Post-traumatic Hydrocephalus Research Articles

Thirty days complications of pediatric hydrocephalus following ventriculoperitoneal shunt surgery

Background: Ventriculoperitoneal shunt (VPS) is one of the commonest procedures in neurosurgical practice for the treatment of hydrocephalus (HCP) in pediatrics, especially in developing countries. Despite being widely used, VPS is still plagued with several complications, so needed repeated interventions. Thereby increase hospital stay, morbidity, and mortality. The majority of the complications were observed in the early postoperative period but over time, the rate of complications decreases. So we conducted this study to identify the complications within 30 days following VPS in children. Materials and Methods: This prospective interventional study was conducted in the Department of Neurosurgery, BSMMU, between January 2019 and January 2020. Children aged 1 month to 5 years, who underwent VPS surgery for the first time were included in this study. Following VPS operation, patients were given regular follow-up for one month, either through the Telephone or asked to visit the outpatients on the specified days. During follow up all patients were evaluated for shunt-related complications. Then the data were analyzed using the SPSS version 26. Results are presented in the form of tables. Results: We evaluated a total of 120 patients, during the study period, there were 75 (62.5%) males and 45 (37.5%) females with a male to female ratio approaching 1.6:1. Patients aged from 1 month to 5 years (60 months). The indications of VPs surgery were: congenital hydrocephalus in 70 (58.3%), post-infectious hydrocephalus in 15 (12.5%), hydrocephalus due to tumor in 30 (25%), and post-traumatic hydrocephalus in five (4.16%) patients. During the follow-up, complications were encountered in 30 patients (25%). Complications observed between day 1 and day 30 during follow-up were shunt malfunction (blockage, cranial or caudal migration, misplacement) 8(6.66%), shunt infections 10 (8.33%), CSF leakage 3(2.5%),ileus 5 (4.16),convulsion one(0.83%),gut perforation one (0.83%) and abdominal complications 2 ( 1.6%) among 120 patients. Conclusion: VP surgery is very porn to complications and in our study, almost every fourth case of VPS arises complications. Shunt malfunction due to blockage, infections, and abdominal wound-related complications are common earlier in pediatric patients with hydrocephalus.

What is the incidence of post-traumatic hydrocephalus in traumatic brain injury patients that underwent DC versus those that were managed conservatively: lessons from a meta-analysis

What is the incidence of post-traumatic hydrocephalus in traumatic brain injury patients that underwent DC versus those that were managed conservatively: lessons from a meta-analysis

Endoscopic third ventriculostomy in post traumatic hydrocephalus- Institutional experience

Introduction: Hydrocephalus is a known sequelae in traumatic brain injury patients. It may occur early or late and presents with dementia, urinary incotinence and difficulty in walking as described by Hakim and Adams. There are two distinct types of normal pressure hydrocephalus one is idiopathic most commonly seen in the elderly age groups and the other is secondary due to a cerebro vascular accident, trauma or surgery. The idiopathic type may not respond to the CSF diversion procedure, but the secondary type which responds to CSF diversion procedure. Our study aims at exploring the option of ETV in these patients not making them shunt dependent. Materials and Methods: The patients with traumatic brain injury admitted in the dept. of neurosurgery between January 2012 and January 2018 were included into the study. Congenital hydrocephalus and secondary hydrocephalus due to spontaneous SAH and tumours were excluded. 14 patients were identified and if there was some improvement in their condition after CSF tap test were planned for endoscopic third ventriculostomy. Results: Out of the 14 patients 2 were females and the remaining 12 were males. 2 did not improve at all. 12 had some improvement out of which 3 had a failure and underwent a v-p shunt. Hence there were 5 failures out of 14 which made 35.7%. Mitchel et al and Michelangelo et al reported 72-75% success rates in their study which is similar to our results. Conclusion: ETV is an option which can be offered to patients with secondary hydrocephalus. The chances of failure though present the procedure is minimally invasive and improves CSF dynamics. Keywords: Secondary hydrocephalus due to trauma, Endoscopic third ventriculostomy, Trauma induced hydrocephalus.

The one-step edge-to-edge technique in ventriculoperitoneal shunt

Background Subcutaneous tunneling of the distal catheter is a potentially risky part of ventriculoperitoneal shunt (VPS) insertion. We describe our institutional experience with a simple trick to improve functional and aesthetic results in VPS by reducing the distal catheter tunneling to a single passage. Materials and methods The one-step edge-to-edge technique has been performed in our institution over 14 years in 46 patients with a mean age of 63. 27 were female (58.7%). 7 patients suffered from post-traumatic hydrocephalus, 6 from normal pressure hydrocephalus, 15 from obstructive hydrocephalus and 18 from hydrocephalus secondary to subarachnoid hemorrhage. Operative blood loss varied from 20 to 40 cc. Results No complication related to the modified tunneling technique were described except a transitory peripheral VII nerve palsy (2.2%). The absence of middle skin incision is appreciated by the patient, especially in young females that not presented scars at the level of the neckline. Conclusion Our technique is the first report of one step tunneling in adults. It reduces distal catheter tunneling time in VPS simplifying the procedure to a single step and using a simple reproducible trick.

Regression of Liquorodynamic Disorders and Ventriculoperitoneal Shunt Overdrain Syndrome Clinic in a Patient After Severe Brain Injury with Posttraumatic Hydrocephalus and a Giant Cranial Bones Defect After Cranioplasty: Case Report

Introduction. The frequency of post-traumatic hydrocephalus is 3.9%. The incidence of post-traumatic defects of the skull is 10.46 per 100,000 per year. Overdrain syndrome occurs in 1012% of cases in patients with long-term ventricular shunting. The presence of a cranial defect causes a violation of blood flow and cerebrospinal fluid dynamics in the area of the defect, a displacement of brain structures under the influence of gravity and atmospheric pressure, which can cause a deterioration in the patients condition and a significant slowdown in recovery after a severe head injury. Both craniotomy syndrome and excessive shunting can impede the verticalization and rehabilitation of patients with post-traumatic hydrocephalus and post-traumatic defects of the bones of the cranial vault.
 Description of the clinical case. Clinical case demonstrates an example of a differential approach and an algorithm for deciding on surgical treatment in a patient with post-traumatic hydrocephalus and cranial bones defect in case of deterioration during attempts at verticalization in a complex of rehabilitation measures.
 Conclusion. The clinical manifestations of trephine skull syndrome and syndrome of shunt overdrain in the patient after severe traumatic brain injury combines post-traumatic hydrocephalus, may be similar. And not always, as demonstrated in this clinical case, narrowed ventricles and the relationship of deterioration to verticalization should be interpreted as a syndrome of excessive drainage of the shunt system. The plastic surgery of the defect of the bones of the cranial vault performed in this case made it possible to improve the patients condition and regress symptoms.

Intracranial Pressure during External Ventricular Drainage Weaning Is an Outcome Predictor of Traumatic Brain Injury.

External ventricular drainage (EVD) is widely used in patients with a traumatic brain injury (TBI). However, the EVD weaning trial protocol varies and insufficient studies focus on the intracranial pressure (ICP) during the weaning trial. We aimed to establish the relationship between ICP during an EVD weaning trial and the outcomes of TBI. We enrolled 37 patients with a TBI with an EVD from July 2018 to September 2019. Among them, 26 were allocated to the favorable outcome group and 11 to the unfavorable outcome group (death, post-traumatic hydrocephalus, persistent vegetative state, and severe disability). Groups were well matched for sex, pupil reactivity, admission Glasgow Coma Scale score, Marshall computed tomography score, modified Fisher score, intraventricular hemorrhage, EVD days, cerebrospinal fluid output before the weaning trial, and the complications. Before and during the weaning trial, we recorded the ICP at 1-hour intervals to calculate the mean ICP, delta ICP, and ICP burden, which was defined as the area under the ICP curve. There were significant between-group differences in the age, surgery types, and intensive care unit days (p = 0.045, p = 0.028, and p = 0.004, respectively). During the weaning trial, 28 (75.7%) patients had an increased ICP. Although there was no significant difference in the mean ICP before and during the weaning trial, the delta ICP was higher in the unfavorable outcome group (p = 0.001). Moreover, patients who experienced death and hydrocephalus had a higher ICP burden, which was above 20 mmHg (p = 0.016). Receiver operating characteristic analyses demonstrated the predictive ability of these variables (area under the curve [AUC] = 0.818 [p = 0.002] for delta ICP and AUC = 0.758 [p = 0.038] for ICP burden > 20 mmHg). ICP elevation is common during EVD weaning trials in patients with TBI. ICP-related parameters, including delta ICP and ICP burden, are significant outcome predictors. There is a need for larger prospective studies to further explore the relationship between ICP during EVD weaning trials and TBI outcomes.

Clinical features associated with the development of hydrocephalus following TBI in the paediatric age group

IntroductionPredictive factors for post-traumatic hydrocephalus (PTH) in adults have been elucidated but remain uncertain for children. We aimed to identify the prevalence of PTH in paediatric patients and identify clinical/radiological factors which may increase the probability of children developing PTH.MethodsThis was a retrospective study of all patients < 16 years old admitted to our unit with traumatic brain injury (TBI) between March 2013 and June 2018, 108 patients in total. Patients were classified as mild (13–15), moderate (9–12) or severe (3–8) TBI based on admission GCS. Three independent reviewers collected data from case notes. CT scans were reviewed for hydrocephalus using Evan’s index. Two-tailed Fisher’s exact tests with a p value < 0.05 were considered statistically significant.ResultsMedian patient age was 7 years, and 65% were males (n = 70). PTH wasn’t identified in any patients with mild/moderate TBI (n = 79). In cases of severe TBI (n = 29), three patients developed PTH requiring ventriculoperitoneal shunting (10%; p = 0.02). Radiological features which were significantly more common in the PTH group were intraventricular haemorrhage (p = 0.05) and subarachnoid haemorrhage (p = 0.03). There was also a trend towards a statistically significant association with subdural haematoma (p = 0.07). The need for other neurosurgical procedures, such as fracture elevation and craniotomy, did not increase the probability of developing with PTH (p = 0.08).DiscussionThe prevalence of PTH in our study is 2.7%. Factors which may be associated with a higher probability of developing PTH may include IVH, SAH, severity of TBI, and subdural haematoma. We propose a national prospective multicentre database of paediatric PTH. The data collected on prevalence, presentation, risk factors, and management could guide contemporary management and improve the outcomes of children with PTH.

Early cranioplasty associated with a lower rate of post-traumatic hydrocephalus after decompressive craniectomy for traumatic brain injury.

Post-traumatic hydrocephalus (PTH) is one of the primary complications during the course of traumatic brain injury (TBI). The aim of this study was to define factors associated with the development of PTH in patients who underwent unilateral decompressive craniectomy (DC) for TBI. A total of 126 patients, who met the inclusion criteria of the study, were divided into two groups: patients with PTH (n = 25) and patients without PTH (n = 101). Their demographic, clinical, radiological, operative, and postoperative factors, which may be associated with the development of PTH, were compared. Multivariate logistic regression analysis revealed that cranioplasty performed later than 2months following DC was significantly associated with the requirement for ventriculoperitoneal shunting due to PTH (p < 0.001). Also, a significant unfavorable outcome rate was observed in patients with PTH at 1-year follow-up according to the Glasgow Outcome Scale-Extended (p = 0.047). Our results show that early cranioplasty within 2months after DC was associated with a lower rate of PTH development after TBI.

Risk Factors for the Development of Post-Traumatic Hydrocephalus in Children

The aim of this study was to investigate the national impact of demographic, hospital, and inpatient risk factors on posttraumatic hydrocephalus (PTH) development in pediatric patients who presented to the emergency department after a traumatic brain injury (TBI). The Nationwide Emergency Department Sample database 2010-2014 was queried. Patients (<21 years old) with a primary diagnosis of TBI and subsequent secondary diagnosis of PTH were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. We identified 1,244,087 patients who sustained TBI, of whom 930 (0.07%) developed PTH. The rates of subdural hemorrhage and subarachnoid hemorrhage were both significantly higher for the PTH cohort. On multivariate regression, age 6-10 years (odds ratio [OR], 0.6; 95% confidence interval [CI], 0.38-0.93; P= 0.022), 11-15 years (OR,0.32; 95% CI, 0.21-0.48; P < 0.0001), and 16-20 years (OR, 0.24; 95% CI, 0.15-0.37; P < 0.0001) were independently associated with decreased risk of developing hydrocephalus, compared with ages 0-5 years. Extended loss of consciousness with baseline return and extended loss of consciousness without baseline return were independently associated with increased risk of developing hydrocephalus. Respiratory complication (OR, 28.35; 95% CI, 15.75-51.05; P < 0.0001), hemorrhage (OR, 37.12; 95% CI, 4.79-287.58; P=0.0001), thromboembolic (OR, 8.57; 95% CI, 1.31-56.19; P= 0.025), and neurologic complication (OR, 64.64; 95% CI, 1.39-3010.2; P= 0.033) were all independently associated with increased risk of developing hydrocephalus. Our study using the Nationwide Emergency Department Sample database shows that various demographic, hospital, and clinical risk factors are associated with the development of hydrocephalus after traumatic brain injury.

A venous mechanism of ventriculomegaly shared between traumatic brain injury and normal ageing.

Recently, age-related timing dissociation between the superficial and deep venous systems has been observed; this was particularly pronounced in patients with normal pressure hydrocephalus, suggesting a common mechanism of ventriculomegaly. Establishing the relationship between venous drainage and ventricular enlargement would be clinically relevant and could provide insight into the mechanisms underlying brain ageing. To investigate a possible link between venous drainage and ventriculomegaly in both normal ageing and pathological conditions, we compared 225 healthy subjects (137 males and 88 females) and 71 traumatic brain injury patients of varying ages (53 males and 18 females) using MRI-based volumetry and a novel perfusion-timing analysis. Volumetry, focusing on the CSF space, revealed that the sulcal space and ventricular size presented different lifespan profiles with age; the latter presented a quadratic, rather than linear, pattern of increase. The venous timing shift slightly preceded this change, supporting a role for venous drainage in ventriculomegaly. In traumatic brain injury, a small but significant disease effect, similar to idiopathic normal pressure hydrocephalus, was found in venous timing, but it tended to decrease with age at injury, suggesting an overlapping mechanism with normal ageing. Structural bias due to, or a direct causative role of ventriculomegaly was unlikely to play a dominant role, because of the low correlation between venous timing and ventricular size after adjustment for age in both patients and controls. Since post-traumatic hydrocephalus can be asymptomatic and occasionally overlooked, the observation suggested a link between venous drainage and CSF accumulation. Thus, hydrocephalus, involving venous insufficiency, may be a part of normal ageing, can be detected non-invasively, and is potentially treatable. Further investigation into the clinical application of this new marker of venous function is therefore warranted.

Does the skull Hounsfield unit predict shunt dependent hydrocephalus after decompressive craniectomy for traumatic acute subdural hematoma?

Posttraumatic hydrocephalus affects 11.9%-36% of patients undergoing decompressive craniectomy (DC) after traumatic brain injury and necessitates a ventriculo-peritoneal shunt placement. As bone and arachnoid trabeculae share the same collagen type, we investigated possible connections between the skull Hounsfield unit (HU) values and shunt-dependent hydrocephalus (SDHC) in patients that received cranioplasty after DC for traumatic acute subdural hematoma (SDH). We measured HU values in the frontal bone and internal occipital protuberance from admission brain CT. Receiver operating characteristic curve analysis was performed to identify the optimal cut-off skull HU values for predicting SDHC in patients receiving cranioplasty after DC due to traumatic acute SDH. We investigated independent predictive factors for SDHC occurrence using multivariable logistic regression analysis. A total of 162 patients (>15 years of age) were enrolled in the study over an 11-year period from two university hospitals. Multivariable logistic analysis revealed that the group with simultaneous frontal skull HU ≤797.4 and internal occipital protuberance HU ≤586.5 (odds ratio, 8.57; 95% CI, 3.05 to 24.10; P<0.001) was the only independent predictive factor for SDHC in patients who received cranioplasty after DC for traumatic acute SDH. Our study reveals a potential relationship between possible low bone mineral density and development of SDHC in traumatic acute SDH patients who had undergone DC. Our findings provide deeper insight into the association between low bone mineral density and hydrocephalus after DC for traumatic acute SDH.

Wet, Wacky, Wobbly, and WILD: Disinhibition as an Outcome of Post-traumatic Hydrocephalus

Wet, Wacky, Wobbly, and WILD: Disinhibition as an Outcome of Post-traumatic Hydrocephalus

Posttraumatic Hydrocephalus in Pediatric Patients After Decompressive Craniectomy

The risk for developing posttraumatic hydrocephalus (PTH) is higher when patients undergo decompressive craniectomy as part of their treatment. The purpose of this study is to determine the prevalence of PTH after decompressive craniectomy in pediatric patients and determine associated risk factors that may lead to PTH. A retrospective analysis was conducted by searching the Puerto Rico neurologic surgery database from 2010 to 2019. All pediatric patients (1-18 years old) at the University Pediatric Hospital of the Puerto Rico Medical Center who had traumatic brain injury and had a decompressive craniectomy were included in the study. Data were reviewed to determine if time to decompressive craniectomy, side of decompressive craniectomy, gender, mechanism of trauma, amount of subarachnoid hemorrhage, and time to cranioplasty were risk factors for the development of PTH. Incidence of PTH after decompressive craniectomy was 21%. Neither gender, side of decompressive craniectomy, mechanism of trauma, amount of subarachnoid hemorrhage, time from trauma to decompressive craniectomy, nor cranioplasty intervention had statistical significance for developing PTH. Time from decompressive craniectomy to cranioplasty was significant for development of PTH. Longer time to cranioplasty was associated with an increased likelihood of PTH. We recommend performing cranioplasty as soon as possible to reduce hydrocephalus development.

Post-traumatic hydrocephalus following decompressive hemicraniectomy: Incidence and risk factors in a prospective cohort of severe TBI patients

BackgroundIn severe traumatic brain injury (TBI) patients undergoing decompressive hemicraniectomy (DHC), the rate of post-traumatic hydrocephalus (PTH) is high at 12–36%. Early diagnosis and shunt placement can improve outcomes. Herein, we examined the incidence of and predictors of PTH after craniectomy. MethodsA retrospective analysis of prospectively collected database of severe TBI patients at a single U.S. Level 1 trauma center from May 2000 to July 2014 was performed. Demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), bleeding pattern and time-to-cranioplasty were analyzed. Glasgow Outcome Scale (GOS) scores at 6 and 12-months were studied. Statistical significance was assessed at p < 0.05. ResultsA total of 402 patients were enrolled and 105 patients had DHC. Twenty-two (21.0%) of 105 required ventriculoperitoneal shunt (VPS), compared to 18 (6%) of 297 patients without DHC. There was increased odds ratio for shunting after DHC at 3.62 (95%CI:1.62–8.07; p < 0.01). Mean age at time of DHC was 43.8 ± 17.7 years old, and 81.9% were male. Subdural hematoma (SDH) was most common at 57.1%. Median time from admission to cranioplasty was 63 days. Patients who experienced PTH after DHC were younger (35.5 ± 17.7 versus 46.0 ± 17.7 years, p < 0.01) and had higher ISS scores (35 versus 26, p = 0.04) compared to patients without shunt after DHC. ConclusionsAfter severe TBI requiring hemicraniectomy, shunt-dependent hydrocephalus was 21%. Younger patients and higher ISS score were associated with PTH. Shunt-dependent patients achieved similar 6- and 12-month outcomes as those without PTH. Early diagnosis and shunt placement can enhance long-term neurological recovery.

Factors associated with the development and outcome of hydrocephalus after decompressive craniectomy for traumatic brain injury.

Posttraumatic hydrocephalus (PTH) is common in patients undergoing decompressive craniectomy (DC) for traumatic brain injury (TBI), but the incidence, mechanisms, and risk factors have not been fully elucidated. This study aimed to determine the incidence of and the factors associated with PTH. We retrospectively reviewed patients who underwent DC for TBI at our institute between January 2014 and December 2018. We identified and compared the demographic, clinical, and radiological data, and 12-month functional outcome (as assessed by the Glasgow Outcome Scale [GOS]) between patients who developed PTH and those who did not. Logistic regression analyses were performed to identify risk factors for PTH. Additionally, the influence of PTH on unfavorable functional outcome was analyzed. PTH developed in 18 (18.95%) of the 95 patients who survived at 1month after DC. A multivariate analysis indicated that postoperative intraventricular hemorrhage (odds ratio [OR] 4.493, P = 0.020), postoperative subdural hygroma (OR 4.074, P = 0.021), and postoperative hypothermia treatment (OR 9.705, P = 0.010) were significantly associated with PTH. The 12-month functional outcome significantly differed between the patients who developed PTH and those who did not (P = 0.049). Patients who developed PTH had significantly poorer 12-month functional outcomes than those who did not (P = 0.049). Another multivariate analysis indicated that subdural hemorrhage (OR 6.814, P = 0.031) and the presence of at least one dilated pupil before DC (OR 8.202, P = 0.000) were significantly associated with unfavorable functional outcomes (GOS grades 1-3). Although the influence of PTH (OR 5.122, P = 0.056) was not statistically significant in the multivariate analysis, it had a great impact on unfavorable functional outcomes. PTH considerably affects functional outcomes at 12months after DC for TBI. Furthermore, postoperative imaging findings such as intraventricular hemorrhage and subdural hygroma can predict the development of PTH; therefore, careful observation is required during the follow-up period.

Case Report: Ventriculoperitoneal Shunt Catheter Migration and Transanal Extrusion in Persistent Vegetative State Adult Patient

The complications of ventriculoperitoneal (VP) shunts are many and are reported in literature extensively. The complication of transanal extrusion after bowel perforation is known although rare. This complication is very well described amongst the children. The authors describe the case of bowel perforation and transanal extrusion of a VP shunt occurring in a 51-year-old adult patient. The patient has a history of craniotomy for acute subdural hematoma after severe head injury one year ago continued with VP shunt for post-traumatic hydrocephalus. Home care with bedridden conditions is done at home until finally, the family gets the catheter extrude from the transanal. Bowel perforation and transanal extrusion of VP shunt catheter is a rare but serious problem. The exact pathogenesis of shunt-related organ perforation and extrusion through the anus is unclear, and various mechanisms have been suggested, Among many factors, age is the prominent factor for bowel perforation.1 Because of weak bowel musculature and stronger peristaltic activity, children are more susceptible to bowel perforation than adult patients. In adult shunted patient, one of the risk factors is related to PVS with chronic immobilization, as described in this case. Risk factors of bowel perforation in adult are quite distinct from children. Persistent vegetative state (PVS) with chronic immobilization is one of the risk factors to be aware of.

Post Traumatic Hydrocephalus in Indian Subpopulation: An Institutional Experience.

To identify subgroups of cases with ventriculomegaly who will benefit from the cerebrospinal fluid (CSF) diversion procedures, n patients with post-traumatic hydrocephalus (PTH), and to identify the risk factors for its development to minimize its occurrence. We analyzed 500 head injury cases who were admitted over a one and a half year period in our institute with PTH, to assess them for treatment benefit by CSF diversion procedures and associated risk factors for its development. The patients were assigned to one of three groups: Group 1 had ventriculomegaly with periventricular lucency (PVL), and raised intracranial pressure (ICP) 2.1% (10/500). Group 2 had ventriculomegaly with PVL, and normal opening pressure 1.75% (7/500) and Group three had no ventriculomegaly 95.75% (483/500). The incidence of radiological PTH in this study was 3.4% (17/500), and it developed after an average interval of 16.43 ± 23.7 (SD) in Group 1 and 19.76 ± 8.9 (SD) weeks in Group 2. Lower Glasgow Coma Score (GCS) (p < 0.001), decompressive craniotomy (p < 0.001) and requirement for prolonged ventilatory support (p < 0.001) were significantly associated with the development of PTH. Significantly better results were found in cases with PTH and high opening CSF pressure (? 15 mmHg) on Lumbar puncture (p < 0.001). Decompressive craniotomy cases required significantly more shunt revisions compared to conservatively managed cases (p < 0.05). CSF diversion procedures help to improve ventriculomegaly cases with documented evidence of raised ICP but not in cases without raised ICP. The subgroup of PTH, which cannot be treated by CSF diversion procedures, can only be managed by minimizing many of the risk factors for its development. In cases with severe head injury, a low GCS, and prolonged ICU stay, decompressive craniotomy should be used judiciously. The duration of mechanical ventilation should be minimized and combined with necessary measures to improve GCS.

Predicting the outcomes of shunt implantation in patients with post-traumatic hydrocephalus and severe conscious disturbance: a scoring system based on clinical characteristics.

Post-traumatic hydrocephalus is a common complication secondary to traumatic brain injury. It can cause cerebral metabolic impairment and dysfunction. Therefore, timely treatment with shunt implantation is necessary. However, the outcomes of shunt surgery in patients with post-traumatic hydrocephalus combined with disturbance of consciousness are doubtful. The objective was to develop a predictive model that uses the information available before surgery to predict the outcome of shunt implantation in such patients. Retrospectively collected data were used to develop a clinical prediction model. The model was derived from 59 patients using logistic regression analysis, and then it was evaluated by the area under the receiver operating characteristic curve and Hosmer-Lemshow test. A validation cohort verified the model. Four independent predictors were identified: age < 50 years, mild hydrocephalus, Glasgow Coma Scale scores 9-12 at the time of injury, and time interval from trauma to shunting < 3 months. We calculated the total score and defined the patients into three groups: low-probability (0-10 points), medium-probability (11-16 points), and high-probability (17-30 points). The rates of improved outcomes in the three groups were 14.3%, 52.6%, and 94.7%, respectively (P < 0.0001). The correlative rates of the validation cohort were 21.4%, 54.5%, and 85.7%. The prognostic model showed good discrimination (area under the receiver operating characteristic curve = 0.869) and calibration (Hosmer-Lemshow test, P = 0.391). The developed predictive model can identify patients with post-traumatic hydrocephalus combined with disturbance of consciousness who can benefit from shunt implantation. Therefore, our prognostic model can predict the outcomes of patients with post-traumatic hydrocephalus and disturbance of consciousness after shunt surgery.

Is Endoscopic Third Ventriculostomy a Feasible Option or Ventriculoperitoneal Shunt a Safer Bet for the Treatment of Posttraumatic Hydrocephalus? A Gap Time Model-based Algorithm.

Posttraumatic hydrocephalus (PTH) adds to the morbidity and mortality of traumatic brain injury (TBI) and there are insufficient clinical data to suggest usefulness of ventriculoperitoneal shunt (VPS) over endoscopic third ventriculostomy (ETV) in PTH or vice versa. To evaluate the usefulness of VPS and ETV in the treatment of PTH and to establish the indications for their usage. This was an ambispective study of 141 patients who developed PTH out of 2500 cases of TBI treated during the study duration (2012-2016). These patients were segregated into two groups depending on the primary procedure for PTH-ETV group and VPS group. The two groups were compared to analyze the differences in radiological and clinical outcome. 141 patients were included in the study and 175 procedures were performed in these patients. ETV group had 30 procedures and VPS had 145 procedures. In the ETV group, 37% of cases showed improvement v/s 73% cases in the VPS group. A statistically significant number of patients had improvement in presenting symptoms in the VPS group, as compared with the ETV group (P = 0.001). There was no significant difference in Glasgow coma scale (GCS) at discharge (P = 0.15) and Glasgow outcome score at 6 months of follow-up (P = 0.22) between the two groups. Poor GCS, previous cerebrospinal fluid infection, and postoperative meningitis were found to have significant effect on the failure-free period of the procedure. On comparing the probabilities of failure-free period of ETV v/s VPS, the chances of VPS failure are 61% lesser than ETV. VPS is an effective modality for the management of PTH and has a much lower failure rate as compared to ETV. However, ETV can be considered as a salvage procedure in difficult situations of recurrent shunt malfunction or infection.

Determinants affecting the prognosis of decompressive craniectomy for traumatic brain injury.

Objective:This research was designed to investigate the prognostic determinants of patients with traumatic brain injury (TBI) undergoing decompressive craniectomy (DC).Methods:The present study was a retrospective single center research including a total of 112 patients undergoing DC for TBI in Liaocheng People’s Hospital between January 2017 and December 2018. The results were measured by Extended Glasgow Outcome Sale (GOSE). The prognostic determinants were identified by univariate and binary logistic regression analysis between the deaths and survivors or favorable and unfavorable outcomes.Results:At the six-month follow-up, the mortality was 45.5% including 37 (33.0%) patients died within 30 days. The independent prognostic factors of 30-day mortality were age (p=0.033), D-dimer level at admission (p=0.032) and postoperative hypernatremia (p=0.014). Seventy five patients survived more than 30 days after DC, among which 27 (36.0%) patients had unfavorable prognosis (GOSE 1-4) and 48 (64.0%) patients presented favorable prognosis (GOSE 5-8). After 30 days from DC, the occurrence of post-traumatic hydrocephalus(PTH) (p= 0.008) was associated with unfavorable prognosis.Conclusions:Although DC is an effective treatment for TBI patients, the mortality and morbidity risk remain high. A combination of age, D-dimer level at admission and postoperative hypernatremia may be a good prognostic factor for 30-day mortality. Developing an accurate therapy strategy to prevent and control PTH may be beneficial to the 6-month prognosis for TBI patients undergoing DC.