Predictors for delayed ventriculoperitoneal shunt placement after external ventricular drain removal in patients with subarachnoid hemorrhage

2014 ◽  
Vol 29 (2) ◽  
pp. 219-224 ◽  
Author(s):  
Ariane Lewis ◽  
Hannah Irvine ◽  
Christopher Ogilvy ◽  
W. Taylor Kimberly
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Ventriculoperitoneal Shunt ◽  
External Ventricular Drain ◽  
Shunt Placement ◽  
Drain Removal

A Cohort Comparison Analysis of Fixed Pressure Ventriculoperitoneal Shunt Valves With Programmable Valves for Hydrocephalus Following Nontraumatic Subarachnoid Hemorrhage

2019 ◽  
Author(s):  
Eduardo Orrego-González ◽  
Alejandro Enriquez-Marulanda ◽  
Luis C Ascanio ◽  
Noah Jordan ◽  
Khalid A Hanafy ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Ventriculoperitoneal Shunt ◽  
Chart Review ◽  
External Ventricular Drain ◽  
Retrospective Chart Review ◽  
Comparison Analysis ◽  
Replacement Rate ◽  
Ventriculoperitoneal Shunts ◽  
Initial Hospitalization ◽  
Programmable Valves

Abstract BACKGROUND Hydrocephalus after nontraumatic subarachnoid hemorrhage (SAH) is a common sequela that may require the placement of ventriculoperitoneal shunts (VPS). Adjustable-pressure valves (APVs) are being widely used in this situation though more expensive than differential-pressure valves (DPVs). OBJECTIVE To compare outcomes between APV and DPV in SAH-induced hydrocephalus. METHODS We performed a retrospective chart review of patients with nontraumatic SAH who underwent VPS placement for the treatment of hydrocephalus after SAH, between July 2007 and December 2016. Patients were classified according to the type of valve (APV vs DPV). We evaluated factors that could predict the type of valve used, outcomes in VPS revision/replacement rate, and complications. RESULTS A total of 66 patients underwent VPS placement who were equally distributed into the 2 groups of valves. VPS failure with the need for revision/replacement occurred in 13 (19.7%) cases. Ten (30.3%) patients with DPV had a VPS failure, while 3 (9.1%) patients with an APV had a similar failure with the need for revision/replacement (P = .03). VPS placement before discharge during the initial hospitalization (P = .02) was statistically significant associated with the use of a DPV, while the reason of external ventricular drain (EVD) failure (P = .03) was associated with the use of an APV. CONCLUSION APVs had a lower rate of surgical revisions compared to DPVs. Early placement of VPS was associated with the use of a DPV. The need for EVD replacement due to EVD infection or malfunction was associated with higher rates of APV use.

scholarly journals Associations between Features of External Ventricular Drain Management, Disposition, and Shunt Dependence

2020 ◽  
Author(s):  
Corey Engel ◽  
Amanda L. Faulkner ◽  
David W. Van Wyck ◽  
Ali R. Zomorodi ◽  
Nicolas Kon Kam King ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ventriculoperitoneal Shunt ◽  
External Ventricular Drain ◽  
The United States ◽  
University Hospital ◽  
Shunt Placement ◽  
Modifiable Factors ◽  
Duke University ◽  
Neuroscience Intensive Care Unit ◽  
Drain Management

Abstract Background In the United States, nearly 25,000 patients annually undergo percutaneous ventriculostomy for the management of increased intracranial pressure with little consensus on extraventricular drain management. To characterize relationships between external ventricular drain management, permanent ventriculoperitoneal shunt placement, and hospital disposition, we hypothesized that patients requiring extended drainage would have greater association with ventriculoperitoneal shunt placement and unfavorable disposition. Methods Adult patients admitted to the Duke University Hospital Neuroscience Intensive Care Unit between 2008 and 2010 with extraventricular drains were analyzed. A total of 115 patient encounters were assessed to determine relative impact of age, sex, days of extraventricular placement, weaning attempts, cerebrospinal fluid drainage volumes, Glasgow Coma Scale, and physician’s experience on disposition at discharge and ventriculoperitoneal shunt placement. Univariate logistic regression was first used to test the effect of each variable on the outcome, followed by backward selection to determine a final multivariable logistic regression. Variables in the final model meeting p < 0.05 were declared as significant factors for the outcome. Results Increased extraventricular drain duration (odds ratio [OR] = 1.17, confidence interval [CI] = 1.05–1.30, p = 0.0049) was associated with ventriculoperitoneal shunt placement, while older age (OR = 1.05, CI = 1.02–1.08, p = 0.0027) and less physician extraventricular drain management experience (OR = 4.04, CI = 1.67–9.79, p = 0.0020) were associated with unfavorable disposition. Conclusion In a small cohort, exploratory analyses demonstrate potentially modifiable factors are associated with important clinical outcomes. These findings warrant further study to refine how such factors affect patient outcomes.

Role of Fever in Ventriculoperitoneal Shunt Placement After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽  
2011 ◽  
Vol 70 (6) ◽  
pp. 1361-1368 ◽  
Author(s):  
Robert M. Starke ◽  
Ricardo J. Komotar ◽  
Brian Y. Hwang ◽  
Fred Rincon ◽  
Ivan S. Kotchetkov ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Ventriculoperitoneal Shunt ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Shunt Failure ◽  
Persistent Fever ◽  
Shunt Placement ◽  
Patient Demographics ◽  
Increased Risk

Abstract BACKGROUND: Central fever is common after aneurysmal subarachnoid hemorrhage (aSAH) and may delay ventriculoperitoneal shunt (VPS) placement. OBJECTIVE: We hypothesize that drain-dependent aSAH patients with central fever or persistent fever after treatment of an identifiable cause are not at an increased risk of infectious VPS failure. METHODS: Patient demographics, radiographic characteristics, temperature, incidence of infection, and shunt failure were prospectively recorded in a consecutive cohort of aSAH patients. Central fever was defined as temperature higher than 38.3°C with no identifiable cause. RESULTS: Of 580 patients, 61 (11%) were drain dependent. Central fever developed in 18, 35 had fever of known etiology, and 8 remained afebrile. There was no shunt failure at discharge, and 2 failures (3.2%) at follow-up were attributed to infection. One patient with central fever (6%), none with fever of identifiable etiology, and 1 (13%) with no fever had infectious shunt failures at a median follow-up of 10.2 ± 3.6 months (P &gt; .05). Nine patients with central fever (50%) and 6 (17%) who were treated for fever of known etiologies had persistent fever at shunt placement. Patients who were febrile on the day of surgery had similar infectious shunt failure rates at discharge compared with those who were afebrile (0% vs 0%; P = 1.0). Similarly, febrile and afebrile patients at VPS insertion had comparable rates of infectious shunt failure at follow-up (7% vs 2%; P = .43). CONCLUSION: aSAH patients with central fever or persistent fever after treatment of fever of identifiable etiology are not at an increased risk of infectious VPS failure.

scholarly journals Reduction of shunt dependency rates following aneurysmal subarachnoid hemorrhage by tandem fenestration of the lamina terminalis and membrane of Liliequist during microsurgical aneurysm repair

2018 ◽  
Vol 129 (5) ◽  
pp. 1166-1172 ◽  
Author(s):  
Ethan A. Winkler ◽  
Jan-Karl Burkhardt ◽  
W. Caleb Rutledge ◽  
Jonathan W. Rick ◽  
Carlene P. Partow ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Surgical Repair ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
External Ventricular Drain ◽  
Number Needed To Treat ◽  
Lamina Terminalis ◽  
Vp Shunt ◽  
Shunt Placement ◽  
Fisher Grade ◽  
Shunt Dependency

OBJECTIVEShunt-dependent hydrocephalus is an important cause of morbidity following aneurysmal subarachnoid hemorrhage (aSAH) in excess of 20% of cases. Hydrocephalus leads to prolonged hospital and ICU stays, well as to repeated surgical interventions, readmissions, and complications associated with ventriculoperitoneal (VP) shunts, including shunt failure and infection. Whether variations in surgical technique at the time of aneurysm treatment may modify rates of shunt dependency remains a matter of debate. Here, the authors report on their experience with tandem fenestration of the lamina terminalis (LT) and membrane of Liliequist (MoL) at the time of open microsurgical repair of the ruptured aneurysm.METHODSThe authors conducted a retrospective review of 663 consecutive patients with aSAH treated from 2005 to 2015 by open microsurgery via a pterional or orbitozygomatic craniotomy by the senior author (M.T.L.). Data collected from review of the electronic medical record included age, Hunt and Hess grade, Fisher grade, need for an external ventricular drain, and opening pressure. Patients were stratified into those undergoing no fenestration and those undergoing tandem fenestration of the LT and MoL at the time of surgical repair. Outcome variables, including VP shunt placement and timing of shunt placement, were recorded and statistically analyzed.RESULTSIn total, shunt-dependent hydrocephalus was observed in 15.8% of patients undergoing open surgical repair following aSAH. Tandem microsurgical fenestration of the LT and MoL was associated with a statistically significant reduction in shunt dependency (17.9% vs 3.2%, p < 0.01). This effect was confirmed with multivariate analysis of collected variables (multivariate OR 0.09, 95% CI 0.03–0.30). Number-needed-to-treat analysis demonstrated that tandem fenestration was required in approximately 6.8 patients to prevent a single VP shunt placement. A statistically significant prolongation in days to VP shunt surgery was also observed in patients treated with tandem fenestration (26.6 ± 19.4 days vs 54.0 ± 36.5 days, p < 0.05).CONCLUSIONSTandem fenestration of the LT and MoL at the time of open microsurgical clipping and/or bypass to secure ruptured anterior and posterior circulation aneurysms is associated with reductions in shunt-dependent hydrocephalus following aSAH. Future prospective randomized multicenter studies are needed to confirm this result.

scholarly journals Relationship between external ventricular drain clamp trials and ventriculoperitoneal shunt insertion following nontraumatic subarachnoid hemorrhage: a single-center study

2019 ◽  
Vol 130 (3) ◽  
pp. 956-962 ◽  
Author(s):  
Luis C. Ascanio ◽  
Raghav Gupta ◽  
Nimer Adeeb ◽  
Justin M. Moore ◽  
Christoph J. Griessenauer ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
External Ventricular Drain ◽  
Median Number ◽  
Study Patient ◽  
Shunt Insertion ◽  
Female Ratio ◽  
Posthemorrhagic Hydrocephalus ◽  
Vp Shunt ◽  
Shunt Placement ◽  
Lengths Of Stay

OBJECTIVECurrently, there is no established standard regarding the ideal number of external ventricular drain (EVD) clamp trials performed before ventriculoperitoneal (VP) shunt insertion following nontraumatic subarachnoid hemorrhage (SAH). In this study, the authors aimed to evaluate this relationship.METHODSA retrospective review of all patients presenting with SAH between July 2007 and December 2016 was performed. Patients with SAH who had received an EVD within the first 24 hours of hospital admission and had undergone at least 1 clamp trial prior to EVD removal were eligible for inclusion in the study. Patient demographics, clinical presentations, SAH etiologies and grades, clamp trial data, hospital lengths of stay, and functional outcomes were recorded.RESULTSOne hundred fourteen patients with nontraumatic SAH complicated by posthemorrhagic hydrocephalus were included in the study. The median patient age was 57 years (range 28–90 years), with a male/female ratio of 1:1.7. A ruptured aneurysm was the underlying etiology of SAH in 79.8% of patients. A majority of patients (69.4%) had a Hunt and Hess grade III–V on admission. The median number of clamp trials performed was 2 (range 1–6). A VP shunt was required in 40.4% of patients. In those who underwent 2 and 3 clamp trials, 60% and 38.9%, respectively, did not require subsequent VP shunt placement.CONCLUSIONSSurgical placement of a VP shunt is associated with complications. Clamp trials are routinely performed before making the decision to insert a shunt. In the present study, the authors found that a significant percentage of patients passed their second and third clamp trials without requiring subsequent shunt insertion. These data support performing multiple clamp trials prior to shunt placement.

Nimodipine pharmacokinetics after intraventricular injection of sustained-release nimodipine for subarachnoid hemorrhage

2021 ◽  
Vol 134 (1) ◽  
pp. 95-101 ◽  
Author(s):  
R. Loch Macdonald ◽  
Daniel Hänggi ◽  
Poul Strange ◽  
Hans Jakob Steiger ◽  
J Mocco ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Sustained Release ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
External Ventricular Drain ◽  
Plasma Concentrations ◽  
Intraventricular Injection ◽  
World Federation ◽  
Maximum Plasma ◽  
Clinical Trial Registration ◽  
Sustained Release Formulation

OBJECTIVEThe objective of this study was to measure the concentration of nimodipine in CSF and plasma after intraventricular injection of a sustained-release formulation of nimodipine (EG-1962) in patients with aneurysmal subarachnoid hemorrhage (SAH).METHODSPatients with SAH repaired by clip placement or coil embolization were randomized to EG-1962 or oral nimodipine. Patients were classified as grade 2–4 on the World Federation of Neurosurgical Societies grading scale for SAH and had an external ventricular drain inserted as part of their standard of care. Cohorts of 12 patients received 100–1200 mg of EG-1962 as a single intraventricular injection (9 per cohort) or they remained on oral nimodipine (3 per cohort). Plasma and CSF were collected from each patient for measurement of nimodipine concentrations and calculation of maximum plasma and CSF concentration, area under the concentration-time curve from day 0 to 14, and steady-state concentration.RESULTSFifty-four patients in North America were randomized to EG-1962 and 18 to oral nimodipine. Plasma concentrations increased with escalating doses of EG-1962, remained stable for 14 to 21 days, and were detectable at day 30. Plasma concentrations in the oral nimodipine group were more variable than for EG-1962 and were approximately equal to those occurring at the EG-1962 800-mg dose. CSF concentrations of nimodipine in the EG-1962 groups were 2–3 orders of magnitude higher than in the oral nimodipine group, in which nimodipine was only detected at low concentrations in 10% (21/213) of samples. In the EG-1962 groups, CSF nimodipine concentrations were 1000 times higher than plasma concentrations.CONCLUSIONSPlasma concentrations of nimodipine similar to those achieved with oral nimodipine and lasting for 21 days could be achieved after a single intraventricular injection of EG-1962. The CSF concentrations from EG-1962, however, were at least 2 orders of magnitude higher than those with oral nimodipine. These results supported a phase 3 study that demonstrated a favorable safety profile for EG-1962 but yielded inconclusive efficacy results due to notable differences in clinical outcome based on baseline disease severity.Clinical trial registration no.: NCT01893190 (ClinicalTrials.gov).

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