Predictors of long-term shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

Clinical article

Fred Rincon Department of Medicine, Division of Neurology, Critical Care, and Cardiovascular Medicine, Robert Wood Johnson Medical School, UMDNJ, Camden, New Jersey;

Search for other papers by Fred Rincon in
Current site
Google Scholar
PubMed
Close
 M.D., M.Sc.
,
Errol Gordon Department of Neurosurgery, Mount Sinai School of Medicine, New York; Departments of

Search for other papers by Errol Gordon in
Current site
Google Scholar
PubMed
Close
 M.D.
,
Robert M. Starke Neurology and

Search for other papers by Robert M. Starke in
Current site
Google Scholar
PubMed
Close
 M.D., M.Sc.
,
Manuel M. Buitrago Department of Neurology, The Cleveland Clinic Foundation, Cleveland, Ohio;

Search for other papers by Manuel M. Buitrago in
Current site
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Andres Fernandez Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida;

Search for other papers by Andres Fernandez in
Current site
Google Scholar
PubMed
Close
 M.D.
,
J. Michael Schmidt Neurology and

Search for other papers by J. Michael Schmidt in
Current site
Google Scholar
PubMed
Close
 Ph.D.
,
Jan Claassen Neurology and
Neurosurgery, Columbia University College of Physicians and Surgeons, New York, New York;

Search for other papers by Jan Claassen in
Current site
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Katja E. Wartenberg Department of Neurology, University Hospital Carl Gustav Carus Dresden, Germany;

Search for other papers by Katja E. Wartenberg in
Current site
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Jennifer Frontera Department of Neurosurgery, Mount Sinai School of Medicine, New York; Departments of

Search for other papers by Jennifer Frontera in
Current site
Google Scholar
PubMed
Close
 M.D.
,
David B. Seder Department of Medicine, Division of Pulmonary and Critical Care Medicine, Maine Medical Center, Portland, Maine; and

Search for other papers by David B. Seder in
Current site
Google Scholar
PubMed
Close
 M.D.
,
David Palestrant Department of Neurosurgery, Cedars Sinai Medical Center, Los Angeles, California

Search for other papers by David Palestrant in
Current site
Google Scholar
PubMed
Close
 M.D.
,
E. Sander Connolly Department of Neurology, University Hospital Carl Gustav Carus Dresden, Germany;

Search for other papers by E. Sander Connolly in
Current site
Google Scholar
PubMed
Close
 M.D.
,
Kiwon Lee Neurology and
Neurosurgery, Columbia University College of Physicians and Surgeons, New York, New York;

Search for other papers by Kiwon Lee in
Current site
Google Scholar
PubMed
Close
 M.D.
,
Stephan A. Mayer Neurology and
Neurosurgery, Columbia University College of Physicians and Surgeons, New York, New York;

Search for other papers by Stephan A. Mayer in
Current site
Google Scholar
PubMed
Close
 M.D.
, and
Neeraj Badjatia Neurology and
Neurosurgery, Columbia University College of Physicians and Surgeons, New York, New York;

Search for other papers by Neeraj Badjatia in
Current site
Google Scholar
PubMed
Close
 M.D., M.Sc.
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $536.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $636.00
USD  $45.00
USD  $536.00
USD  $636.00
Print or Print + Online Sign in

Object

The purpose of this study was to identify predictors of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH).

Methods

The authors evaluated the incidence of shunt-dependent hydrocephalus in a consecutive cohort of 580 patients with SAH who were admitted to the Neurological Intensive Care Unit of Columbia University Medical Center between July 1996 and September 2002. Patient demographics, 24-hour admission variables, initial CT scan characteristics, daily transcranial Doppler variables, and development of in-hospital complications were analyzed. Odds ratios and 95% CIs for candidate predictors were calculated using multivariate nominal logistic regression.

Results

Admission glucose of at least 126 mg/dl (adjusted OR 1.6; 95% CI 1.0–2.6), admission brain CT scan with a bicaudate index of at least 0.20 (adjusted OR 1.43; 95% CI 1.0–2.0), Fisher Grade 4 (adjusted OR 2.71; 95% CI 1.2–5.7), fourth ventricle hemorrhage (adjusted OR 1.78; 95% CI 1.1–2.7), and development of nosocomial meningitis (adjusted OR 2.2; 95% CI 1.4–3.7) were independently associated with shunt dependency.

Conclusions

These data suggest that permanent CSF diversion after aneurysmal SAH may be independently predicted by hyperglycemia at admission, findings on the admission CT scan (Fisher Grade 4, fourth ventricle intraventricular hemorrhage, and bicaudate index ≥ 0.20), and development of nosocomial meningitis. Future research is needed to assess if tight glycemic control, reduction of fourth ventricle clot burden, and prevention of nosocomial meningitis may reduce the need for permanent CSF diversion after aneurysmal SAH.

Abbreviations used in this paper:

APACHE-II = Acute Physiologic and Chronic Health Evaluation II; BI = bicaudate index; DM = diabetes mellitus; EVD = external ventricular drain; GCS = Glasgow Coma Scale; ICH = intracerebral hemorrhage; ICP = intracranial pressure; IQR = interquartile range; IVH = intraventricular hemorrhage; MCA = middle cerebral artery; PI = pulsatility index; SAH = subarachnoid hemorrhage; SHOP = SAH Outcomes Project; TCD = transcranial Doppler; VP = ventriculoperitoneal.
  • Collapse
  • Expand
  • 1

    Aaslid R, , Huber P, & Nornes H: Evaluation of cerebrovascular spasm with transcranial Doppler ultrasound. J Neurosurg 60:3741, 1984

  • 2

    Chan M, , Alaraj A, , Calderon M, , Herrera SR, , Gao W, & Ruland S, et al.: Prediction of ventriculoperitoneal shunt dependency in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg 110:4449, 2009

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Claassen J, , Carhuapoma JR, , Kreiter KT, , Du EY, , Connolly ES, & Mayer SA: Global cerebral edema after subarachnoid hemorrhage: frequency, predictors, and impact on outcome. Stroke 33:12251232, 2002

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Claassen J, , Vu A, , Kreiter KT, , Kowalski RG, , Du EY, & Ostapkovich N, et al.: Effect of acute physiologic derangements on outcome after subarachnoid hemorrhage. Crit Care Med 32:832838, 2004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Demirgil BT, , Tugcu B, , Postalci L, , Guclu G, , Dalgic A, & Oral Z: Factors leading to hydrocephalus after aneurysmal subarachnoid hemorrhage. Minim Invasive Neurosurg 46:344348, 2003

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Dóczi T, , Nemessányi Z, , Szegváry Z, & Huszka E: Disturbances of cerebrospinal fluid circulation during the acute stage of subarachnoid hemorrhage. Neurosurgery 12:435438, 1983

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Dorai Z, , Hynan LS, , Kopitnik TA, & Samson D: Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 52:763771, 2003

  • 8

    Ellington E, & Margolis G: Block of arachnoid villus by subarachnoid hemorrhage. J Neurosurg 30:651657, 1969

  • 9

    Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 26:1 Suppl S5S20, 2003

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Frontera JA, , Fernandez A, , Claassen J, , Schmidt M, , Schumacher HC, & Wartenberg K, et al.: Hyperglycemia after SAH: predictors, associated complications, and impact on outcome. Stroke 37:199203, 2006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Hansen TK, , Thiel S, , Wouters PJ, , Christiansen JS, & Van den Berghe G: Intensive insulin therapy exerts antiinflammatory effects in critically ill patients and counteracts the adverse effect of low mannose-binding lectin levels. J Clin Endocrinol Metab 88:10821088, 2003

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Harada K, , Hayashi T, , Anegawa S, , Torigoe R, , Nishio N, & Moriyama T, et al.: [Transcranial Doppler sonography in acute intracranial hypertension model—usefulness of pulsatility index.]. No To Shinkei 45:851856, 1993. (Jpn)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Hijdra A, , van Gijn J, , Nagelkerke NJ, , Vermeulen M, & van Crevel H: Prediction of delayed cerebral ischemia, rebleeding, and outcome after aneurysmal subarachnoid hemorrhage. Stroke 19:12501256, 1988

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Homburg AM, , Jakobsen M, & Enevoldsen E: Transcranial Doppler recordings in raised intracranial pressure. Acta Neurol Scand 87:488493, 1993

  • 15

    Hunt WE, & Hess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:1420, 1968

  • 16

    Jartti P, , Karttunen A, , Jartti A, , Ukkola V, , Sajanti J, & Pyhtinen J: Factors related to acute hydrocephalus after subarachnoid hemorrhage. Acta Radiol 45:333339, 2004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Knaus WA, , Draper EA, , Wagner DP, & Zimmerman JE: APACHE II: a severity of disease classification system. Crit Care Med 13:818829, 1985

  • 18

    Langouche L, , Vanhorebeek I, , Vlasselaers D, , Vander Perre S, , Wouters PJ, & Skogstrand K, et al.: Intensive insulin therapy protects the endothelium of critically ill patients. J Clin Invest 115:22772286, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Lin CL, , Kwan AL, & Howng SL: Acute hydrocephalus and chronic hydrocephalus with the need of postoperative shunting after aneurysmal subarachnoid hemorrhage. Kaohsiung J Med Sci 15:137145, 1999

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Lindegaard KF, , Nornes H, , Bakke SJ, , Sorteberg W, & Nakstad P: Cerebral vasospasm after subarachnoid haemorrhage investigated by means of transcranial Doppler ultrasound. Acta Neurochir Suppl (Wien) 42:8184, 1988

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Rainov NG, , Weise JB, & Burkert W: Transcranial Doppler sonography in adult hydrocephalic patients. Neurosurg Rev 23:3438, 2000

  • 22

    Sanker P, , Richard KE, , Weigl HC, , Klug N, & van Leyen K: Transcranial Doppler sonography and intracranial pressure monitoring in children and juveniles with acute brain injuries or hydrocephalus. Childs Nerv Syst 7:391393, 1991

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Seibert JJ, , McCowan TC, , Chadduck WM, , Adametz JR, , Glasier CM, & Williamson SL, et al.: Duplex pulsed Doppler US versus intracranial pressure in the neonate: clinical and experimental studies. Radiology 171:155159, 1989

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Sheehan JP, , Polin RS, , Sheehan JM, , Baskaya MK, & Kassell NF: Factors associated with hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 45:11201128, 1999

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Teasdale G, & Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:8184, 1974

  • 26

    Vale FL, , Bradley EL, & Fisher WS III: The relationship of subarachnoid hemorrhage and the need for postoperative shunting. J Neurosurg 86:462466, 1997

  • 27

    Van den Berghe G, , Wilmer A, , Hermans G, , Meersseman W, , Wouters PJ, & Milants I, et al.: Intensive insulin therapy in the medical ICU. N Engl J Med 354:449461, 2006

  • 28

    van Gijn J, , Hijdra A, , Wijdicks EF, , Vermeulen M, & van Crevel H: Acute hydrocephalus after aneurysmal subarachnoid hemorrhage. J Neurosurg 63:355362, 1985

  • 29

    Vanhorebeek I, , De Vos R, , Mesotten D, , Wouters PJ, , De Wolf-Peeters C, & Van den Berghe G: Protection of hepatocyte mitochondrial ultrastructure and function by strict blood glucose control with insulin in critically ill patients. Lancet 365:5359, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Weekers F, , Giulietti AP, , Michalaki M, , Coopmans W, , Van Herck E, & Mathieu C, et al.: Metabolic, endocrine, and immune effects of stress hyperglycemia in a rabbit model of prolonged critical illness. Endocrinology 144:53295338, 2003

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Widenka DC, , Wolf S, , Schürer L, , Plev DV, & Lumenta CB: Factors leading to hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurol Neurochir Pol 34:6 Suppl 5660, 2000

    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1504 245 38
Full Text Views 492 137 53
PDF Downloads 320 30 4
EPUB Downloads 0 0 0