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

Clinical article

Fred Rincon M.D., M.Sc.1, Errol Gordon M.D.2, Robert M. Starke M.D., M.Sc.3, Manuel M. Buitrago M.D., Ph.D.4, Andres Fernandez M.D.5, J. Michael Schmidt Ph.D.3, Jan Claassen M.D., Ph.D.3,6, Katja E. Wartenberg M.D., Ph.D.7, Jennifer Frontera M.D.2, David B. Seder M.D.8, David Palestrant M.D.9, E. Sander Connolly M.D.7, Kiwon Lee M.D.3,6, Stephan A. Mayer M.D.3,6, and Neeraj Badjatia M.D., M.Sc.3,6
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  • 1 Department of Medicine, Division of Neurology, Critical Care, and Cardiovascular Medicine, Robert Wood Johnson Medical School, UMDNJ, Camden, New Jersey;
  • | 2 Department of Neurosurgery, Mount Sinai School of Medicine, New York; Departments of
  • | 3 Neurology and
  • | 6 Neurosurgery, Columbia University College of Physicians and Surgeons, New York, New York;
  • | 4 Department of Neurology, The Cleveland Clinic Foundation, Cleveland, Ohio;
  • | 5 Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida;
  • | 7 Department of Neurology, University Hospital Carl Gustav Carus Dresden, Germany;
  • | 8 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Maine Medical Center, Portland, Maine; and
  • | 9 Department of Neurosurgery, Cedars Sinai Medical Center, Los Angeles, California
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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.

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