Effect of choice of treatment modality on the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

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.

The Pathogenesis of Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage

“…Some studies have suggested that endovascular treatment is independently associated with the development of chronic hydrocephalus in aSAH patients [ 124 , 125 ]. However, other research has demonstrated a significantly lower incidence of chronic hydrocephalus after endovascular treatment compared with after surgical clipping [ 126 ]. Surgical clipping via the traditional pterional transsylvian approach with arachnoid membrane dissection may directly alter CSF flow dynamics and resorption [ 126 ].…”

“…However, other research has demonstrated a significantly lower incidence of chronic hydrocephalus after endovascular treatment compared with after surgical clipping [ 126 ]. Surgical clipping via the traditional pterional transsylvian approach with arachnoid membrane dissection may directly alter CSF flow dynamics and resorption [ 126 ]. In a retrospective review of 839 patients with aSAH [ 127 ], endovascular coiling was associated with a lower risk of shunt dependency for Fisher grade 2 patients (2% vs. 13% with clipping, p = 0.043), while surgical clipping lowered the likelihood of shunt dependency in patients with Fisher grade 4 aSAH (23% vs. 44%, p = 0.004).…”

“…Other studies reported no significant difference for the predictive risks of shunt-dependent hydrocephalus between surgical clipping and coiling groups [ 24 , 129 , 130 , 131 , 132 ]. Also, a multicenter aSAH database in Japan consisting of 566 patients treated for aSAH has revealed that shunt dependency following aSAH occurred significantly more frequently in patients who underwent clipping than in those treated with endovascular coiling (30% vs. 16%) [ 126 ]. Last but not least, another large database of 10,899 aSAH patients which consisted of 6593 patients receiving clipping and 4306 receiving coiling reported that their incidence of VP shunt insertion was similar (9.3% vs. 10.5%) between the surgeries [ 133 ].…”

Clipping versus coiling for aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of prospective studies

“…The overall methodological quality of cohort studies included was relatively high, as 70.00% of them earned ≥ 8 scores. The representativeness of the cohort was low in 5 studies because they did not include consecutive or random samples [2,16,28,52,60]. Seven studies did not state clearly how they assessed the outcomes [3,12,16,25,46,56,60].…”

Efficacy of translamina terminalis ventriculostomy tube in prevention of chronic hydrocephalus after aneurysmal subarachnoid hemorrhage

“…The rate of development of chronic hydrocephalus after aSAH was affected by treatment modality used to secure the ruptured aneurysm, whether microsurgical clipping or endovascular coiling, in some reports and not affected in other ones. [ 1 , 2 , 9 , 11 , 13 , 15 - 19 , 23 , 29 , 30 , 32 , 33 , 46 , 47 , 49 ]…”