Effect of choice of treatment modality on the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

Restricted access


Shunt-dependent hydrocephalus (SDHC) may arise after aneurysmal subarachnoid hemorrhage (aSAH) as CSF resorptive mechanisms are disrupted. Using propensity score analysis, the authors aimed to investigate which treatment modality, surgical clipping or endovascular treatment, is superior in reducing rates of SDHC after aSAH.


The authors’ multicenter SAH database, comprising 3 stroke centers affiliated with Kyoto University, Japan, was used to identify patients treated between January 2009 and July 2016. Univariate and multivariate analyses were performed to characterize risk factors for SDHC after aSAH. A propensity score model was generated for both treatment groups, incorporating relevant patient covariates to detect any superiority for prevention of SDHC after aSAH.


A total of 566 patients were enrolled in this study. SDHC developed in 127 patients (22%). On multivariate analysis, age older than 53 years, the presence of intraventricular hematoma, and surgical clipping as opposed to endovascular coiling were independently associated with SDHC after aSAH. After propensity score matching, 136 patients treated with surgical clipping and 136 with endovascular treatment were matched. Propensity score–matched cohorts exhibited a significantly lower incidence of SDHC after endovascular treatment than after surgical clipping (16% vs 30%, p = 0.009; OR 2.2, 95% CI 1.2–4.2). SDHC was independently associated with poor neurological outcomes (modified Rankin Scale score 3–6) at discharge (OR 4.3, 95% CI 2.6–7.3; p < 0.001).


SDHC after aSAH occurred significantly more frequently in patients who underwent surgical clipping. Strategies for treatment of ruptured aneurysms should be used to mitigate SDHC and minimize poor outcomes.

ABBREVIATIONS ACA = anterior cerebral artery; aSAH = aneurysmal subarachnoid hemorrhage; ICA = internal carotid artery; ICH = intracerebral hemorrhage; IQR = interquartile range; IVH = intraventricular hemorrhage; MCA = middle cerebral artery; SDHC = shunt-dependent hydrocephalus; WFNS = World Federation of Neurosurgical Societies.

Article Information

Correspondence Masaomi Koyanagi: National Hospital Organization Himeji Medical Center, Himeji, Japan. koyanagm@gmail.com.

INCLUDE WHEN CITING Published online March 9, 2018; DOI: 10.3171/2017.9.JNS171806.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.




Adams HBan VSLeinonen VAoun SGHuttunen JSaavalainen T: Risk of shunting after aneurysmal subarachnoid hemorrhage: a collaborative study and initiation of a consortium. Stroke 47:248824962016


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


Austin PC: Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharm Stat 10:1501612011


Chohan MOCarlson APHart BLYonas H: Lack of functional patency of the lamina terminalis after fenestration following clipping of anterior circulation aneurysms. J Neurosurg 119:6296332013


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 43:171117372012


Daou BKlinge PTjoumakaris SRosenwasser RHJabbour P: Revisiting secondary normal pressure hydrocephalus: does it exist? A review. Neurosurg Focus 41(3):E62016


de Oliveira JGBeck JSetzer MGerlach RVatter HSeifert V: Risk of shunt-dependent hydrocephalus after occlusion of ruptured intracranial aneurysms by surgical clipping or endovascular coiling: a single-institution series and meta-analysis. Neurosurgery 61:9249342007


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


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


Greenberg JKWashington CWGuniganti RDacey RG JrDerdeyn CPZipfel GJ: Causes of 30-day readmission after aneurysmal subarachnoid hemorrhage. J Neurosurg 124:7437492016


Hayhurst CBeems TJenkinson MDByrne PClark SKandasamy J: Effect of electromagnetic-navigated shunt placement on failure rates: a prospective multicenter study. J Neurosurg 113:127312782010


Hijdra ABrouwers PJVermeulen Mvan Gijn J: Grading the amount of blood on computed tomograms after subarachnoid hemorrhage. Stroke 21:115611611990


Hoh BLKleinhenz DTChi YYMocco JBarker FG II: Incidence of ventricular shunt placement for hydrocephalus with clipping versus coiling for ruptured and unruptured cerebral aneurysms in the Nationwide Inpatient Sample database: 2002 to 2007. World Neurosurg 76:5485542011


Hütter BOGilsbach JM: Short- and long-term neurobehavioral effects of lumbar puncture and shunting in patients with malabsorptive hydrocephalus after subarachnoid haemorrhage: an explorative case study. J Clin Neurosci 36:88932017


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


Komotar RJHahn DKKim GHStarke RMGarrett MCMerkow MB: Efficacy of lamina terminalis fenestration in reducing shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: a systematic review. Clinical article. J Neurosurg 111:1471542009


Lee LKing NKKumar DNg YPRao JNg H: Use of programmable versus nonprogrammable shunts in the management of hydrocephalus secondary to aneurysmal subarachnoid hemorrhage: a retrospective study with cost-benefit analysis. J Neurosurg 121:8999032014


Lo BWFukuda HNishimura YMacdonald RLFarrokhyar FThabane L: Pathophysiologic mechanisms of brain-body associations in ruptured brain aneurysms: a systematic review. Surg Neurol Int 6:1362015


May CKaye JAAtack JRSchapiro MBFriedland RPRapoport SI: Cerebrospinal fluid production is reduced in healthy aging. Neurology 40:5005031990


McGovern RAKelly KMChan AKMorrissey NJMcKhann GM II: Should ventriculoatrial shunting be the procedure of choice for normal-pressure hydrocephalus? J Neurosurg 120:145814642014


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


Patwardhan RVNanda A: Implanted ventricular shunts in the United States: the billion-dollar-a-year cost of hydrocephalus treatment. Neurosurgery 56:1391452005


Reddy GKBollam PShi RGuthikonda BNanda A: Management of adult hydrocephalus with ventriculoperitoneal shunts: long-term single-institution experience. Neurosurgery 69:7747812011


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


von Elm EAltman DGEgger MPocock SJGøtzsche PCVandenbroucke JP: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370:145314572007


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


Yamada SIshikawa MYamamoto KIno TKimura TKobayashi S: Aneurysm location and clipping versus coiling for development of secondary normal-pressure hydrocephalus after aneurysmal subarachnoid hemorrhage: Japanese Stroke DataBank. J Neurosurg 123:155515612015


Zaidi HAMontoure AElhadi ANakaji PMcDougall CGAlbuquerque FC: Long-term functional outcomes and predictors of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms in the BRAT trial: revisiting the clip vs coil debate. Neurosurgery 76:6086142015




All Time Past Year Past 30 Days
Abstract Views 127 127 127
Full Text Views 58 58 58
PDF Downloads 51 51 51
EPUB Downloads 0 0 0


Google Scholar