Relationship between external ventricular drain clamp trials and ventriculoperitoneal shunt insertion following nontraumatic subarachnoid hemorrhage: a single-center study

Restricted access


Currently, there is no established standard regarding the ideal number of external ventricular drain (EVD) clamp trials performed before ventriculoperitoneal (VP) shunt insertion following nontraumatic subarachnoid hemorrhage (SAH). In this study, the authors aimed to evaluate this relationship.


A retrospective review of all patients presenting with SAH between July 2007 and December 2016 was performed. Patients with SAH who had received an EVD within the first 24 hours of hospital admission and had undergone at least 1 clamp trial prior to EVD removal were eligible for inclusion in the study. Patient demographics, clinical presentations, SAH etiologies and grades, clamp trial data, hospital lengths of stay, and functional outcomes were recorded.


One hundred fourteen patients with nontraumatic SAH complicated by posthemorrhagic hydrocephalus were included in the study. The median patient age was 57 years (range 28–90 years), with a male/female ratio of 1:1.7. A ruptured aneurysm was the underlying etiology of SAH in 79.8% of patients. A majority of patients (69.4%) had a Hunt and Hess grade III–V on admission. The median number of clamp trials performed was 2 (range 1–6). A VP shunt was required in 40.4% of patients. In those who underwent 2 and 3 clamp trials, 60% and 38.9%, respectively, did not require subsequent VP shunt placement.


Surgical placement of a VP shunt is associated with complications. Clamp trials are routinely performed before making the decision to insert a shunt. In the present study, the authors found that a significant percentage of patients passed their second and third clamp trials without requiring subsequent shunt insertion. These data support performing multiple clamp trials prior to shunt placement.

ABBREVIATIONS CSF = cerebrospinal fluid; EVD = external ventricular drain; GCS = Glasgow Coma Scale; HH = Hunt and Hess; ICP = intracranial pressure; SAH = subarachnoid hemorrhage; VP = ventriculoperitoneal; WFNS = World Federation of Neurosurgical Societies.

Article Information

Correspondence Ajith J. Thomas: Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA.

INCLUDE WHEN CITING Published online March 16, 2018; DOI: 10.3171/2017.10.JNS171644.

L.C.A. and R.G. contributed equally to this study and share first authorship.

Disclosures This research received no specific grant from any funding agency. The authors have no personal, financial, or institutional interest with regard to the authorship and/or publication of this manuscript.

© AANS, except where prohibited by US copyright law.





Arroyo-Palacios JRudz MFidler RSmith WKo NPark S: Characterization of shape differences among ICP pulses predicts outcome of external ventricular drainage weaning trial. Neurocrit Care 25:4244332016


Bondurant CPJimenez DF: Epidemiology of cerebrospinal fluid shunting. Pediatr Neurosurg 23:2542591995


Borgbjerg BMGjerris FAlbeck MJHauerberg JBørgesen SE: Frequency and causes of shunt revisions in different cerebrospinal fluid shunt types. Acta Neurochir (Wien) 136:1891941995


Connolly ES JrRabinstein AACarhuapoma JRDerdeyn CPDion JHigashida RT: Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 43:1711173720122012


Di Rocco CMarchese EVelardi F: A survey of the first complication of newly implanted CSF shunt devices for the treatment of nontumoral hydrocephalus. Cooperative survey of the 1991-1992 Education Committee of the ISPN. Childs Nerv Syst 10:3213271994


Dorai ZHynan LSKopitnik TASamson D: Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 52:7637712003


Drake CG: Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg 68:9859861988 (Letter)


Esposito DPGoldenberg FDFrank JIArdelt AARoitberg BZ: Permanent cerebrospinal fluid diversion in subarachnoid hemorrhage: influence of physician practice style. Surg Neurol Int 2:1172011


Fisher CMKistler JPDavis JM: Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:191980


Hasan DVermeulen MWijdicks EFHijdra Avan Gijn J: Management problems in acute hydrocephalus after subarachnoid hemorrhage. Stroke 20:7477531989


Hunt WEHess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14201968


Jeong TSYoo CJKim WKYee GTKim EYKim MJ: Factors related to the development of shunt-dependent hydrocephalus following subarachnoid hemorrhage in the elderly. Turk Neurosurg [epub ahead of print]2017


Karimy JKZhang JKurland DBTheriault BCDuran DStokum JA: Inflammation-dependent cerebrospinal fluid hypersecretion by the choroid plexus epithelium in posthemorrhagic hydrocephalus. Nat Med 23:99710032017


Kirmani ARSarmast AHBhat AR: Role of external ventricular drainage in the management of intraventricular hemorrhage; its complications and management. Surg Neurol Int 6:1882015


Klopfenstein JDKim LJFeiz-Erfan IHott JSGoslar PZabramski JM: Comparison of rapid and gradual weaning from external ventricular drainage in patients with aneurysmal subarachnoid hemorrhage: a prospective randomized trial. J Neurosurg 100:2252292004


Lai LMorgan MK: Predictors of in-hospital shunt-dependent hydrocephalus following rupture of cerebral aneurysms. J Clin Neurosci 20:113411382013


Lewis AIrvine HOgilvy CKimberly WT: Predictors for delayed ventriculoperitoneal shunt placement after external ventricular drain removal in patients with subarachnoid hemorrhage. Br J Neurosurg 29:2192242015


Massicotte EMDel Bigio MR: Human arachnoid villi response to subarachnoid hemorrhage: possible relationship to chronic hydrocephalus. J Neurosurg 91:80841999


Motiei-Langroudi RAdeeb NForeman PMHarrigan MRFisher WSVyas NA: Predictors of shunt insertion in aneurysmal subarachnoid hemorrhage. World Neurosurg 98:4214262017 (Erratum in World Neurosurg 104:1043 2017)


O’Kelly CJKulkarni AVAustin PCUrbach DWallace MC: Shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage: incidence, predictors, and revision rates. Clinical article. J Neurosurg 111:102910352009


Rincon FGordon EStarke RMBuitrago MMFernandez ASchmidt JM: Predictors of long-term shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage. Clinical article. J Neurosurg 113:7747802010


Schoenbaum SCGardner PShillito J: Infections of cerebrospinal fluid shunts: epidemiology, clinical manifestations, and therapy. J Infect Dis 131:5435521975


Teasdale GJennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81841974


Wilson CDSafavi-Abbasi SSun HKalani MYSZhao YDLevitt MR: Meta-analysis and systematic review of risk factors for shunt dependency after aneurysmal subarachnoid hemorrhage. J Neurosurg 126:5865952017


Wu YGreen NLWrensch MRZhao SGupta N: Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery 61:5575632007


Yamada SNakase HPark YSNishimura FNakagawa I: Discriminant analysis prediction of the need for ventriculoperitoneal shunt after subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 21:4934972012


Zolal AJuratli TDengl MFicici KHSSchackert GSobottka SB: Daily drained CSF volume is a predictor for shunt dependence – a retrospective study. Clin Neurol Neurosurg 138:1471502015




All Time Past Year Past 30 Days
Abstract Views 234 234 234
Full Text Views 96 96 96
PDF Downloads 50 50 50
EPUB Downloads 0 0 0


Google Scholar