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Published on: October 2, 2014
Prognostic Model for Chronic Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage
Hendrik-Jan Mijderwijk1, Igor Fischer2, Angelika Zhivotovskaya1
1Department of Neurosurgery, Heinrich-Heine University, Düsseldorf, Germany.
Insights
A new prognostic model helps identify patients with aneurysmal subarachnoid hemorrhage (aSAH) who may need a shunt due to hydrocephalus. This model considers factors like external ventricular drainage and blood clearance duration, aiding early intervention for better outcomes.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Aneurysmal subarachnoid hemorrhage (aSAH) frequently leads to chronic shunt-dependent hydrocephalus.
- Identifying patients at risk for this complication remains a clinical challenge.
- Existing prognostic variables for aSAH do not fully capture the risk of hydrocephalus development.
Purpose of the Study:
- To develop and validate a prognostic model for identifying patients with aSAH at high risk of developing chronic shunt-dependent hydrocephalus.
- To incorporate cerebrospinal fluid (CSF) blood clearance dynamics into hydrocephalus risk prediction.
- To improve early detection and management of post-aSAH hydrocephalus.
Main Methods:
- Retrospective analysis of 227 patients with aSAH treated between January 2012 and January 2016.
- Development of a multivariable logistic regression model using candidate variables including age, neurological grades, and CSF blood clearance.
- Internal validation using bootstrapping to assess model performance (R², calibration, c-statistic).
Main Results:
- 90 out of 227 patients (39.6%) required ventriculoperitoneal shunt placement within 30 days.
- The final model integrated external ventricular drainage, presence of intraventricular blood, and duration of basal cistern blood clearance.
- The model demonstrated good performance with a c-statistic of 0.85 (0.84 after bootstrapping) and 33% explained variance (20% after bootstrapping).
Conclusions:
- The developed prognostic model shows promise in identifying patients requiring CSF diversion after aSAH.
- Further external validation and refinement are necessary for widespread clinical application.
- Strategies to accelerate blood clearance in basal cisterns may prevent chronic hydrocephalus post-aSAH.
Background:
Patients with aneurysmal subarachnoid hemorrhage (aSAH) are at risk of the development of chronic shunt-dependent hydrocephalus. However, identification of shunt-dependent patients remains challenging. We sought to develop a prognostic model to identify patients with aSAH at risk of chronic shunt-dependent hydrocephalus. In addition to the well-known prognostic variables, blood clearance in the cerebrospinal fluid (CSF) spaces was considered.
Methods:
We retrospectively analyzed the data from 227 patients treated at our institution from January 2012 to January 2016. The outcome was ventriculoperitoneal shunt placement within 30 days after aSAH. The candidate prognostic variables were patient age, World Federation of Neurological Surgeons grade and Fisher grade, external ventricular drainage, ventricular and intracerebral hemorrhage, and interval to blood clearance in the peripheral/basal CSF spaces. Adjustment for multiple testing was performed. Multivariable logistic regression analysis was used for model development. Bootstrapping was applied for internal validation. The model performance measures included indexes for explained variance (R2), calibration (graphic plot, Hosmer-Lemeshow test), and discrimination (c-statistic).
Results:
Of the 227 patients, 90 (39.6%) required a ventriculoperitoneal shunt. The constructed prognostic model combined external ventricular drainage placement, the presence of ventricular blood, and the duration of blood clearance in the basal cisterns. The model performance was promising, with an R2 of 33% (20% after bootstrapping), the calibration plot was adequate, the Hosmer-Lemeshow test result was not significant, and the c-statistic was 0.85 (0.84 as assessed after bootstrapping) indicating a good discriminating prognostic model.
Conclusions:
Our prognostic model could help identify patients requiring permanent CSF diversion after aSAH, although additional modification and external validation are needed. Interventions aimed at accelerating the clearance of blood in the basal cisterns might have the potential to prevent the development of chronic hydrocephalus after aSAH.
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