Predictors of shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: a pilot study in a single Egyptian institute

Abstract

BackgroundAcute hydrocephalus can cause neurological deterioration after aneurysmal subarachnoid hemorrhage (aSAH). Predicting which patient would require shunting is challenging.MethodsThis prospective study was conducted upon twenty patients who suffered acute hydrocephalus due to subarachnoid hemorrhage of ruptured aneurysms. Surgical or non-surgical management of hydrocephalus was conducted. Glasgow Coma scale (GCS) was assessed, and hydrocephalus was graded by bicaudate index. Fisher grade was determined from CT scan. Aneurysm site was determined by conventional or CT angiography. Either surgical clipping or endovascular coiling of aneurysms was performed.ResultsInitially, 3 (15%) patients had emergency CSF diversion on admission due to poor GCS on arrival. Initially, the remaining 17 patients were managed conservatively. Five patients did not require any intervention. Twelve patients had external ventricular drainage placement, 4 were weaned, and 8 failed weaning. High bicaudate index (> 0.2) correlated with shunting. Aneurysm site correlated well with shunting (ACoA or PCoA).ConclusionsPatients with fair GCS can be managed conservatively. Any deterioration warrants shifting to CSF diversion. Higher bicaudate index will usually need CSF diversion. The value of Fisher carries no significant value. Aneurysm location (ACoA or PCoA) correlates with an increased incidence of ventriculoperitoneal shunt placement.

Arachnoid granulations may be protective against the development of shunt dependent chronic hydrocephalus after aneurysm subarachnoid hemorrhage

“…Age ≥50 years, female gender, high Hunt-Hess grade, Glasgow Coma Scale ≤8, Fisher grade ≥3, acute hydrocephalus, external ventricular drainage (EVD) insertion, intraventricular hemorrhage, posterior circulation aneurysm, anterior communicating artery aneurysm, meningitis, and re-bleeding have all been found to be associated with shunt dependence 15 . Factors such as Fisher grade which may be linked intuitively with hydrocephalus and shunt dependence, in reality, have conflicting evidence 10 , including findings from this study. Clinical factors which were once thought to be associated with shunt dependence, such as the duration of EVD have not been linked with definite evidence 16 .…”

“…CTA acquisitions were performed from C6 to the vertex in the helical half-scan mode with the following parameters: 0.7 mL/kg of iodinated contrast (to a maximum of 90 mL through an antecubital vein via at least an 18-or 20-ga angiocatheter), 120 kV(p), 270 mA, 1 s/rotation, 1.25-mm section thickness at 0.625-mm intervals, and table speed of 3.75 mm/rotation. The initial unenhanced CT images were evaluated to determine the modified Fisher (mFisher) grade and the Evans' index as previously described 9,10 . AGs were identified as eccentric spherical low-density filling defects within the dural venous sinuses using multiplanar reformat of baseline CTA images.…”

“…Several factors have been proposed as clinical predictors of hydrocephalus and/or shunt dependence; however, many of these remain controversial due to conflicting evidence 10 . The presence of intraventricular hemorrhage, Hunt and Hess grade (and Fisher grade), re-hemorrhage, higher age, and infection have all been variably linked to increased risk of shunt dependence 11 .…”

Arachnoid granulations may be protective against the development of shunt dependent chronic hydrocephalus after aneurysm subarachnoid hemorrhage**

“…Age ≥50 years, female gender, high Hunt-Hess grade, Glasgow Coma Scale ≤8, Fisher grade ≥3, acute hydrocephalus, external ventricular drainage (EVD) insertion, intraventricular hemorrhage, posterior circulation aneurysm, anterior communicating artery aneurysm, meningitis, and re-bleeding have all been found to be associated with shunt dependence. 15 Factors such as Fisher grade which may be linked intuitively with hydrocephalus and shunt dependence, in reality, have conflicting evidence, 10 including findings from this study. Clinical factors which were once thought to be associated with shunt dependence, such as the duration of EVD have not been linked with definite evidence.…”

“…The initial unenhanced CT images were evaluated to determine the modified Fisher (mFisher) grade and the Evans’ index as previously described. 9 , 10 AGs were identified as eccentric spherical low-density filling defects within the dural venous sinuses using multiplanar reformat of baseline CTA images. Examples of AGs are provided in Figure 1 , morphologically identified as smooth and spherical filling defect within the dural venous sinuses.…”