scholarly journals Intermittent CSF drainage and rapid EVD weaning approach after subarachnoid hemorrhage: association with fewer VP shunts and shorter length of stay

2020 ◽  
Vol 132 (5) ◽  
pp. 1583-1588 ◽  
Author(s):  
Shyam S. Rao ◽  
David Y. Chung ◽  
Zoe Wolcott ◽  
Faheem Sheriff ◽  
Ayaz M. Khawaja ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Length Of Stay ◽  
Neurocritical Care ◽  
External Ventricular Drain ◽  
Multivariable Analysis ◽  
The United States ◽  
Management Approach ◽  
Vp Shunt ◽  
Symptomatic Vasospasm ◽  
Csf Drainage

OBJECTIVEThere is variability and uncertainty about the optimal approach to the management and discontinuation of an external ventricular drain (EVD) after subarachnoid hemorrhage (SAH). Evidence from single-center randomized trials suggests that intermittent CSF drainage and rapid EVD weans are safe and associated with shorter ICU length of stay (LOS) and fewer EVD complications. However, a recent survey revealed that most neurocritical care units across the United States employ continuous CSF drainage with a gradual wean strategy. Therefore, the authors sought to determine the optimal EVD management approach at their institution.METHODSThe authors reviewed records of 200 patients admitted to their institution from 2010 to 2016 with aneurysmal SAH requiring an EVD. In 2014, the neurocritical care unit of the authors’ institution revised the internal EVD management guidelines from a continuous CSF drainage with gradual wean approach (continuous/gradual) to an intermittent CSF drainage with rapid EVD wean approach (intermittent/rapid). The authors performed a retrospective multivariable analysis to compare outcomes before and after the guideline change.RESULTSThe authors observed a significant reduction in ventriculoperitoneal (VP) shunt rates after changing to an intermittent CSF drainage with rapid EVD wean approach (13% intermittent/rapid vs 35% continuous/gradual, OR 0.21, p = 0.001). There was no increase in delayed VP shunt placement at 3 months (9.3% vs 8.6%, univariate p = 0.41). The intermittent/rapid EVD approach was also associated with a shorter mean EVD duration (10.2 vs 15.6 days, p < 0.001), shorter ICU LOS (14.2 vs 16.9 days, p = 0.001), shorter hospital LOS (18.2 vs 23.7 days, p < 0.0001), and lower incidence of a nonfunctioning EVD (15% vs 30%, OR 0.29, p = 0.006). The authors found no significant differences in the rates of symptomatic vasospasm (24.6% vs 20.2%, p = 0.52) or ventriculostomy-associated infections (1.3% vs 8.8%, OR 0.30, p = 0.315) between the 2 groups.CONCLUSIONSAn intermittent CSF drainage with rapid EVD wean approach is associated with fewer VP shunt placements, fewer complications, and shorter LOS compared to a continuous CSF drainage with gradual EVD wean approach. There is a critical need for prospective multicenter studies to determine if the authors’ experience is generalizable to other centers.

Abstract 1122‐000094: EVD Weaning Criteria Decreases VPS/ETV Placement and Hospital Stay in Subarachnoid Hemorrhage Patients

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Sachin A Kothari ◽  
Mevish S Siddiq ◽  
Scott Rahimi ◽  
Manan Shah ◽  
Klepper A Garcia
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Neurocritical Care ◽  
External Ventricular Drain ◽  
Third Ventriculostomy ◽  
Chi Square ◽  
Normal Limits ◽  
Chi Square Analysis ◽  
Weaning Criteria

Introduction : The Neurocritical Care Society encourages an external ventricular drain (EVD) wean “as quickly as is clinically feasible” but guidelines on achieving it are limited (1). This study aims to improve quality of care by sharing a protocol to initiate EVD weaning. These criteria were developed over 7 years and showed a reduction in ventriculoperitoneal shunt/endoscopic third ventriculostomy (VPS/ETV) placement and length of stay (LOS) at our institute compared to national averages. Methods : 151 subarachnoid hemorrhage (SAH) patients from January 2016 to January 2019 were analyzed. 60 aneurysmal SAH (aSAH) and 18 non‐aneurysmal nontraumatic SAH (naSAH) patients required EVD placement. A gradual EVD weaning protocol was initiated if patients met the following criteria: the reason for EVD placement has resolved or is resolving, quantity of CSF output must be <250mL over 24 hours, quality of CSF must be nonbloody, ICP must be within normal limits, and the patient must be neurologically stable. It was acceptable to wean when the patient had mild cerebral vasospasm, but not moderate to severe cerebral vasospasm. EVD weaning was performed by increasing drain height by 5 millimeters of mercury every 24 hours if criteria were met. Charts were reviewed for LOS and rate of VPS/ETV. Gender, age, race, wean failure incidence, infection rates, and SIADH/CSW rates were obtained. Results : Average LOS for aSAH patients with EVD at our institute was 20.35 days. Incidence of VPS/ETV was 11%. Chi‐square analysis was performed, and aSAH patients were found to have higher rates of VPS/ETV placement (p<0.001) and EVD wean failures (p<0.001) than naSAH patients. Conclusions : Our criteria to initiate EVD weaning provided a reduction in VPS/ETV placement among aSAH patients compared to national averages and provides a standardized approach to EVD management. aSAH patients at our institute had a lower incidence of VPS/ETV placement of 11% compared to 21% nationally (2). aSAH patients at our institute also had a lower LOS at 20.35 days compared to 21.5 days nationally (3).

scholarly journals Continuous cerebral spinal fluid drainage associated with complications in patients admitted with subarachnoid hemorrhage

2013 ◽  
Vol 119 (4) ◽  
pp. 974-980 ◽  
Author(s):  
DaiWai M. Olson ◽  
Meg Zomorodi ◽  
Gavin W. Britz ◽  
Ali R. Zomorodi ◽  
Anthony Amato ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Subarachnoid Hemorrhage ◽  
Complication Rate ◽  
Interim Analysis ◽  
Best Practice ◽  
External Ventricular Drain ◽  
Icp Monitoring ◽  
Blood Products ◽  
Clinical Trial Registration ◽  
Csf Drainage

Object Cerebral artery vasospasm is a major cause of death and disability in patients recovering from subarachnoid hemorrhage (SAH). Although the exact cause of vasospasm is unknown, one body of research suggests that clearing blood products by CSF drainage is associated with a lower frequency and severity of vasospasm. There are multiple approaches to facilitating CSF drainage, but there is inadequate evidence to determine the best practice. The purpose of this study was to explore whether continuous or intermittent CSF drainage was superior for reducing vasospasm. Methods The authors performed a randomized clinical trial. Within 72 hours of admission for SAH, patients with an external ventricular drain (EVD) were randomized to undergo continuous CSF drainage with intermittent intracranial pressure (ICP) monitoring (open-EVD group) or continuous ICP monitoring with intermittent CSF drainage (monitor-ICP group). Results After 60 patients completed the study, an interim analysis was performed. The complication rate of 52.9% for the open-EVD group was significantly higher than the 23.1% complication rate for the monitor-ICP group (OR 3.75, 95% CI 1.21–11.66, p = 0.022). These results were reported to the Data Safety and Monitoring Board and enrollment was terminated. The odds ratio of vasospasm for the open-EVD versus monitor-ICP group was not significant (OR 0.44, 95% CI 0.13–1.45, p = 0.177). Conclusions Continuous CSF drainage with intermittent ICP monitoring is associated with a higher rate of complications than continuous ICP monitoring with intermittent CSF drainage, but there is no difference between the two types of monitoring in vasospasm. Clinical trial registration no.: NCT01169454 (clinicaltrials.gov).

Costs of Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽  
2010 ◽  
Vol 67 (2) ◽  
pp. 345-352 ◽  
Author(s):  
Chia-Hung Chou ◽  
Shelby D. Reed ◽  
Jennifer S. Allsbrook ◽  
Janet L. Steele ◽  
Kevin A. Schulman ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Length Of Stay ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Endovascular Coiling ◽  
Billing Data ◽  
Surgical Clipping ◽  
Physician Billing ◽  
Symptomatic Vasospasm ◽  
Hospital Stays ◽  
The Impact

Abstract OBJECTIVE To assess the impact of vasospasm on costs, length of stay, and mortality among inpatients with aneurysmal subarachnoid hemorrhage. METHODS We combined hospital accounting and physician billing data for a consecutive cohort of 198 patients who underwent surgical clipping or endovascular coiling for subarachnoid hemorrhage repair. We considered patients with transcranial Doppler (TCD) velocity of 120 cm/s or greater in the middle cerebral artery to have TCD-defined vasospasm and patients with delayed ischemic neurological deficit to have symptomatic vasospasm. We compared outcomes of patients with TCD-defined vasospasm (n = 116) and those without (n = 73) and patients with symptomatic vasospasm (n = 62) and those without (n = 127), adjusting for demographic and clinical characteristics. RESULTS In adjusted analyses, the incremental cost attributable to TCD-defined vasospasm was 1.20 times higher (95% confidence interval, 1.06–1.36; P = .004) than for patients without TCD-defined vasospasm. Length of stay was an estimated 1.22 times longer for patients with TCD-defined vasospasm (95% CI, 1.07–1.39; P &lt; .01). For symptomatic vasospasm, adjusted costs were 1.27 times higher (95% CI, 1.12–1.43; P &lt; .001) and length of stay was an estimated 1.24 times longer (95% CI, 1.09–1.40; P &lt; .01) for patients with vasospasm than for those without. There was no significant relationship between either type of vasospasm and in-hospital mortality. CONCLUSION Patients with subarachnoid hemorrhage and TCD-defined or symptomatic vasospasm incur higher inpatient costs and longer hospital stays than those without vasospasm.

Abstract TP422: Platelet Transfusion In Patients Presenting With Aneurysmal Subarachnoid Hemorrhage Does Not Improve Outcome

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ali Sultan-Qurraie ◽  
Adam de Havenon ◽  
John Lynch ◽  
David Tirschwell ◽  
Marc Lazzaro ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Subarachnoid Hemorrhage ◽  
Platelet Transfusion ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
External Ventricular Drain ◽  
The United States ◽  
Ordinal Logistic Regression ◽  
Hospital Length Of Stay ◽  
P Value ◽  
Fisher Score

Introduction: The effect of platelet transfusion (PT) has been studied in patients with intracerebral hemorrhage, but has not been reported for aneurysmal subarachnoid hemorrhage (aSAH). We investigated the effect of PT on the outcome of patients with aSAH. Methods: We retrospectively evaluated 84 patients admitted with aSAH to a Comprehensive Stroke Center in the United States between 2011 and 2015. Charts were reviewed for variables including length of hospitalization, 3-month modified Rankin Scale (mRS), and complications related to endovascular treatment of cerebral aneurysm. Intergroup differences were evaluated with the Chi-squared and Student’s t-test. mRS was evaluated using multivariate ordinal logistic regression. Variables with a univariate p-value <0.2 association with 3 month mRS were included in the ordinal logistic regression model. Results: Patient demographics and clinical variables are seen in Table 1. 30% of patients received PT. PT was associated with male gender, Hunt-Hess score, Fisher Score, external ventricular drain placement, and longer hospital length of stay. After multivariate ordinal regression, PT was associated with higher mRS and there was a trend for association with Hunt-Hess score (Table 2). Conclusion: Our findings suggest that platelet transfusion is common in patients presenting with aSAH. Platelet transfusion in these patients is associated with longer hospital stay and a significantly lower rate of good clinical outcome, with a nearly 4- to 6-fold higher odds of a one-point increase in mRS at 3 months. The association of platelet transfusion to worse outcome in patients with aSAH warrants further study.

Abstract TP376: Infections in Patients With Spontaneous Intraventricular Hemorrhage- Results From the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III Trial

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Jharna N Shah ◽  
Santosh B Murthy ◽  
Nichol McBee ◽  
Rachel Dlugash ◽  
Malathi Ram ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Intracerebral Hemorrhage ◽  
Outcome Measures ◽  
Intraventricular Hemorrhage ◽  
External Ventricular Drain ◽  
Randomized Study ◽  
Multivariable Analysis ◽  
Hospital Length Of Stay ◽  
Secondary Outcome ◽  
Clot Lysis

Introduction: Intraventricular hemorrhage (IVH) occurs in about 40% of patients with intracerebral hemorrhage (ICH) and is associated with higher mortality and worse outcomes than ICH patients without IVH. Infections are common in ICH patients but data in IVH patients are limited. Methods: Prospective analysis of adjudicated adverse event infection reporting during first 180 days in 500 patients enrolled in the CLEAR III trial, a multicenter, double-blind, randomized study comparing external ventricular drain (EVD) + intraventricular recombinant tissue plasminogen activator (rtPA) vs. EVD + placebo for treatment of obstructive IVH and intracerebral hemorrhage (ICH) volume <30cc. Primary outcome measures were 90-day and 180-day mortality. Secondary outcome measures were hospital length of stay (LOS). We constructed binary logistic and linear regression models for multivariable analysis. Results: Infection was reported in 269 patients (53.8%). Pneumonia was the most common infection (33%), followed by UTI (16%), and bacterial ventriculitis (4.4%). Overall 180-day mortality was 20%. Patients with infection were more likely to have older age (p=0.012), lower admission GCS (p=0.007), higher ICH volume (8.8 vs 6.7ml, p=0.001), and higher ICH+IVH volume (37.7 vs 31.7 ml, p=0.002). In the regression model, IVH volume was associated with higher odds of 90-day or 180-day mortality, but presence of any infection was not a significant predictor of mortality. Infection was however associated with longer length of stay (26 vs 22 days, p<0.001). Subgroup analysis of individual infections, showed only bacterial ventriculitis to be associated with 90-day (OR: 3.84, CI: 1.36-10.82), and 180-day mortality (OR: 2.9, CI: 1.05-8.06), while pneumonia and UTI were not. Conclusion: Patients with IVH have a high incidence of infections, which is associated with longer hospitalization but does not appear to influence mortality. Of the infections, bacterial ventriculitis is a significant predictor of mortality in our 7-factor model. IVH volume did not predict infections but predicted mortality.These results form a basis for future correlation of infectious complications with treatment rendered (thrombolysis versus placebo), with upcoming unblinding of the trial.

Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism

2021 ◽  
pp. 197140092110246
Author(s):  
Fawaz Al-Mufti ◽  
Stephan A Mayer ◽  
Gurmeen Kaur ◽  
Daniel Bassily ◽  
Boyi Li ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Care Management ◽  
Neurocritical Care ◽  
External Ventricular Drain ◽  
High Grade ◽  
Selective Treatment ◽  
Poor Grade ◽  
Cardiopulmonary Support ◽  
Aggressive Care ◽  
Improvement In Survival

Background and purpose Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. Materials and methods We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. Results Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. Conclusions Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.

PREDICTORS OF CEREBRAL INFARCTION IN PATIENTS WITH ANEURYSMAL SUBARACHNOID HEMORRHAGE

Neurosurgery ◽  
2007 ◽  
Vol 60 (4) ◽  
pp. 658-667 ◽  
Author(s):  
Sherise Ferguson ◽  
R. Loch Macdonald
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Infarction ◽  
Odds Ratio ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Multivariable Analysis ◽  
Double Blind ◽  
Poor Outcome ◽  
Symptomatic Vasospasm ◽  
Explained Variance ◽  
The Impact

Abstract OBJECTIVE Cerebral infarction would be expected to be associated with poor outcome after aneurysmal subarachnoid hemorrhage (SAH), although there are few data on which to base this assumption. The goals of this study were to determine the impact of cerebral infarction on outcome and to examine predictors of infarction in these patients. METHODS Univariate and multivariable statistical methods were used to examine the impact of cerebral infarction on the Glasgow Outcome Scale score 3 months after SAH among 3567 patients entered into four prospective, randomized, double-blind, placebo-controlled trials of tirilazad conducted in neurosurgical centers around the world between 1991 and 1997. Patient demographics, clinical variables, radiographic characteristics, and treatment variables associated with cerebral infarction were also determined by the same methods. RESULTS Seven hundred and seven (26%) out of 2741 patients with complete data had cerebral infarction on computed tomographic scans 6 weeks after SAH. Multivariable logistic regression showed that cerebral infarction increased the odds of unfavorable outcome by a factor of 5.4 (adjusted odds ratio, 5.4; 95% confidence interval, 4.2–6.8; P &lt; 0.0001), which was a higher odds ratio than all other factors associated with outcome. The proportion of explained variance in outcome was also highest for cerebral infarction and accounted for 39% of the explained variance. Multivariable analysis found that cerebral infarction was significantly associated with increasing patient age, worse neurological grade on admission, history of hypertension or diabetes mellitus, larger aneurysm, use of prophylactically or therapeutically induced hypertension, temperature more than 38°C 8 days after SAH, and symptomatic vasospasm. CONCLUSION Cerebral infarction was strongly associated with poor outcome after aneurysmal SAH. The most important potentially treatable factor associated with infarction was symptomatic vasospasm.

Venous Thromboembolism in Neurocritical Care Patients

2019 ◽  
Vol 35 (11) ◽  
pp. 1226-1234 ◽  
Author(s):  
Tanuwong Viarasilpa ◽  
Nicha Panyavachiraporn ◽  
Jack Jordan ◽  
Seyed Mani Marashi ◽  
Meredith van Harn ◽  
...  
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Length Of Stay ◽  
Critically Ill ◽  
Neurocritical Care ◽  
Central Venous Catheterization ◽  
Multivariable Analysis ◽  
Central Venous ◽  
Neurological Intensive Care Unit ◽  
Venous Catheterization

Background: Venous thromboembolism (VTE) is a potentially life-threatening complication among critically ill patients. Neurocritical care patients are presumed to be at high risk for VTE; however, data regarding risk factors in this population are limited. We designed this study to evaluate the frequency, risk factors, and clinical impact of VTE in neurocritical care patients. Methods: We obtained data from the electronic medical record of all adult patients admitted to neurological intensive care unit (NICU) at Henry Ford Hospital between January 2015 and March 2018. Venous thromboembolism was defined as deep vein thrombosis, pulmonary embolism, or both diagnosed by Doppler, chest computed tomography (CT) angiography or ventilation–perfusion scan >24 hours after admission. Patients with ICU length of stay <24 hours or who received therapeutic anticoagulants or were diagnosed with VTE within 24 hours of admission were excluded. Results: Among 2188 consecutive NICU patients, 63 (2.9%) developed VTE. Prophylactic anticoagulant use was similar in patients with and without VTE (95% vs 92%; P = .482). Venous thromboembolism was associated with higher mortality (24% vs 13%, P = .019), and longer ICU (12 [interquartile range, IQR 5-23] vs 3 [IQR 2-8] days, P < .001) and hospital (22 [IQR 15-36] vs 8 [IQR 5-15] days, P < .001) length of stay. In a multivariable analysis, potentially modifiable predictors of VTE included central venous catheterization (odds ratio [OR] 3.01; 95% confidence interval [CI], 1.69-5.38; P < .001) and longer duration of immobilization (Braden activity score <3, OR 1.07 per day; 95% CI, 1.05-1.09; P < .001). Nonmodifiable predictors included higher International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) scores (which accounts for age >60, prior VTE, cancer and thrombophilia; OR 1.66; 95% CI, 1.40-1.97; P < .001) and body mass index (OR 1.05; 95% CI, 1.01-1.08; P = .007). Conclusions: Despite chemoprophylaxis, VTE still occurred in 2.9% of neurocritical care patients. Longer duration of immobilization and central venous catheterization are potentially modifiable risk factors for VTE in critically ill neurological patients.

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.

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