neurosurgery. The popularity of such techniques is constantly evolving as new studies are performed and data about their utility become available.
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Affiliation(s)
- Geoffrey P Colby
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 8-181, Baltimore, MD 21287, USA
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Komotar RJ, Hahn DK, Kim GH, Starke RM, Garrett MC, Merkow MB, Otten ML, Sciacca RR, Connolly ES. Efficacy of lamina terminalis fenestration in reducing shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: a systematic review. J Neurosurg 2009; 111:147-54. [DOI: 10.3171/2009.1.jns0821] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Chronic hydrocephalus requiring shunt placement is a common complication following aneurysmal subarachnoid hemorrhage (SAH). Controversy exists over whether microsurgical fenestration of the lamina terminalis during aneurysm surgery affords a reduction in the development of shunt-dependent hydrocephalus. To resolve this debate, the authors performed a systematic review and quantitative analysis of the literature to determine the efficacy of lamina terminalis fenestration in reducing aneurysmal SAH–associated shunt-dependent hydrocephalus.
Methods
A MEDLINE (1950–2007) database search was performed using the following keywords, singly and in combination: “ventriculoperitoneal shunt,” “hydrocephalus,” “subarachnoid hemorrhage,” “aneurysm,” “fenestration,” and “lamina terminalis.” Additional studies were manually singled out by scrutinizing references from identified manuscripts, major neurosurgical journals and texts, and personal files. A recent study from the authors' institution was also incorporated into the review. Data from included studies were analyzed using the chi-square analysis and Student t-test. The Cochran-Mantel-Haenszel test was used to compare overall incidence of shunt-dependent hydrocephalus.
Results
The literature search revealed 19 studies, but only 11 were included in this review, involving 1973 patients. The fenestrated and nonfenestrated cohorts (combined from the various studies) differed significantly with regard to patient sex, age, and clinical grade as well as aneurysm location (p = 0.0065, 0.0028, 0.0003, and 0.017, respectively). The overall incidence of shunt-dependent hydrocephalus in the fenestrated cohort was 10%, as compared with 14% in the nonfenestrated cohort (p = 0.089). The relative risk of shunt-dependent hydrocephalus in the fenestrated cohort was 0.88 (95% CI 0.62–1.24).
Conclusions
This systematic review revealed no significant association between lamina terminalis fenestration and a reduced incidence of shunt-dependent hydrocephalus. The interpretation of these results, however, is restricted by unmatched cohort differences as well as other inherent study limitations. Although the overall literature supports lamina terminalis fenestration, a number of authors have questioned the technique's benefits, thus rendering its efficacy in reducing shunt-dependent hydrocephalus unclear. A well-designed, multicenter, randomized controlled trial is needed to definitively address the efficacy of this microsurgical technique.
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Perioperative Use of Recombinant Factor VII to Prevent Intraoperative Aneurysm Rupture in High Risk Patients: A Preliminary Safety Evaluation. Neurocrit Care 2008; 10:55-60. [DOI: 10.1007/s12028-008-9149-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Accepted: 09/05/2008] [Indexed: 10/21/2022]
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