Predisposing Factors Related to Shunt-Dependent Chronic Hydrocephalus after Aneurysmal Subarachnoid Hemorrhage

Kwon, Jae-Hyun,Sung, Soon-Ki,Song, Young-Jin,Choi, Hyu-Jin,Huh, Jae-Taeck,Kim, Hyung-Dong The Korean Neurosurgical Society 2008 Journal of Korean neurosurgical society Vol.43 No.4

Objective : Hydrocephalus is a common sequelae of aneurysmal subarachnoid hemorrhage (SAH) and patients who develop hydrocephalus after SAH typically have a worse prognosis than those who do not. This study was designed to identify factors predictive of shunt-dependent chronic hydrocephalus among patients with aneurysmal SAH, and patients who require permanent cerebrospinal fluid diversion. Methods : Seven-hundred-and-thirty-four patients with aneurysmal SAH who were treated surgically between 1990 and 2006 were retrospectively studied. Three stages of hydrocephalus have been categorized in this paper, i.e., acute (0-3 days after SAH), subacute (4-13 days after SAH), chronic (${\geqq}14$ days after SAH). Criteria indicating the occurrence of hydrocephalus were the presence of significantly enlarged temporal horns or ratio of frontal horn to maximal biparietal diameter more than 30% in computerized tomography. Results : Overall, 66 of the 734 patients (8.9%) underwent shunting procedures for the treatment of chronic hydrocephalus. Statistically significant associations among the following factors and shunt-dependent chronic hydrocephalus were observed. (1) Increased age (p < 0.05), (2) poor Hunt and Hess grade at admission (p < 0.05), (3) intraventricular hemorrhage (p < 0.05), (4) Fisher grade III, IV at admission (p < 0.05), (5) radiological hydrocephalus at admission (p < 0.05), and (6) post surgery meningitis (p < 0.05) did affect development of chronic hydrocephalus. However the presence of intracerebral hemorrhage, multiple aneurysms, vasospasm, and gender did not influence the development of shunt-dependent chronic hydrocephalus. In addition, the location of the ruptured aneurysms in posterior cerebral circulation did not show significant correlation of development of shunt-dependent chronic hydrocephalus. Conclusion : Hydrocephalus after aneurysmal subarachnoid hemorrhage seems to have a multifactorial etiology. Understanding predisposing factors related to the shunt-dependent chronic hydrocephalus may help to guide neurosurgeons for better treatment outcomes.

자발성 지주막하출혈 후 발생하는 수두증에 대한 단락술의 필요성 및 예후에 관한 분석 - 뇌실외배액술의 기간, 일일배액량 및 총배액량과 예후관계 -

이원창,최창화,Lee, Won Chang,Choi, Chang Hwa 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.1

Objective : Hydrocephalus and vasospasm are the common complications following subarachnoid hemorrhage (SAH). In spite of development of perioperative management and operative technique, hydrocephalus cause neurological deficit and poor prognosis. Usually CSF drainage procedure(external ventricular drainage(EVD) or shunt) is needed in hydrocephalus following SAH. The aim of this study was to investigate whether the need for shunting and the outcome after shunting in hydrocephaus following SAH can be related to the duration, daily and total amount of cerebrospinal fluid(CSF) drainage at EVD. Material and Method : IVH is one of several factors which cause hydrocephalus. In this retrospective study, firstly we investigated the incidence of IVH in total cases and frequency of IVH according to aneurysmal site and then prognosis of IVH following SAH. Among 629 patients with SAH, hydrocephalus was diagnosed by CT scan and symptoms. And then those 102 hydrocephalus following SAH were divided into two groups which were hydrocephalus with IVH group and without IVH group. In these two groups, we investigated and compared the incidence of hydrocephalus in all case, frequency of hydrocephalus according to aneurysmal site, the outcome according to H-H grade on admission and the need rate of shunt, etc. Of those hydrocephalus, 100 EVD procedures were done. The duration, daily and total amount of CSF drainage at EVD were investigated. Fifty cases expired during EVD was excluded. We analyzed whether the need rate of shunt and the final outcome after shunting can be related to IVH, the duration and daily and total amount of CSF drainage. Result : The incidence of hydrocephalus following SAH was 20%(with IVH group ; 64%, without IVH group ; 11%). As H-H grade on admission was better, the outcome of hydrocephalus was also better. The mortality rate of hydrocephalus with IVH was 64% which was higher than 40% that of hydrocephalus without IVH. The need rate of shunt in all cases of hydrocephalus following SAH was 20%, but those with IVH group excluding expired patients before shunt was 40%. This was very similar to 41% of the need rate of shunt in hydrocephalus without IVH. The total amount of CSF drainage was statistically related to the need rate of shunt(total amount : need rate of shunt/<1000cc : 15%, 1000-2000cc : 40%, >2000cc : 50%). The duration and daily amount of CSF drainage were not statistically related to the need rate of shunt, but as daily amount of CSF drainage was more and duration was longer, the need rate of shunt was increased(daily amount : need rate of shunt /<100cc : 16%, 100-200cc : 25%, >200cc : 40%//duration : need rate of shunt/<1week : 8%, 1-2weeks : 30%, >2weeks : 47%), and also the final outcome after shunting was poor. Especially the total amount of CSF drainage was significant related to the final outcome after shunting(total amount : GOS/<1000cc : I&II(3/4), 1000-2000cc : II(2/4), III(2/4), >2000cc : III&IV(6/7)). Conclusion : This study revealed that the incidence and mortality rate of hydrocephalus following SAH were influenced by IVH. So SAH associated IVH has the higher incidence of hydrocephalus and poor outcome. As the CSF drainage amount was more and duration of drainage was longer, the need rate of shunt was increased and the final outcome after shunting was poor. Especially the total amount of CSF drainage were strongly related to the need rate of shunt and the outcome after shunting.

Comparison of cerebrospinal fluid biomarkers between idiopathic normal pressure hydrocephalus and subarachnoid hemorrhage-induced chronic hydrocephalus: A pilot study

Lee, Jeong-Hyun,Park, Dong-Hyuk,Back, Dong-Bin,Lee, Jea-Young,Lee, Chang-In,Park, Kyung-Jae,Kang, Shin-Hyuk,Cho, Tai-Hyoung,Chung, Yong-Gu International Scientific Literature, Inc. 2012 Medical science monitor Vol.18 No.12

<P><B>Summary</B></P><P><B>Background</B></P><P>We examined the cerebrospinal fluid (CSF) markers of subarachnoid hemorrhage (SAH)-induced and idiopathic normal pressure hydrocephalus (INPH) to investigate the pathophysiology and mechanism of communicating hydrocephalus compared to obstructive hydrocephalus.</P><P><B>Material/Methods</B></P><P>We obtained CSF samples from 8 INPH, 10 SAH-induced hydrocephalus, and 6 unmatched patients with non-hemorrhagic obstructive hydrocephalus during their ventriculoperitoneal shunt operations. Transforming growth factor (TGF)-β1, tumor necrosis factor (TNF)-α, vascular endothelial growth factor (VEGF), and total tau in the CSF were analyzed via enzyme-linked immunosorbent assay.</P><P><B>Results</B></P><P>The mean VEGF levels in the CSF of patients with SAH-induced hydrocephalus, INPH, and obstructive hydrocephalus were 239±131, 239±75, and 163±122 pg/mL, respectively. The total tau concentrations in the CSF of the groups were 1139±1900, 325±325, and 1550±2886 pg/mL, respectively. TNF-α values were 114±34, 134±38, and 55±16 pg/mL, respectively. TGF-β1 values were 953±430, 869±447, and 136±63 pg/mL, respectively. A significant difference in TNF-α and TGF-β1 levels was observed only between SAH-induced and chronic obstructive hydrocephalus, and between INPH and chronic obstructive hydrocephalus (p<0.01).</P><P><B>Conclusions</B></P><P>No significant differences in the 4 CSF biomarker levels were observed between INPH and SAH-induced hydrocephalus, whereas CSF TNF-α and TGF-β1 levels were increased compared to those in patients with chronic obstructive hydrocephalus. Post-SAH hydrocephalus and INPH are probably more destructive to neural tissues, and then stimulate the inflammatory reaction and healing process, compared with obstructive hydrocephalus.</P>

Treatment Outcome of Hydrocephalus Associated with Vestibular Schwannoma

신동원,송상우,정상준,김영훈,조영현,홍석호,김정훈 대한신경과학회 2021 Journal of Clinical Neurology Vol.17 No.3

Background and Purpose Managing hydrocephalus in patients with vestibular schwannoma (VS) is controversial. We evaluated the clinical factors associated with hydrocephalus. Methods Between 2000 and 2019, 562 patients with VS were treated at our institute. We applied endoscopic third ventriculostomy (ETV), external ventricular drainage (EVD), and ventriculoperitoneal (VP) shunts to patients with hydrocephalus. The relationships of patient, tumor, and surgical variables with the hydrocephalus outcome were assessed. Results Preoperative hydrocephalus (Evans ratio ≥0.3) was present in 128 patients. Six patients who received a preresectional VP shunt were excluded after analyzing the hydrocephalus outcome. Seven of the remaining 122 patients had severe hydrocephalus (Evans ratio ≥0.4). Primary tumor resection, VP shunting, ETV, and EVD were performed in 60, 6, 57, and 5 patients, respectively. The hydrocephalus treatment failure rate was highest in the EVD group. Persistent hydrocephalus was present in five (8%) and seven (12%) patients in the primary resection and ETV groups, respectively. Multivariate analysis revealed that severe hydrocephalus, the cystic tumor, and the extent of resection (subtotal resection or partial resection) were associated with hydrocephalus treatment failure. Conclusions Larger ventricles and a higher cystic portion are predictive of persistent hydrocephalus. We recommend attempting near-total tumor resection in patients with VS.

흰쥐의 실험적 수두증에서 뇌실막세포 중간세사의 형태학적 변화

김호정,박경아,이원택 대한해부학회 1999 Anatomy & Cell Biology Vol.32 No.3

뇌동맥류 파열에 의한 지주막하 출혈 후 수두증 발생의 위험 인자에 대한 임상 연구

최정재,고현송,조준희,김선환,염진영,송시헌,김윤,Choi, Jeong-Jae,Koh, Hyeon-Song,Cho, Jun-Hee,Kim, Seon-Hwan,Youm, Jin-Young,Song, Shi-Hun,Kim, Youn 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.12

Objective : The authors analyzed the incidence, the cause and the prognosis of hydrocephalus following aneurysmal subarachnoid hemorrhage to evaluate the risk factors of hydrocephalus and to provide the proper treatment method for hydrocephalus following aneurysmal subarachnoid hemorrhage. Methods : The 505 cases of subarachnoid hemorrhage followed by aneurysmal surgery from January 1990 to May 1999, were divided into shunt group and shunt-free group and we were reviewed for the clinical status, Fisher's grade, brain CT findings and prognosis. Results : The incidence of acute hydrocephalus was 37.2% of patients and 18.9% to developed chronic hydrocephalus. Shunt surgery due to chronic hydrocephalus was required in 6.5% of patients. We found following variables were significantly related to shunt-dependent hydrocephalus : high Hunt-Hess and Fisher grade, initial CT findings of intraventricular hemorrahge, posterior circulation aneurysm, preoperative rebleeding, delayed ischemic deficits, and initial high ventricular size index. There were no statistically significant relationships between shunt-dependent hydrocephalus and patient age or sex, timing of operation. The previous hypertension was not related to shunt dependent hydrocephalus. Prognosis in shunt group showed poor result. Conclusion : The risk factors of hydrocephalus following aneurysmal subarachnoid hemorrhage are high Hunt-Hess grade, high Fisher's grade, aneurysms of posterior circulations, preoperative aneurysmal rebleeding, delayed ischemic deficits, initial CT findings of intraventricular hemorrahge and initially increased ventricular size. The patients with these factors should the carefully observed and managed accordingly due to poor prognosis related to hydrocephalus requiring shunt operation.

수두증 치료에 있어 내시경을 이용한 제3뇌실 천자술의 역할

전병찬,김도헌 고신대학교(의대) 고신대학교 의과대학 학술지 2002 고신대학교 의과대학 학술지 Vol.17 No.1

Background : Owing to the development of endoscopic equipment, endoscopic 3rd ventriculostomy (ETV) is commonly used in the treatment of hydrocephalus substituting shunt operation. ETV is the preferred treatment of aqueductal stenosis or 4th ventricle outlet obstruction. Recently, the role of ETV is expanded to selected cases of communicating hydrocephalus. We elucidated the effectiveness of ETV in hydrocephalus with our experience. Methods : Twelve endoscopic 3rd ventriculosomies were done between February 1999 and February 2001. These included 8 non-communicating hydrocephalus and 4 communicating hydrocephalus. Non-communicating hydrocephalus were caused by four pineal gland tumors, one invasive pituitary adenoma, one spontaneous cerebellar hemorrhage, and two cerebellar tumors. Communicating hydrocephalus were caused by two subarachnoid hemorrhages, one meningitis, and one acute subdural hematoma. Mean follow-up period was 11.5 months. Results : Nine of 12 patients achieved clinical success. Seven patients showed clinical improvement among eight non-communicating hydrocephalus. Two of four communicating hydrocephalus patients improved. A case of meningitis and two cases of transient fever due to hypothalamic injury were observed as complications. Conclusion : ETV can be suggested in the treatment of selected cases of communicating hydrocephalus as well as non-communicating hydrocephalus replacing the shunt operation with high morbidities and reoperation rates. Reliable clinical tests that can predict whether ETV will be successful are necessary.

수두증 치료에 있어 내시경을 이용한 제3뇌실 천자술의 역할

전병찬,김도헌 고신대학교 의학부 2002 高神大學校 醫學部 論文集 Vol.17 No.1

Background Owing to the development of endoscopic equipment, endoscopic 3rd ventriculostomy (ETV) is commonly used in the treatment of hydrocephalus substituting shunt operation. ETV is the preferred treatment of aqueductal stenosis or 4th ventricle outlet obstruction. Recently, the role of ETV is expanded to selected cases of communicating hydrocephalus. We elucidated the effectiveness of ETV in hydrocephalus with our experience. Methods Twelve endoscopic 3rd ventriculosomies were done between February 1999 and February 2001. These included 8 non-communicating hydrocephalus and 4 communicating hydrocephalus Non-communicating hydrocephalus were caused by four pineal gland tumors, one invasive pituitary adenoma, one spontaneous cerebellar hemorrhage, and two cerebellar tumors. Communicating hydrocephalus were caused by two subarachnoid hemorrhages, one meningitis, and one acute subdural hematoma. Mean follow-up period was 11.5 months. Results Nine of 12 patients achieved clinical success Seven patients showed clinical improvement among eight non-communicating hydrocephalus. Two of four communicating hydrocephalus patients improved. A case of meningitis and two cases of transient fever due to hypothalamic injury were observed as complications. Conclusion ETV can be suggested in the treatment of selected cases of communicating hydrocephalus as well as non-communicating hydrocephalus replacing the shunt operation with high morbidities and reoperation rates. Reliable clinical tests that can predict whether ETV will be successful are necessary.

Does Neurosurgical Clipping or Endovascular Coiling Lead to More Cases of Delayed Hydrocephalus in Patients with Subarachnoid Hemorrhage?

Tae Oong Eom,Eun Suk Park,Jun Bum Park,Soon Chan Kwon,Hong Bo Sim,In Uk Lyo,Min Soo Kim 대한뇌혈관외과학회 2018 Journal of Cerebrovascular and Endovascular Neuros Vol.20 No.2

Objective : We investigated whether clipping or endovascular treatment (EVT) can reduce the incidence of delayed hydrocephalus. We also investigated whether additional procedures, namely lumbar drainage and extra- ventricular drainage (EVD), decrease the incidence of delayed hydrocephalus in patients with subarachnoid hemorrhage (SAH). Materials and Methods : One-hundred and fifty-two patients who had undergone an operation for SAH were enrolled in this study. Clinical data, radiological data, and procedural data were investigated. Procedural data included the operating technique (clipping vs. EVT) and the use of additional procedures (no procedure, lumbar drainage, or EVD). Delayed hydrocephalus was defined as a condition in which the Evan's index was 0.3 or higher, as assessed using brain computed tomography more than 2 weeks after surgery, requiring shunt placement due to neurological deterioration. Results : Of the 152 patients, 45 (29.6%) underwent surgical clipping and 107 (70.4%) underwent EVT. Twenty-five (16.4%) patients developed delayed hydrocephalus. Age (p = 0.019), procedure duration (p = 0.004), and acute hydrocephalus (p = 0.030) were significantly correlated with the incidence of delayed hydrocephalus. However, the operation technique (p = 0.593) and use of an additional procedure (p = 0.378) were not significantly correlated with delayed hydrocephalus incidence. Conclusion : No significant difference in the incidence of delayed hydrocephalus was associated with operation technique or use of an additional procedure in patients with SAH. However, delayed hydrocephalus was significantly correlated with old age, long procedural duration, and acute hydrocephalus. Therefore, we recommend that additional procedures should be discontinued as soon as possible.

정상 흰쥐 및 실험적으로 유도된 수두증에서 별아교세포의 분포와 형태비교

김호정 관동대학교 의과학연구소 2001 關東醫大學術誌 Vol.5 No.1

In hydrocephalus, it is well known that astrocytes and microglia proliferate in response to the expansion of ventricular system. The expansile force of the ventricular wall is applied to glial cells and causes cell deformity in a degree. Glial fibrillary acidic protein(GFAP) is the intermediate filament of the glial cells and useful as a marker for the astrocytes. As it is known that the intermediate filaments of a cell act as a framework that resists changes in cellular shape, the GFAP in astrocytes of hydrocephalus would show some informations about the biological reactions in response to the expanding ventricles. Congenital and postnatal hydrocephalus were induced experimentally in white rats. The distribution patterns and morphological characteristics of GFAP reactive astrocytes of each location were investigated in both types of hydrocephalus. To induce congenital hydrocephalus, 40 mg/kg of ethylenethiourea(ETU) was orally administered to pregnant rats on the 15th day after conception. Rats of 2 weeks after birth were obtained and processed for immunohistochemistry for GFAP. Postnatal hydrocephalus was induced by injecting kaolin suspension into the subarachnoid space of 15-day-old rats. Brain tissues were processed for immunohistochemistry after 2 weeks following injection. The results were as follows; 1.The astrocytic proliferations were prominent in the lateral region of enlarged ventricular wall in postnatal hydrocephalus, while those were prominent in the lateral and dorsal regions of enlarged wall in congenital hydrocephalus. 2.The cell bodies of the astrocytes in hydrocephalus are larger than those in control group and band-like clusters composed of numerous elongated astrocytes were observed in postnatal hydrocephalus. In concluson, according to the distribution patterns and morphologies of astrocytes, the expansile forces of ventricular wall in hydrocephalus are greater in dorsal and lateral regions than others.