Related Experiment Video
Updated: Feb 27, 2026
Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus
Published on: October 14, 2022
Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial
Santosh B Murthy1, Issam Awad2, Sagi Harnof2
1From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD. sam9200@med.cornell.edu.
Insights
Permanent cerebrospinal fluid (CSF) shunting after intraventricular hemorrhage (IVH) is linked to higher CSF output and elevated intracranial pressure. While shunting did not affect mortality, it was associated with poorer functional outcomes in survivors.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Spontaneous intraventricular hemorrhage (IVH) poses significant risks, often necessitating cerebrospinal fluid (CSF) diversion.
- The need for permanent CSF shunting and its impact on functional outcomes remain critical areas of study.
Purpose of the Study:
- To investigate factors predicting the need for permanent CSF diversion in patients with spontaneous IVH.
- To examine the relationship between CSF shunting and functional outcomes, including mortality and neurological recovery.
Main Methods:
- Analysis of data from the Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III) trial.
- Multivariate analysis to identify predictors of permanent CSF shunting.
- Assessment of 180-day mortality and modified Rankin Scale scores.
Main Results:
- 18% of patients with IVH required permanent CSF shunting.
- Predictors of shunting included black race, longer external ventricular drainage (EVD) duration, multiple EVD placements, high CSF output, and elevated intracranial pressure (>30 mm Hg).
- CSF shunting was not associated with 180-day mortality but correlated with poorer functional outcomes in survivors.
Conclusions:
- Elevated intracranial pressure, high CSF output, and multiple EVD placements are associated with an increased likelihood of permanent CSF shunting in IVH patients.
- Intraventricular alteplase, early imaging, and CSF measures were not predictive of permanent shunting.
- Permanent CSF shunting impacts functional recovery in survivors of spontaneous IVH.
Objective:
To study factors associated with permanent CSF diversion and the relationship between shunting and functional outcomes in spontaneous intraventricular hemorrhage (IVH).
Methods:
Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III), a randomized, multicenter, double-blind, placebo-controlled trial, was conducted to determine if pragmatically employed external ventricular drainage (EVD) plus intraventricular alteplase improved outcome, in comparison to EVD plus saline. Outcome measures were predictors of shunting and blinded assessment of mortality and modified Rankin Scale at 180 days.
Results:
Among the 500 patients with IVH, CSF shunting was performed in 90 (18%) patients at a median of 18 (interquartile range [IQR] 13-30) days. Patient demographics and IVH characteristics were similar among patients with and without shunts. In the multivariate analysis, black race (odds ratio [OR] 1.98; 95% confidence interval [CI] 1.18-3.34), duration of EVD (OR 1.10; CI 1.05-1.15), placement of more than one EVD (OR 1.93; CI 1.13-3.31), daily drainage CSF per 10 mL (OR 1.07; CI 1.04-1.10), and intracranial pressure >30 mm Hg (OR 1.70; CI 1.09-2.88) were associated with higher odds of permanent CSF shunting. Patients who had CSF shunts had similar odds of 180-day mortality, while survivors with shunts had increased odds of poor functional outcome, compared to survivors without shunts.
Conclusions:
Among patients with spontaneous IVH requiring emergency CSF diversion, those with early elevated intracranial pressure, high CSF output, and placement of more than one EVD are at increased odds of permanent ventricular shunting. Administration of intraventricular alteplase, early radiographic findings, and CSF measures were not useful predictors of permanent CSF diversion.
