Risk factors for hydrocephalus requiring external ventricular drainage in patients with intraventricular hemorrhage

Abstract

OBJECT External ventricular drainage (EVD) after intraventricular hemorrhage (IVH) without symptomatic hydrocephalus is controversial. The object of this study was to examine indicators or the timeframe for hydrocephalus in patients not immediately treated with EVD after IVH. METHODS Records from 2007 to 2014 were searched for “intraventricular hemorrhage” or “IVH.” Inclusion criteria were IVH after intracerebral hemorrhage (ICH), trauma, tumor, or vascular anomalies. Exclusion criteria were IVH with more than minimal subarachnoid hemorrhage, catastrophic ICH, layering IVH only, or hydrocephalus treated immediately with EVD. IVH was measured with the modified Graeb Score (mGS). An mGS of 5 indicates a full ventricle with dilation. Statistics included chi-square, Student’s t-test, and Mann-Whitney tests; receiver operating characteristics; and uni- and multivariate logistic regression. RESULTS One hundred five patients met the criteria; of these, 30 (28.6%) required EVD. Panventricular IVH was the most common pattern (n = 49, 46.7%), with 25 of these patients (51%) requiring EVD. The median mGS was 18 ± 5.4 (range 12–29) and 9 ± 4.5 (range 2–21) in the EVD and No-EVD groups, respectively (p < 0.001). Factors associated with EVD were radiological hydrocephalus at presentation, midline shift > 5 mm, Glasgow Coma Scale (GCS) score < 8, mGS > 13, third ventricle mGS = 5, and fourth ventricle mGS = 5. On multivariate analysis, GCS score < 8 [4.02 (range 1.13–14.84), p = 0.032], mGS > 13 [3.83 (range 1.02–14.89), p = 0.046], and fourth ventricle mGS = 5 [5.01 (range 1.26–22.78), p = 0.022] remained significant. Most patients treated with EVD (n = 25, 83.3%) required it soon after presentation [6.4 ± 3.3 (range 1.5–14) hrs]. The remaining 5 patients (16.7%) had a delayed EVD requirement [70.7 ± 22.7 (range 50–104.5) hrs]. CONCLUSIONS In this study population, the risk for EVD was variable, but greater with mGS > 13, coma, and a dilated fourth ventricle. While the need for EVD occurs within the 1st day after IVH in most patients, a minority require EVD after 48 hours.

Clinical features and prognostic factors in patients with intraventricular hemorrhage caused by ruptured arteriovenous malformations

“…[ 27 ] The younger age and better consciousness could explain the lower rate of 6-month poor outcomes compared with patients with hypertension-related IVH. [ 3 ] The incidence of hydrocephalus was higher in AVM-related IVH (49%) than HICH-related IVH (28.6%), [ 28 ] and 1 study [ 29 ] also suggested the high rate of shun-dependent hydrocephalus (44%) in ruptured AVMs. Although the rate of hydrocephalus was relatively higher than the rate of brain ischemia and herniation, these complications attributed to the increased poor outcomes in AVM-related IVH compared with ruptured AVMs without IVH.…”

Hydrocephalus after Subarachnoid Hemorrhage: Pathophysiology, Diagnosis, and Treatment

“…Patients with acute course of HCP, in-hospital complications, IVH, high Hunt and Hess Scale score (or low initial Glasgow Coma Scale or high Fisher score), rehemorrhage, posterior circulation location of ruptured aneurysm, and age ≥ 60 have been reported to be at a higher risk of shunt-dependency [3–5]. Other research reported similarly higher risk of HCP with posterior circulation aneurysm, IVH, greater hemorrhage volume, and older age [4, 5, 28, 36]. Dependency on factors like economy, medical development, and methods to cope with ruptured aneurysms also leads to deferent incidences of shunt-dependent HCP [5].…”

Quantitative versus qualitative blood amount assessment as a predictor for shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage

“…8,28,39 Blood location, specifically in the third and fourth ventricles, plays a critical role in prognosis and SDHC development. 16,33,39 Therefore, mGraeb is a robust predictive model because it integrates several independent risk factors for SDHC in one scale: blood quantity, blood location, and acute hydrocephalus. Furthermore, mGraeb is an assessment scale that might be easily and quickly performed during patient evaluation, even in the emergency department, as there is no need for computers or radiological image software.…”

“…9,23 Eagles et al suggested an optimal cutoff point of 3 on the mGraeb scale in order to predict delayed cerebral ischemia. 16 Lagares et al found a critical value of 20 ml of total blood volume at which the proportion of patients with poor outcome increased by more than 2-fold. 23 Instead of using the cutoff points obtained with the Youden Index, we tried to find a threshold tailored to the very particular circumstances of SDHC and aimed for a more exigent or specific cutoff point.…”

“…However, despite the aforementioned skewness and the number of cases being limited, the cohort was similar to those of many other reported studies on the same topic, and the results reached statistical significance. 16,23,25,40 In any case, the predictive models proposed here should be validated with a prospective cohort of patients, and thus further studies are still needed.…”