Efficacy of lamina terminalis fenestration in reducing shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: a systematic review

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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.


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.


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).


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.

Abbreviations used in this paper: ACoA = anterior communicating artery; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Ricardo J. Komotar, M.D., Department of Neurosurgery, Columbia University, 710 West 168th Street, Room 431, New York, New York 10032. email: rjk2103@columbia.edu.

© AANS, except where prohibited by US copyright law.




Akyuz MTuncer R: The effects of fenestration of the interpeduncular cistern membrane arousted to the opening of lamina terminalis in patients with ruptured ACoA aneurysms: a prospective, comparative study. Acta Neurochir (Wien) 148:7257322006


Andaluz NVan Loveren HRKeller JTZuccarello M: Anatomic and clinical study of the orbitopterional approach to anterior communicating artery aneurysms. Neurosurgery 52:114011492003


Andaluz NZuccarello M: Fenestration of the lamina terminalis as a valuable adjunct in aneurysm surgery. Neurosurgery 55:105010592004


Auer LMMokry M: Disturbed cerebrospinal fluid circulation after subarachnoid hemorrhage and acute aneurysm surgery. Neurosurgery 26:8048091990


Borgbjerg BMGjerris FAlbeck MJHauerberg JBorgesen SV: A comparison between ventriculo-peritoneal and ventriculoatrial cerebrospinal fluid shunts in relation to rate of revision and durability. Acta Neurochir (Wien) 140:4594651998


Dehdashti ARRilliet BRufenacht DAde Tribolet N: Shuntdependent hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality. J Neurosurg 101:4024072004


Del Bigio MRBruni JE: Periventricular pathology in hydrocephalic rabbits before and after shunting. Acta Neuropathol 77:1861951988


Fode NCLaws ER JrSundt TM Jr: Communicating hydrocephalus after subarachnoid hemorrhage: results of shunt procedures. J Neurosurg Nurs 11:2532561979


Gjerris FBorgesen SESorensen PSBoesen FSchmidt KHarmsen A: Resistance to cerebrospinal fluid outflow and intracranial pressure in patients with hydrocephalus after subarachnoid hemorrhage. Acta Neurochir (Wien) 88:79861987


Grant JAMcLone DG: Third ventriculostomy: a review. Surg Neurol 47:2102121997


Gruber AReinprecht ABavinzski GCzech TRichling B: Chronic shunt-dependent hydrocephalus after early surgical and early endovascular treatment of ruptured intracranial aneurysms. Neurosurgery 44:5035121999


Joakimsen OMathiesen EBMonstad PSelseth B: CSF hydrodynamics after subarachnoid hemorrhage. Acta Neurol Scand 75:3193271987


Katzman RNormal pressure hydrocephalus. Wells CE: Dementia ed 2PhiladelphiaFA Davis1977. 6992


Kim JMJeon JYKim JHCheong JHBak KHKim CH: Influence of lamina terminalis fenestration on the occurrence of the shunt-dependent hydrocephalus in anterior communicating artery aneurysmal subarachnoid hemorrhage. J Korean Med Sci 21:1131182006


Komotar RJHahn DKKim GHKhandji JMocco JMayer SA: The impact of microsurgical fenestration of the lamina terminalis on shunt-dependent hydrocephalus and vasospasm following aneurysmal subarachnoid hemorrhage. Neurosurgery 62:1231342008


Komotar RJMocco JRansom ERMack WJZacharia BEWilson DA: Herniation secondary to critical postcraniotomy cerebrospinal fluid hypovolemia. Neurosurgery 57:2862922005


Komotar RJOlivi ARigamonti DTamargo RJ: Microsurgical fenestration of the lamina terminalis reduces the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 51:140314132002


Komotar RJRansom ERMocco JZacharia BEMcKhann GM IIMayer SA: Critical postcraniotomy cerebrospinal fluid hypovolemia: risk factors and outcome analysis. Neurosurgery 59:2842902006


Kosteljanetz M: CSF dynamics in patients with subarachnoid and/or intraventricular hemorrhage. J Neurosurg 60:9409461984


Lam CHVillemure JG: Comparison between ventriculoatrial and ventriculoperitoneal shunting in the adult population. Br J Neurosurg 11:43481997


Schmieder KKoch RLucke SHarders A: Factors influencing shunt dependency after aneurysmal subarachnoid haemorrhage. Zentralbl Neurochir 60:1331401999


Sindou M: Favourable influence of opening the lamina terminalis and Lilliequist's membrane on the outcome of ruptured intracranial aneurysms. A study of 197 consecutive cases. Acta Neurochir (Wien) 127:15161994


Tomasello Fd'Avella Dde Divitiis O: Does lamina terminalis fenestration reduce the incidence of chronic hydrocephalus after subarachnoid hemorrhage?. Neurosurgery 45:8278321999


Torvik ABhatia RMurthy VS: Transitory block of the arachnoid granulations following subarachnoid haemorrhage. A postmortem study. Acta Neurochir (Wien) 41:1371461978


Udvarhelyi GBWood JHJames AE JrBartelt D: Results and complications in 55 shunted patients with normal pressure hydrocephalus. Surg Neurol 3:2712751975


Yonekawa YImhof HGOgata NBernays RKaku YFandino J: Aneurysm surgery in the acute stage: results of structured treatment. Neurol Med Chir (Tokyo) 38:45491998




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