Successful weaning versus permanent cerebrospinal fluid diversion after aneurysmal subarachnoid hemorrhage: post hoc analysis of a Swiss multicenter study
Author:
El-Garci Ahmed1, Zindel-Geisseler Olivia2, Dannecker Noemi2, Rothacher Yannick2, Schlosser Ladina2, Zeitlberger Anna1, Velz Julia34, Sebök Martina34, Eggenberger Noemi2, May Adrien5, Bijlenga Philippe5, Guerra-Lopez Ursula6, Maduri Rodolfo7, Beaud Valérie8, Starnoni Daniele9, Chiappini Alessio1011, Rossi Stefania12, Robert Thomas10, Bonasia Sara1, Goldberg Johannes13, Fung Christian1314, Bervini David13, Gutbrod Klemens15, Maldaner Nicolai134, Früh Severin16, Schwind Marc16, Bozinov Oliver1, Neidert Marian C.1, Brugger Peter217, Keller Emanuela34, Germans Menno R.34, Regli Luca34, Hostettler Isabel C.1, Stienen Martin N.1, _ _, _ _, Krayenbühl Niklaus, Esposito Giuseppe, Moiraghi Alessandro, Starnoni Daniele, Rocca Alda, Seule Martin A., Weyerbrock Astrid, Hlavica Martin, Mueller Mandy
Affiliation:
1. Department of Neurosurgery, Cantonal Hospital St. Gallen; 2. Neuropsychology Unit, Department of Neurology, University Hospital Zurich; 3. Department of Neurosurgery, University Hospital Zurich; 4. Clinical Neuroscience Center, University of Zurich; 5. Department of Neurosurgery, University Hospital Geneva; 6. Neuropsychology Unit, Department of Neurology, University Hospital Geneva; 7. Swiss Medical Network, Clinique de Genolier; 8. Neuropsychology Unit, Department of Neurology, University Hospital Lausanne; 9. Department of Neurosurgery, University Hospital Lausanne; 10. Department of Neurosurgery, Cantonal Hospital Lugano; 11. Department of Neurosurgery, University Hospital Basel; 12. Neuropsychology Unit, Department of Neurology, Cantonal Hospital Lugano; 13. Department of Neurosurgery, University Hospital Berne, Switzerland; 14. Department of Neurosurgery, University Hospital Freiburg, Germany; 15. Neuropsychology Unit, Department of Neurology, University Hospital Berne; 16. Neuropsychology Unit, Department of Neurology, Cantonal Hospital St. Gallen; and 17. Neuropsychology Unit, Rehabilitation Clinic Valens, Switzerland
Abstract
OBJECTIVE
Acute hydrocephalus is a frequent complication after aneurysmal subarachnoid hemorrhage (aSAH). Among patients needing CSF diversion, some cannot be weaned. Little is known about the comparative neurological, neuropsychological, and health-related quality-of-life (HRQOL) outcomes in patients with successful and unsuccessful CSF weaning. The authors aimed to assess outcomes of patients by comparing those with successful and unsuccessful CSF weaning; the latter was defined as occurring in patients with permanent CSF diversion at 3 months post-aSAH.
METHODS
The authors included prospectively recruited alert (i.e., Glasgow Coma Scale score 13–15) patients with aSAH in this retrospective study from six Swiss neurovascular centers. Patients underwent serial neurological (National Institutes of Health Stroke Scale), neuropsychological (Montreal Cognitive Assessment), disability (modified Rankin Scale), and HRQOL (EuroQol-5D) examinations at < 72 hours, 14–28 days, and 3 months post-aSAH.
RESULTS
Of 126 included patients, 54 (42.9%) developed acute hydrocephalus needing CSF diversion, of whom 37 (68.5%) could be successfully weaned and 17 (31.5%) required permanent CSF diversion. Patients with unsuccessful weaning were older (64.5 vs 50.8 years, p = 0.003) and had a higher rate of intraventricular hemorrhage (52.9% vs 24.3%, p = 0.04). Patients who succeed in restoration of physiological CSF dynamics improve on average by 2 points on the Montreal Cognitive Assessment between 48–72 hours and 14–28 days, whereas those in whom weaning fails worsen by 4 points (adjusted coefficient 6.80, 95% CI 1.57–12.04, p = 0.01). They show better neuropsychological recovery between 48–72 hours and 3 months, compared to patients in whom weaning fails (adjusted coefficient 7.60, 95% CI 3.09–12.11, p = 0.02). Patients who receive permanent CSF diversion (ventriculoperitoneal shunt) show significant neuropsychological improvement thereafter, catching up the delay in neuropsychological improvement between 14–28 days and 3 months post-aSAH. Neurological, disability, and HRQOL outcomes at 3 months were similar.
CONCLUSIONS
These results show a temporary but clinically meaningful cognitive benefit in the first weeks after aSAH in successfully weaned patients. The resolution of this difference over time may be due to the positive effects of permanent CSF diversion and underlines its importance. Patients who do not show progressive neuropsychological improvement after weaning should be considered for repeat CT imaging to rule out chronic (untreated) hydrocephalus.
Publisher
Journal of Neurosurgery Publishing Group (JNSPG)
Subject
Neurology (clinical),General Medicine,Surgery
Reference47 articles.
1. Subarachnoid haemorrhage: diagnosis, causes and management;van Gijn J,2001 2. Cause-specific mortality of 1-year survivors of subarachnoid hemorrhage;Korja M,2013 3. Management problems in acute hydrocephalus after subarachnoid hemorrhage;Hasan D,1989 4. Comparison of rapid and gradual weaning from external ventricular drainage in patients with aneurysmal subarachnoid hemorrhage: a prospective randomized trial;Klopfenstein JD,2004 5. Communicating hydrocephalus from subarachnoid bleeding;Foltz EL,1956
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