Elsevier

World Neurosurgery

Volume 106, October 2017, Pages 844-860.e6
World Neurosurgery

Original Article
Predictors of Shunt-dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage? A Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.wneu.2017.06.119Get rights and content

Background

Hydrocephalus is a well-recognized complication after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to identify predictors for shunt-dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis.

Methods

A systematic search was conducted using the Embase, MEDLINE, and Web of Science databases for studies pertaining to aSAH and SDHC. Risk factors were assessed by meta-analysis when they were reported by at least 2 studies. The results were presented as odd ratios or risk ratios according to the study design with the corresponding 95% confidence intervals (CI).

Results

Twenty-five studies were included. In primary analysis of 14 potential risk factors, 12 were identified as predictors of SDHC after aSAH including age ≥50 years, female gender, high Hunt-Hess grade, Glasgow Coma Scale ≤8, Fisher grade ≥3, acute hydrocephalus, external ventricular drainage insertion, intraventricular hemorrhage, postcirculation aneurysm, anterior communicating artery aneurysm, meningitis, and rebleeding. The meta-analysis based on cohort studies found a significantly increased risk for SDHC in patients with aSAH treated by coiling (risk ratio, 1.16; 95% CI, 1.05–1.29), while the meta-analysis based on case-controlled studies failed to replicate this finding (odds ratio, 1.27; 95% CI, 0.95–1.71).

Conclusions

Several new predictors of SDHC after aSAH were identified that may assist with the early recognition and prevention of SDHC. The controversial evidence found in this study was insufficient to support the potential of neurosurgical clipping for reducing the risk of shunt dependency. Further well-designed studies are warranted to explore the effect of treatment modality on SDHC risk.

Section snippets

Background

Aneurysmal subarachnoid hemorrhage (aSAH) is a common but devastating disease. It is associated with a high fatality rate that varies from 27%–44% in different regions, leaving 8%–20% patients with persistent dependence.1 Hydrocephalus is a well-known complication after aSAH that was first recognized by Bagley in 1928.2 As defined by Vale in 1997, hydrocephalus after aSAH can be divided into 3 stages (acute stage, 48–72 hours after SAH; subacute stage, 3–14 days; chronic stage: >14 days).3 The

Methods

The methodology of this study is in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (checklist provided in Supplementary material).

Study Selection

A total of 3647 publications were identified through our initial database search. After screening the titles, abstracts, and key words, 3620 duplicates or irrelevant articles were excluded according to our prescribed criteria. Twenty-five studies were included in a detailed assessment. The PRISMA flow diagram of the publication selection is presented in Figure 1.

Study Characteristics

Table 1 summarizes the main characteristics of the included studies. These studies were published between 1993 and 2016, with sample

Discussion

A meta-analysis published by Wilson et al.33 identified several risk factors of shunt dependency in patients with aSAH, including increased age, high Hunt-Hess Scale scores, high Fisher grades, acute hydrocephalus, presence of intraventricular blood, posterior circulation location of the aneurysm in-hospital complications, and rebleeding. With an update of the literature review and modified inclusion criteria, our study covered all the risk factors reported by Wilson et al.33 and analyzed every

Conclusions

In conclusion, this study indicated that increased age, female gender, high Hunt-Hess grades, low GCS scores (GCS score ≤8), high Fisher grades (Fisher grade ≥3), acute hydrocephalus, EVD insertion, IVH, postcirculation aneurysm, AcomA aneurysm, clinical vasospasm, meningitis, and rebleeding were predictors of SDHC after aSAH. Controversial evidence on coiling as a potential risk factor has been reported among studies with different designs. Current published data were insufficient to support

Acknowledgments

We would like to thank Dr. Lu Ma, associate professor at the Department of Neurosurgery, West China Hospital, for reviewing the statistical analysis.

References (46)

  • K.C. Wang et al.

    Intrathecal lactate predicting hydrocephalus after aneurysmal subarachnoid hemorrhage

    J Surg Res

    (2015)
  • C. Bagley

    Blood in the cerebrospinal fluid: resultant functional and organic alterations in the central nervous system a. experimental data

    Arch Surg

    (1928)
  • F.L. Vale et al.

    The relationship of subarachnoid hemorrhage and the need for postoperative shunting

    J Neurosurg

    (1997)
  • J.H. Kwon et al.

    Predisposing factors related to shunt-dependent chronic hydrocephalus after aneurysmal subarachnoid hemorrhage

    J Korean Neurosurg Soc

    (2008)
  • P. Jartti et al.

    Chronic hydrocephalus after neurosurgical and endovascular treatment of ruptured intracranial aneurysms

    Acta Radiol

    (2008)
  • B.T. Demirgil et al.

    Factors leading to hydrocephalus after aneurysmal subarachnoid hemorrhage

    Minim Invasive Neurosurg

    (2003)
  • Z. Dorai et al.

    Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage

    Neurosurgery

    (2003)
  • F. Rincon et al.

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

    J Neurosurg

    (2010)
  • C.J. O'Kelly et al.

    Shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage: incidence, predictors, and revision rates. Clinical article

    J Neurosurg

    (2009)
  • A.S. Little et al.

    Ventriculoperitoneal shunting after aneurysmal subarachnoid hemorrhage: analysis of the indications, complications, and outcome with a focus on patients with borderline ventriculomegaly

    Neurosurgery

    (2008)
  • R.J. Komotar et al.

    The impact of microsurgical fenestration of the lamina terminalis on shunt-dependent hydrocephalus and vasospasm after aneurysmal subarachnoid hemorrhage

    Neurosurgery

    (2008)
  • J.G. De Oliveira et al.

    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

    (2007)
  • H. Yoshioka et al.

    Chronic hydrocephalus in elderly patients following subarachnoid hemorrhage

    Surg Neurol

    (2000)
  • Cited by (67)

    View all citing articles on Scopus

    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    Zhiyi Xie and Xin Hu contributed equally to this work.

    Supplementary digital content available online.

    View full text