gms | German Medical Science

Objective: Spontaneous aneurysmal subarachnoid hemorrhage (sSAH) is known to cause hydrocephalus in a subset of patients. Several studies discussed predictors for ventriculoperitoneal (VP)-shunting but only few is known about the ideal timing of definite implantation in cases of uncertain temporary closure trials of external drainage. Early VP-shunting might risk unnecessary surgery while late VP-shunting leads to an interruption of neurorehabilitation which might cause worse clinical outcome. Our study focused on the outcome of patients with early (within their first hospital admission) or late (after discharge for rehabilitation) VP-shunting and the occurrence of complications.

Methods: A retrospective 6-year study was conducted, reviewing 62 patients who underwent VP-shunting after good- or poor- (WFNS 1-3 or 4-5) grade sSAH. Based on the initial timing of VP-shunting, patients were subdivided into an early (before) or late (after discharge) VP-shunting group for further comparison. We collected clinical, demographic and follow-up data. All patients who did not fail temporary closure of external ventricular (EVD) or lumbar drainage (LD) were included for further observation of delayed shunting and elicitation of their mRS-Score after 3 and 6 months.

Results: 43 female and 17 male patients met our inclusion criteria for further data analyses. We observed 43.5% good- (WFNS 1-3) and 53.2% poor-grade (WFNS 4-5) sSAH. 8 of 60 (13.3%) patients showed no initial hydrocephalus at admission. No significant differences were found in mRS after 3 or 6 months within both groups (p always >0.05). Revision surgery rate was tendentially higher with 11 (33%) patients before discharge compared to patients with later VP-shunting (15%) (p= 0.09). Regarding delayed complications, VP-shunting before discharge showed significantly more complications (p<0.05).

Conclusion: Regarding timing and clinical outcome of sSAH patients with hydrocephalus, there seems to be a wider time frame for definite VP-shunting without causing neurological aggravation than expected. Thus, giving patients the chance to start rehabilitation as soon as possible. Also, concerning delayed complications such as infections or shunt-dysfunction, we provide proof that implantation of a VP-shunt after discharge, in patients who initially did not fail temporary closure of external drainage, causes less complication rates. Further prospective studies with greater numbers should be accomplished to investigate this proposal.