The relationship of subarachnoid hemorrhage and the need for postoperative shunting

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✓ The incidence of chronic hydrocephalus requiring shunting after aneurysmal subarachnoid hemorrhage (SAH) is not precisely known. The authors investigated whether the need for ventriculoperitoneal (VP) shunting can be predicted by initial Hunt and Hess grade or Fisher computerized tomography score. One hundred eight patients who presented with SAH and underwent 116 surgical procedures for aneurysm clipping were evaluated retrospectively to determine the incidence of chronic hydrocephalus. Chronic hydrocephalus was defined as clinically and radiographically demonstrated hydrocephalus that lasted 2 weeks or longer after the original hemorrhage and that required shunting. All SAH patients were managed in a similar fashion with induced hypervolemia, relative hemodilution, and hypertension complemented by a course of calcium channel blockers. The majority of patients underwent perioperative extracranial ventricular drainage to allow intraoperative brain relaxation and to assist intracranial pressure management. The overall mortality rate of the study group was 17%. Of the surviving patients, 20% underwent VP shunt placement secondary to chronic hydrocephalus. There were no statistically significant relationships between chronic hydrocephalus and patient age or gender, aneurysm type and size, or use of a perioperative drain. There was a high clinical correlation between chronic hydrocephalus and admission Hunt and Hess grades and Fisher grades (p < 0.05). All of the patients who survived a second bleeding episode and almost 46% of the patients who presented with intraventricular hemorrhage required placement of a VP shunt. The authors present predictive tables of chronic hydrocephalus based on the patient's admission Hunt and Hess grade and Fisher classification.

Article Information

Address reprint requests to: Winfield Fisher, M.D., Department of Surgery, Division of Neurosurgery, The University of Alabama at Birmingham, 515 Medical Education Building, 1813 Sixth Avenue South, Birmingham, Alabama 35294–295.

© AANS, except where prohibited by US copyright law.

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Figures

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    Bar graphs displaying the distribution of the patient population according to admission Hunt and Hess (H & H) grades (left) and Fisher CT (F/CT) classification (right).

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    Bar graph depicting the distribution of outcomes based on GOS scores as of a 90-day follow-up evaluation in patients who underwent craniotomy for aneurysm clipping.

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    Left: Bar graph showing the distribution of chronic hydrocephalus according to admission Hunt and Hess (H & H) grades for surviving patients. Note: all patients with an H & H Grade V died despite aggressive treatment. Right: Bar graph showing the distribution of shunt-dependent hydrocephalus according to admission Fisher CT (F/CT) classification for surviving patients.

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    Graphs displaying the probability of survival without shunting after aneurysm surgery. Upper: Kaplan—Meier curve shows that the probability of survival without shunting remains almost 70% after 5 months for all Hunt and Hess (HH) grades. Lower: Survival analysis demonstrates that patients with a lower HH grade fare better than patients with an HH Grade III (3) or higher.

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