Shunt-dependent Hydrocephalus Research Articles

Predictive value of whole brain perfusion on admission for shunt-dependent hydrocephalus fllowing aneurysmal subarachnoid hemorrhage

Objective: To explore the value of predicting shunt-dependent hydrocephalus (SDHC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) based on whole brain CT perfusion(CTP) and clinical data within 24 hours at admission. Methods: The clinical and imaging data of aSAH patients who received interventional embolization in our hospital were retrospectively collected from March 2018 to August 2022. All patients underwent one-stop whole brain CT examination within 24 hours after symptom onset, and the qualitative and quantitative CTP parameters were obtained after post-processing. Follow-up was conducted once every 2 months by consulting electronic medical records or by telephone for 6 months. According to whether SDHC occurred or not, the patients were divided into SDHC group and non-SDHC group. The differences between the two groups were compared. Logistic regression model was used to analyze and determine the predictive factors of SDHC, and the SDHC predictive model was established. The effectiveness of the predictive model was evaluated by drawing the receiver operating characteristic (ROC) curve of the subjects. Results: A total of 414 patients were included, including 132 males and 282 females, aged (59±11) years. 17.6%(73/414) patients had SDHC. There were significant differences in the occurrence of acute hydrocephalus, the World Neurosurgical League Scale (WFNS), the Hunt-Hess scale, the modified Fisher score (mFS), and the qualitative and quantitative parameters of CTP between the two groups (both P<0.001). Multivariate logistic regression analysis showed that acute hydrocephalus (OR=8.621, 95%CI: 4.237-17.542),old age (OR=1.107, 95%CI: 1.068-1.148), high mFS and high Hunt-Hess classification (OR=3.740, 95%CI: 1.352-10.342) were the risk factors of SDHC in aSAH patients, and high mean cerebral blood flow (mCBF) (OR=0.931, 95%CI: 0.885-0.980) was a protective factor of SDHC.The area under ROC curve (AUC) of the prediction model constructed by these five variables was 0.923(95%CI: 0.89-0.95), with 84.5% sensitivity and 87.7% specificity. Conclusion: The mCBF and acute hydrocephalus, age, mFS and Hunt-Hess classification within 24 hours at admission can be used to predict SDHC for aSAH patients.

Risk factors for shunt-dependent hydrocephalus after spontaneous subarachnoid hemorrhage

IntroductionSubarachnoid hemorrhage (SAH) is one of the most frequent neurosurgical emergencies, most of them due to intracranial aneurysm rupture. Hydrocephalus is a prevalent complication with a high rate of complications. The aims of this study are to identify predictors of shunt-dependent hydrocephalus following aneurysmal SAH and to quantify the complications arising from ventriculoperitoneal shunts. MethodsThis study is about an observational retrospective analytic study of the patients with spontaneous SAH admitted to Miguel Servet Universitary Hospital between 2017 and 2022. Patients’ clinical and radiological characteristics, type of treatment, diagnoses and treatment of hydrocephalus, complications of ventriculoperitoneal shunts and mortality are some of the data achieved in this study. A descriptive study of these variables has been done and, subsequently, the most relevant variables have been statistically analyzed to identify patients with increasing risk of shunting for hydrocephalus. This study was authorized by the Ethics Committee prior to its elaboration. ResultsA total of 359 patients with spontaneous SAH were admitted to Miguel Servet Universitary Hospital between 2017 and 2022, with an intrahospitalary death rate of 25,3%. 66,3% of the total of patients with SAH were due to intracranial aneurysm rupture (n = 238). 45,3% of the patients with aneurysmal SAH required an external ventricular drain (EVD) to treat acute hydrocephalus. 11,7% (n = 28) developed a shunt-dependent hydrocephalus. Statistical significance was found between shunt-dependent hydrocephalus and the following: high score in modified Fisher scale and placement of EVD. The mean interval from EVD to ventriculoperitoneal shunt placement was 26,1 days. The mean rate of reoperation of patients after shunt was 17,7%, mostly due to infection. ConclusionsThe most significant risk factor for shunt-dependent hydrocephalus after aneurysmal SAH was high Fisher grade and previous need of EVD. Shunt infections is the main cause of shunt reoperation. Early shunt placement in selected patients might reduce the rate of infectious complications.

Absence of hernia sack in patients undergoing prenatal repair of spina bifida increases the risk of developing shunt-dependent hydrocephalus

Absence of hernia sack in patients undergoing prenatal repair of spina bifida increases the risk of developing shunt-dependent hydrocephalus

Clinical impact of craniectomy on shunt-dependent hydrocephalus after intracerebral hemorrhage: A propensity score-matched analysis.

A consensus on decompressive craniectomy for intracerebral hemorrhage (ICH) has not yet been established. We aimed to investigate the development of shunt-dependent hydrocephalus based on the method of ICH surgery, with a focus on craniectomy. We retrospectively enrolled 458 patients with supratentorial ICH who underwent surgical hematoma evacuation between April 2005 and December 2021 at two independent stroke centers. Multivariate analyses were performed to characterize risk factors for postoperative shunt-dependent hydrocephalus. Propensity score matching (1:2) was undertaken to compensate for group-wise imbalances based on probable factors that were suspected to affect the development of hydrocephalus, and the clinical impact of craniectomy on shunt-dependent hydrocephalus was evaluated by the matched analysis. Overall, 43 of the 458 participants (9.4%) underwent shunt procedures as part of the management of hydrocephalus after ICH. Multivariate analysis revealed that intraventricular hemorrhage (IVH) and craniectomy were associated with shunt-dependent hydrocephalus after surgery for ICH. After propensity score matching, there were no statistically significant intergroup differences in participant age, sex, hypertension status, diabetes mellitus status, lesion location, ICH volume, IVH occurrence, or IVH severity. The craniectomy group had a significantly higher incidence of shunt-dependent hydrocephalus than the non-craniectomy group (28.9% vs. 4.3%,p < 0.001; OR 9.1, 95% CI 3.7-22.7), craniotomy group (23.2% vs. 4.3%,p < 0.001; OR 6.6, 95% CI 2.5-17.1), and catheterization group (20.0% vs. 4.0%,p = 0.012; OR 6.0, 95% CI 1.7-21.3). Decompressive craniectomy seems to increase shunt-dependent hydrocephalus among patients undergoing surgical ICH evacuation. The decision to perform a craniectomy for patients with ICH should be carefully individualized while considering the risk of hydrocephalus.

Unlocking the battle: clipping vs. endovascular therapy for shunt-dependent hydrocephalus after aneurysm rupture – an in-depth institutional analysis

Unlocking the battle: clipping vs. endovascular therapy for shunt-dependent hydrocephalus after aneurysm rupture – an in-depth institutional analysis

The Role of Cisternostomy and Cisternal Drainage in the Treatment of Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review.

Aneurysmal subarachnoid hemorrhage (aSAH) provokes a cascade reaction that is responsible for early and delayed brain injuries mediated by intracranial hypertension, hydrocephalus, cerebral vasospasm (CV), and delayed cerebral ischemia (DCI), which result in increased morbidity and mortality. During open microsurgical repair, cisternal access is achieved essentially to gain proximal vascular control and aneurysm exposition. Cisternostomy also allows brain relaxation, removal of cisternal clots, and restoration of the CSF dynamics through the communication between the anterior and posterior circulation cisterns and the ventricular system, with the opening of the Membrane of Liliequist and lamina terminalis, respectively. Continuous postoperative CSF drainage through a cisternal drain (CD) is a valuable option for treating acute hydrocephalus and intracranial hypertension. Moreover, it efficiently removes the blood and toxic degradation products, with a potential benefit on CV, DCI, and shunt-dependent hydrocephalus. Finally, the CD is an effective pathway to administer vasoactive, fibrinolytic, and anti-oxidant agents and shows promising results in decreasing CV and DCI rates while minimizing systemic effects. We performed a comprehensive review to establish the adjuvant role of cisternostomy and CD performed in cases of direct surgical repair for ruptured intracranial aneurysms and their role in the prevention and treatment of aSAH complications.

Serial Neuroendoscopic Lavage for the Treatment of Elevated Cerebrospinal Fluid Protein Levels in Infants with Gram-Negative Rod Ventriculitis

Introduction: Gram-negative rod (GNR) bacterial ventriculitis is a rare complication of shunt-dependent hydrocephalus, often requiring an extended and invasive treatment course. Accumulation of purulent material, as well as empyema and septation formation, limits circulation of antibiotics and infection clearance. Supplementation of standard care with neuroendoscopic-guided intraventricular lavage with lactated Ringer solution and fenestration of septations may facilitate infection clearance and simplify the eventual shunt construct required. Here, the utility of serial lavage for ventriculitis is described in a population of shunt-dependent neonates and infants at high risk for morbidity and mortality. Methods: Five infants with shunt-dependent hydrocephalus and subsequent GNR ventriculitis were treated with standard care measures with the addition of serial neuroendoscopic lavage. A retrospective chart review was performed to collect patient characteristics, shunt dependency, and shunt revisions within a year of ventriculitis resolution. Results: Patients demonstrated a mean 74% decrease in cerebrospinal fluid (CSF) protein following each neuroendoscopic lavage and trended toward a shorter time to infection clearance in comparison to previously published literature. Patients required 0–2 shunt revisions at 1-year follow-up following hospitalization for shunt-related ventriculitis (mean 0.8 +/− 0.8). Conclusions: Serial neuroendoscopic lavage is an effective technique, used alone or in combination with fenestration of septations, to reduce the CSF protein and bacterial load in the treatment of ventriculitis, decreasing time until eradication of infection. Serial lavage may reduce the risk of future shunt malfunction, simplify the future shunt construct, and decrease duration of infection.

Enhancing the prediction for shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage using a machine learning approach

Early and reliable prediction of shunt-dependent hydrocephalus (SDHC) after aneurysmal subarachnoid hemorrhage (aSAH) may decrease the duration of in-hospital stay and reduce the risk of catheter-associated meningitis. Machine learning (ML) may improve predictions of SDHC in comparison to traditional non-ML methods. ML models were trained for CHESS and SDASH and two combined individual feature sets with clinical, radiographic, and laboratory variables. Seven different algorithms were used including three types of generalized linear models (GLM) as well as a tree boosting (CatBoost) algorithm, a Naive Bayes (NB) classifier, and a multilayer perceptron (MLP) artificial neural net. The discrimination of the area under the curve (AUC) was classified (0.7 ≤ AUC < 0.8, acceptable; 0.8 ≤ AUC < 0.9, excellent; AUC ≥ 0.9, outstanding). Of the 292 patients included with aSAH, 28.8% (n = 84) developed SDHC. Non-ML-based prediction of SDHC produced an acceptable performance with AUC values of 0.77 (CHESS) and 0.78 (SDASH). Using combined feature sets with more complex variables included than those incorporated in the scores, the ML models NB and MLP reached excellent performances, with an AUC of 0.80, respectively. After adding the amount of CSF drained within the first 14 days as a late feature to ML-based prediction, excellent performances were reached in the MLP (AUC 0.81), NB (AUC 0.80), and tree boosting model (AUC 0.81). ML models may enable clinicians to reliably predict the risk of SDHC after aSAH based exclusively on admission data. Future ML models may help optimize the management of SDHC in aSAH by avoiding delays in clinical decision-making.

Lamina Terminalis Fenestration: A Beneficial Approach to Reduce Shunt-dependent Hydrocephalus in Patients with Aneurysmal Subarachnoid Hemorrhage with a Review of Literature

ABSTRACT Objective: Hydrocephalus requiring shunt placement (12%–20%) is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). Various studies suggest that fenestration of lamina terminalis (LT) during microsurgery for aSAH may be associated with a reduced rate of shunt-dependent hydrocephalus. We report a prospective analysis correlating fenestration of the LT with decreased shunt-dependent hydrocephalus after aSAH managed by microsurgical repair. Methodology: A total of 106 patients over a period of 1.5 years with aSAH treated by microsurgical aneurysm repair along with fenestration of LT were analyzed. Patients were treated by same surgical team and those patients where surgical clipping of anterior circulation aneurysms with LT fenestration was performed were included in the study. We compared the rate of shunting in patients operated on by routinely fenestration of the LT with that in cases where LT fenestration was not carried out (taking literature as control). This study design isolates the effect of fenestration of the LT on the incidence of shunt-dependent hydrocephalus. Results: There has been significantly lower rate of shunting (2.3%) in the patients where LT fenestration was done, versus 12%–20% in the cases where it was not preformed (P &lt; 0.05). Furthermore, post-aSAH, hydrocephalus is associated with a higher grade of Fischer’s scale (Grade III and IV). Conclusion: Fenestration of the LT appears to be associated with a decreased incidence of shunt-dependent hydrocephalus of more than 80% after aSAH. This straightforward microsurgical maneuver should be performed whenever possible during aneurysm surgery.

Pretreatment and Posttreatment Factors Associated with Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

Hydrocephalus is a common complication following aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to evaluate novel pre- and postoperative risk factors for shunt- dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis. A systematic search was conducted using Pubmed and Embase databases for studies pertaining to aSAH and SDHC. Articles were assessed by meta-analysis if the number of risk factors for SDHC were reported by greater than 4 studies and could be extracted separately for patients who did or did not develop SDHC. 37 studies were included, comprising 12,667 aSAH patients (SDHC 2,214 vs. non-SDHC 10,453). In a primary analysis of 15 novel potential risk factors, 8 were identified to be significantly associated with increased prevalence of SDHC after aSAH including high World Federation of Neurological Surgeons (WFNS) grades (odds ratio (OR) 2.43), hypertension (OR 1.33), anterior cerebral artery (ACA) (OR 1.36), middle cerebral artery (MCA) (OR 0.65), and vertebrobasilar artery (VBA) (2.21) involvement, decompressive craniectomy (DC) (OR 3.27), delayed cerebral ischemia (DCI) (OR 1.65), and intracerebral hematoma (ICH) (OR 3.91). Several new factors associated with increased odds of developing SDHC following aSAH were found to be significant. By providing evidence-based risk factors for shunt dependency, we describe an identifiable list of pre- and postoperative prognosticators that may influence how surgeons recognize, treat, and manage aSAH patients at high risk for developing SDHC.

Treatment and Outcome of Anterior Inferior Cerebellar Artery (AICA) Aneurysms: Helsinki Series of 15 Consecutive Patients.

Objective Anterior inferior cerebellar artery (AICA) aneurysms are rare posterior circulation lesions that are challenging to treat. This article presents the treatment and clinical outcome of AICA aneurysms in an unselected cohort of patients. Methods A retrospective analysis of patient record files, digital subtraction angiography, and computed tomography angiography images of 15 consecutive patients harboring AICA aneurysms treated between 1968 and 2017. Results Of the 15 AICA aneurysm patients reviewed, 12 (80%) were females. Twenty percent had intracerebral hemorrhage and 40% presented with intraventricular hemorrhage. Eleven out of 15 (73%) patients presented with subarachnoid hemorrhage (SAH); 82% of SAH patients had a good-grade SAH (Hunt and Hess grade 1-3). Eleven patients (73%) were treated surgically, three (20%) were treated conservatively, and one (7%) had coil embolization. In 27% of patients, a subtemporal approach with anterior petrosectomy was performed. A retrosigmoid approach was used in the remaining 73%. In 18% of the patients, a parent vessel occlusion was necessary to occlude the aneurysm. Five out of 11 (47%) of the patients developed postoperative cranial nerve deficits. Twenty-seven percent developed shunt-dependent hydrocephalus. All patients who presented with an unruptured AICA aneurysm had good clinical outcome (modified Rankin scale [mRS] 1-2). In patients with SAH, 82% achieved good clinical outcome and 18% had poor clinical outcome (mRS 3-6) after 1 year. Conclusion Surgical treatment of AICA aneurysms has a high rate of cranial nerve deficits but most of patients have a good long-term clinical outcome.

Absence of a Hernia Sack in Patients Undergoing Prenatal Repair of Spina Bifida Increases the Risk of Developing Shunt-Dependent Hydrocephalus.

Spina bifida aperta (SBA), with (myelomeningocele) or without (myeloschisis) a hernia sack, is the most common congenital defect of the central nervous system. Prenatal surgical closure of SBA lowers the risk for developing shunt-dependent hydrocephalus, which offers a chance at improved motor, urinary, and gastrointestinal function. A total of 96 patients who had undergone open surgery prenatal repair for SBA were analyzed. The patients were divided into two groups: Group I-12 patients (12.5%)-without a hernia sack (myeloschisis) and Group II-84 patients (87.5%)-with a hernia sack (myelomeningocele). In this study, we demonstrated that prenatal SBA repair was statistically significantly less often associated with the need for ventriculoperitoneal shunting (p > 0.00001). The shunting was statistically significantly more often required in patients from Group I (p > 0.004). The absence of a hernia sack increases the risk for developing shunt-dependent hydrocephalus in patients after prenatal SBA repair. However, as prenatal SBA repair is associated with better motor, urinary, and gastrointestinal function, increased risk of developing shunt-dependent hydrocephalus in fetuses without a hernia sack should not be treated as a contraindication to prenatal intervention.

The positive impact of cisternostomy with cisternal drainage on delayed hydrocephalus after aneurysmal subarachnoid hemorrhage

BackgroundHydrocephalus is one of the major complications of aneurysmal subarachnoid haemorrhage (aSAH). In the acute setting, an external ventricular drain (EVD) is used for early management. A cisternal drain (CD) coupled with the micro-surgical opening of basal cisterns can be an alternative when the aneurysm is clipped. Chronic hydrocephalus after aSAH is managed with ventriculo-peritoneal (VP) shunt, a procedure associated with a wide range of complications. The aim of this study is to analyse the impact of micro-surgical opening of basal cisterns coupled with CD on the incidence of VP shunt, compared to patients treated with EVD.MethodsThe authors conducted a retrospective review of 89 consecutive cases of patients with aSAH treated surgically and endovascularly with either EVD or CD between January 2009 and September 2021. Patients were stratified into two groups: Group 1 included patients with EVD, Group 2 included patients with CD. Subgroup analysis with only patients treated surgically was also performed. We compared their baseline characteristics, clinical outcomes and shunting rates.ResultsThere were no statistically significant differences between the two groups in terms of epidemiological characteristics, WFNS score, Fisher scale, presence of intraventricular hemorrhage (IVH), acute hydrocephalus, postoperative meningitis or of clinical outcomes at last follow-up. Cisternostomy with CD (Group 2) was associated with a statistically significant reduction in VP-shunt compared with the use of an EVD (Group 1) (9.09% vs 53.78%; p < 0.001). This finding was confirmed in our subgroup analysis, as among patients with a surgical clipping, the rate of VP shunt was 43.7% for the EVD group and 9.5% for the CD group (p = 0.02).ConclusionsCisternostomy with CD may reduce the rate of shunt-dependent hydrocephalus. Cisternostomy allows the removal of subarachnoid blood, thereby reducing arachnoid inflammation and fibrosis. CD may enhance this effect, thus resulting in lower rates of chronic hydrocephalus.

Management and safety of intraoperative ventriculostomy during early surgery for ruptured intracranial aneurysms.

Brain edema and/or acute hydrocephalus are common features that limit working space during early surgery of aneurysmal subarachnoid hemorrhage (aSAH). Intraoperative ventriculostomy offers an immediate brain relaxation. However, management and complications related to the routine use of intraoperative external ventricular drainage (iEVD) are not well investigated. We retrospectively reviewed all patients who were treated with pterional craniotomy and clipping for ruptured anterior circulation aneurysms in our center between 2012 and 2019. We included in this study all patients submitted to iEVD using the Paine's point on the side of craniotomy. Indication for positioning of an iEVD was given in all cases whenever initial cisternal dissection was hampered by the lack of cerebrospinal fluid (CSF) circulation due to SAH and/or hydrocephalus. In the study period, 162 patients with aSAH underwent surgical clipping. In 103 patients, an iEVD was used. The overall rate of iEVD-related complications was 6.7%, including 3 cases of catheter misplacement, one case of catheter obstruction, one case of related hemorrhage, and 2 cases of infection. The rate of shunt-dependent hydrocephalus was 16.5% (17/103 patients). In our experience, iEVD is a safe technique that facilitates dissection during early surgery for intracranial ruptured aneurysms, without requiring an additional burr hole procedure.

Prediction of Shunt-Dependent Hydrocephalus after Primary Supratentorial Intracerebral Hemorrhage with a Focus on the Influence of Craniectomies.

ObjectiveHydrocephalus after intracerebral hemorrhage (ICH) is known to be related to poor prognosis and mortality. We analyzed predictors of permanent hydrocephalus in the patients with surgically treated supratentorial ICH. MethodsFrom 2004 to 2019, a total of 414 patients with surgically treated primary supratentorial ICH were included. We retrospectively analyzed age, sex, preexisting hypertension and diabetes, location and volume of ICH, presence and severity of intraventricular hemorrhage (IVH), and type of surgery. ResultsForty patients (9.7%) required shunt surgery. Concomitant IVH was higher in the ‘shunt required’ group (92.5%) than in the ‘shunt not required’ group (67.9%) (p=0.001). IVH severity was worse in the ‘shunt required’ group (13.5 vs. 7.5, p=0.008). Craniectomy (47.5%) was significantly high in the ‘shunt required’ group. According to multivariable analysis, the presence of an IVH was 8.1 times more frequent and craniectomy was 8.6 times more frequent in the ‘shunt required’ group. In the comparison between craniotomy and craniectomy group, the presence of an IVH was related with a 3.9 times higher (p=0.033) possibility and craniectomies rather than craniotomies with a 7-times higher possibility of shunt surgery (p<0.001). Within the craniectomy group, an increase in the craniectomy area by 1 cm2 was correlated with a 3.2% increase in the possibility of shunt surgery (odds ratio, 1.032; 95% confidence interval, 1.005-1.061; p=0.022). ConclusionPresence of IVH, the severity of IVH and decompressive craniectomy were related to the development of shunt dependent hydrocephalus in the patients with ICH. The increasing size of craniectomy was related with increasing rate of shunt requirement.

Sociodemographic disparities as a determinant of fetal versus postnatal surgical myelomeningocele repair.

Relatively few women undergo open maternal-fetal surgery (OMFS) for myelomeningocele (MMC) despite the potential to reverse hindbrain herniation, reduce the rate of infant shunt-dependent hydrocephalus, and improve ambulation. These benefits have the potential to significantly reduce morbidity and lifetime medical care. In this study, the authors examined demographics and socioeconomic variables of women who were offered and opted for OMFS for MMC versus postnatal MMC surgery, with the purpose of identifying variables driving the disparity between these two patient populations. This was a retrospective case-control study of patients who underwent evaluation for OMFS for MMC at a single academic hospital from 2015 to 2020. Race/ethnicity, primary insurance type, zip code, and BMI were collected and compared by treatment received and eligibility status for OMFS. Prevalence odds ratios were used to test for associations between each independent variable and the two outcomes. Logistical regression models were utilized to determine significant predictors of undergoing OMFS and being eligible for OMFS. Of 96 women, 36 underwent OMFS for MMC, 40 received postnatal repair, and 20 either terminated the pregnancy or received care at another institution. Overall, 66 (68.8%) women were White, 14 (14.6%) were Black, 13 (13.5%) were Hispanic/Latinx, 1 (1.0%) was Asian, and 2 (2.1%) identified as other or multiple races. Among women who underwent OMFS for MMC, 27 (75.0%) were White, 2 (5.6%) were Black, 4 (11.1%) were Hispanic/Latinx, 1 (2.8%) was Asian, and 2 (5.6%) identified as other or multiple races. Having private insurance or TRICARE was associated with higher odds of being eligible for OMFS compared with women who were uninsured or had Medicaid when accounting for race and income (OR 3.87, 95% CI 1.51-9.59). The population evaluated and treated for MMC was homogeneous and insufficiently representative of the population affected by the disease. This finding raises concern, as it suggests underlying barriers to formal evaluation for OMFS for MMC. Insurance status and BMI have a significant association between the access to and election of OMFS, revealing socioeconomic disparities. This was the first study to explore sociodemographic characteristics of patient populations who may be at risk for limited access to highly specialized fetal surgical care.

The MAI score: A novel score to early predict shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage after surgery

ObjectiveAs a chronic complication of aneurysmal subarachnoid hemorrhage(aSAH), Shunt dependent hydrocephalus (SDHC) often leads to severe neurological deficits. At present, risk factors of SDHC after aSAH are being refined. So this study aims to investigate independent risk factors and develop a novel score to identify early the patients who require a permanent shunt. MethodFive hundred twenty-four patients treated in the first affiliated hospital of Harbin medical university from March 2019 to March 2021 were analyzed. We collected clinical and radiographic data of patients within 72 h after the ictus. The relevant factors were firstly analyzed by univariate analysis, and the significant factors (p < 0.05) were included in the multivariate logistic regression analysis to obtain the independent risk factors with statistical differences. The MAI score was established based on the contribution of different independent risk factors to the outcome. the new score was validated in another cohort (97 patients with aSAH from April and June 2021). ResultWe enrolled 524 aneurysm patients and 41(7.82%) patients who underwent ventriculoperitoneal shunt (VPS) after aneurysm treatment. Based on univariate and multivariate analysis, Acute Hydrocephalus (OR 6.498,:95% confidence interval (CI) 1.98–21.33, p = 0.002), Intraventricular hemorrhage (OR 3.55,:95%CI 1.189–10.599, p = 0.023) and Modified Fisher score ≥ 3 (OR 5.846, 95%CI 2.649–12.900, p = 0.001) were independent risk factors. The novel score was assigned according to the contribution of different independent risk factors to the results. The MAI score: Modified Fisher grade ≥ 3 (1 point), Acute Hydrocephalus (1 point), Intraventricular hemorrhage (1 point). In the receiver operating characteristic curve analysis, the area under the curve (AUC) for the MAI score is 0.773 (p < 0.0001, 95%CI 0.686–0.861). Patients scoring 2–3 MAI points showed a 10-fold higher risk for shunt dependency than patients scoring 0–1 MAI points (p < 0.001). We performed internal validation of the MAI scoring system. The scoring system reliably predicted SDHC after aSAH. The AUC of the internal validation was 0.950 (p ＝ 0.002, 95%CI 0.863–1.000). ConclusionWe develop a novel score based on univariate and multivariate analysis. The effectiveness of the MAI score has been confirmed in this study, which can more accurately predict SDHC after aASH and can be widely used in clinical practice. Prospective studies are needed for validation in the future.

Monocyte Count on Admission Is Predictive of Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage.

The authors sought to evaluate whether immunologic counts on admission were associated with shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage. A retrospective analysis of 143 consecutive patients with aneurysmal subarachnoid hemorrhage over a 9-year period was performed. A stepwise algorithm was followed for external ventricular drain weaning and determining the necessity of shunt placement. Data were compared between patients with and without shunt-dependent hydrocephalus. Overall, 11.19% of the cohort developed shunt-dependent hydrocephalus. On multivariate logistic regression analysis, acute hydrocephalus (OR: 61.027, 95% CI: 3.890–957.327; p = 0.003) and monocyte count on admission (OR: 3.362, 95% CI: 1.024–11.037; p = 0.046) were found to be independent predictors for shunt dependence. Receiver operating characteristic curve analysis for the prediction of shunt-dependent hydrocephalus confirmed that monocyte count exhibited an acceptable area under the curve (AUC = 0.737, 95% CI: 0.601–0.872; p < 0.001). The best predictive cutoff value to discriminate between successful external ventricular drain weaning and shunt-dependent hydrocephalus was identified as a monocyte count ≥0.80 × 103/uL at initial presentation. These preliminary data demonstrate that a monocyte count ≥0.80 × 103/uL at admission predicts shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage; however, further large-scale prospective trials and validation are necessary to confirm these findings.

Assessment of Sustained Systemic Inflammatory Response Syndrome and CSF Markers as Predictive Values Associated with Shunt-Dependent Hydrocephalus after Aneurysmal Subarachnoid Hemorrhage

Aim of the study: This study was conducted to detect incidence and risk factors of shunt-dependent hydrocephalus, including Systemic Inflammatory Response Syndrome.&#x0D; Patients and methods: After obtaining ethical approval from the research ethics committee of Cairo University, this study was conducted in two phases, phase I in the form of follow up study to detect the incidence of shunt dependent hydrocephalus in patients with ruptured subarachnoid aneurysm then phase II in the form of comparative one to detect the risk factors of acquisition of shunt dependent hydrocephalus and detect the predictive role of SIRS in SDH. The study included 90 patients with ruptured subarachnoid aneurysms followed up in the department of neurosurgery of Cairo university hospital from April 2018 to April 2020.&#x0D; Results: The incidence of shunt-dependent hydrocephalus was 28% among the studied patients with significant association with high-grade SIRS, Fisher score, Hunt and Hess score, and leukocytosis. The CSF white blood cells and protein were significantly higher in the hydrocephalus group. Also, there was significant hypernatremia among the hydrocephalic group.&#x0D; Conclusion: Despite the study's analytical design, we observed a link between high fisher, SIRS, hypernatremia, and shunt-dependent hydrocephalus in aneurysmal SAH patients. Serum sodium, CSF WBCs, and protein may all be used to predict HC.

405 Volumetric Quantification of Subarachnoid Hemorrhage Independently Predicts Hydrocephalus and Seizures

INTRODUCTION: Hydrocephalus and seizures greatly impact outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH); however, reliable tools to predict these outcomes are lacking. METHODS: Total hemorrhage volume following aneurysm rupture was retrospectively analyzed on presentation CT imaging using a custom semi-automated computer program developed in MATLAB that employs intensity-based k-means clustering to automatically separate blood voxels from other tissues. Volume data was added to a prospectively maintained SAH database. Through logistic regression analysis, we evaluated the association of hemorrhage volume with shunted-hydrocephalus and seizures and evaluated the diagnostic accuracy by evaluation of the area under the receiver operating characteristic curve (AUC). RESULTS: 288 consecutive patients with aSAH comprised the study population. Mean total hemorrhage volume was 74.9 ml. Thirty-eight patients developed seizures (13.2%). Mean hemorrhage volume in patients who developed seizures was significantly higher than patients with no seizures (mean difference 17.3 ml, P=0.01). In multivariate analysis, larger hemorrhage volume on initial CT scan and hemorrhage volume &gt;50 ml (OR 2.81, P=0.047 CI 1.03-7.80) were predictive of seizures. 48 patients developed shunt-dependent hydrocephalus (17%). The mean hemorrhage volume in patients who developed shunt-dependent hydrocephalus was significantly higher than patients who did not (mean difference 17.2 ml, P=0.006). Larger hemorrhage volume and hemorrhage volume &gt;50 ml (OR 2.45, P=0.03, CI 1.08-5.54) were predictive of shunt-dependent hydrocephalus. Hemorrhage volume had adequate discrimination for the development of seizures (AUC = 0.635) and shunted hydrocephalus (AUC = 0.629). CONCLUSION: Hemorrhage volume is an independent predictor of seizures and hydrocephalus in aSAH. Further evaluation of quantitative volumetric analysis may complement existing scales used in clinical practice and assist in prognostication and management.